October 10, 2016
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Pediatricians play key role in debunking vaccine myths

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The percentage of pediatricians who encounter parental refusal of vaccinations increased from 75% in 2006 to 87% in 2013, according to results of The Periodic Survey of Fellows conducted by the AAP.

Christoph Diasio

Specifically, the proportion of parents who refused one or more vaccinations for their child increased during the 7-year period from 9.1% in 2006 to 16.7% in 2013.

Current reasons for vaccine hesitancy or refusal include the belief that vaccines are not necessary, concerns with pain associated with receiving multiple injections during a single visit, distrust of health care professionals or the government, and lingering concerns regarding the unproven vaccine and autism link.

Elizabeth R. Wolf, MD, MPH, of Virginia Commonwealth University/Children’s Hospital of Richmond, said that pediatricians should first attempt to understand why certain parents are refusing a particular vaccine and then address that concern or misconception specifically.

Photo courtesy of VCU University Relations

“We found that almost all U.S. pediatricians encounter vaccine delays and refusals,” the researchers wrote. “They perceive that vaccine refusals are increasing and that parental reasons are changing.”

Surveyed pediatricians reported experiences with parents increasingly questioning the need to follow the AAP and CDC vaccine schedule — nearly all experienced parental refusal of vaccinations or requests to delay vaccinations.

However, with the exception of the HPV vaccine, experts say the tide appears to be turning — the most recent CDC statistics suggest vaccination rates are rising, while the percentage of parents refusing vaccinations is quite low.

“People refusing vaccines are not the majority, but a tiny group of people who tend to cluster together,” Christoph Diasio, MD, FAAP, chair of the AAP section on administration and practice management, said during an interview. “While we would like to see all vaccination rates higher, the tide has shifted a bit with parental vaccine refusal — particularly after the Disneyland measles outbreak in California [in 2015]. What happened in Disneyland resonated with a lot of people, which helped our case as physicians and health care professionals with regards to the importance of vaccinations.”

Infectious Diseases in Children spoke with several experts about the ever-changing challenges of vaccinations faced by U.S. pediatricians today and how best to approach vaccine hesitancy and debunk vaccination myths.

Concerns should be specific

Pediatricians are encouraged to first understand why certain parents are refusing a particular vaccine and then address that concern or misconception specifically, according to Elizabeth R. Wolf, MD, MPH, of Virginia Commonwealth University/Children’s Hospital of Richmond.

In a study published in Pediatrics in July, Wolf and colleagues assessed childhood vaccination uptake according to parental country of birth among 277,098 children aged 12 to 23 months in Washington State.

According to study results, children of Somali-born parents were less likely to receive the measles-containing vaccine. However, these children were equally or more likely to be immunized with at least one dose of the hepatitis A, pneumococcal and DTaP vaccines. The researchers also learned that children born from Ukrainian and Russian parents were less likely to be immunized with all of the included vaccines when compared with children of two U.S.-born parents.

“Qualitative studies in Minnesota and Washington suggest that the vaccine refusal by Somali families is driven by the belief in the myth that the measles-mumps-rubella vaccine causes autism,” Wolf told Infectious Diseases in Children. “In fact, Andrew Wakefield, the author of the fraudulent, now retracted paper that first connected the measles-mumps-rubella vaccine to autism makes frequent visits to the Somali community in Minnesota.

“On the other hand, qualitative studies of Russian and Ukrainian communities in Washington State have found that their vaccine refusal is multifactorial, but tends to be rooted in the mistrust of medical authority and is fueled by misleading reports by Russian-speaking media. We need to understand what specific public health messages will improve vaccination rates in various immigrant as well as nonimmigrant groups.”

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AAP takes a stance

“Vaccines are one of the greatest inventions of all time — we should celebrate vaccines, not fear them. It is almost ‘Harry Potter-level’ magic that we are able to protect children from these potentially deadly diseases,” Diasio said.

In an effort to address some of the fears and misconceptions surrounding childhood vaccinations, the AAP recently published a clinical report to help equip pediatricians on how to best counsel parents in their offices.

According to the report, published in September in Pediatrics, “vaccine-hesitant parents are a heterogeneous group and specific parental vaccine concerns should be individually identified and addressed. The majority of vaccine-hesitant parents are not necessarily opposed to vaccinations for their children, but are more often than not seeking guidance about the complexity of the vaccination schedule and the lingering concerns about possible adverse effects of vaccines.”

For parents who express concern about the pain associated with vaccinations, the AAP suggests strategies to reduce pain, including administering vaccines quickly without aspirating, holding the child upright, administering the most painful vaccine last and providing tactile stimulation. Concerns regarding the production and composition of vaccines should be addressed by clearly providing any information requested. For example, parents can be reassured that none of the single-dose vaccine preparations currently administered to infants contains mercury.

In addition, to address concerns regarding the presence of aluminum as an adjuvant in some vaccines, physicians should provide evidence for both the necessity of the aluminum for a vigorous immune response and the lack of evidence for its toxicity, according to the AAP.

“Fortunately, most vaccine-hesitant parents are responsive to vaccine information, consider vaccinating their children and are not opposed to all vaccines,” the researchers wrote.

Tackling HPV vaccine stigma

Vaccine safety and triggering early sexual activity are often-cited parental concerns about the HPV vaccine. The AAP suggests that by reassuring parents that the vaccine is safe and that there is no evidence that the HPV vaccine increases sexual activity it may dispel these fears.

Gary S. Marshall

“The bad news is that only 60% of girls and 40% of boys are getting that first dose of the HPV vaccine, and only 40% of girls and 20% of boys are actually getting all three doses,” Gary S. Marshall, MD, professor of pediatrics, chief of the division of pediatric infectious diseases, and director of the Pediatric Clinical Trials Unit at the University of Louisville School of Medicine, said during an interview with Infectious Diseases in Children. “This is absolutely mind-boggling to me. If I was told back when I was in training that we would one day have a vaccine that will protect against cervical, penile and anal cancer, and most likely against oral cancers, this would have been hard for me to believe. However, it would be even more unimaginable that people are refusing to take the vaccine that prevents these cancers.

“The number of these types of cancers is huge. I saw a recent paper that showed between 2008 and 2012 there were an average of almost 39,000 HPV-associated cancers each year. That is almost 40,000 cancers each year, and all of these cancers are potentially preventable with the 9-valent HPV vaccine.”

Kenneth A. Alexander

In contrast to many of the other childhood vaccines, one of the biggest reasons for non-HPV vaccination is not parent refusal, but the provider’s failure to even discuss the vaccine during an office visit, according to Kenneth A. Alexander, MD, PhD, professor of pediatrics, chief of the section of pediatric infectious diseases at the University of Chicago.

“If the pediatrician does bring it up, it is brought up very poorly and is talked about in the wrong way,” Alexander told Infectious Diseases in Children. “The conversation around HPV vaccination has been mishandled. We have focused on the wrong thing. There is this idea that if we immunize a child against HPV, that they all of a sudden become crazy sex fiends. This is absurd and is very demeaning to our young people. We now have the scientific data that prove this idea is completely off-base.”

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In a 2012 study published in Pediatrics, Bednarczyk and colleagues examined sexual activity-related clinical outcomes after adolescent vaccination among 493 girls aged 11 and 12 years exposed to the HPV vaccine in comparison with 905 girls who were not exposed to the HPV vaccine.

The researchers reported that the risk for any pregnancy, sexually transmitted infection testing and diagnosis or contraceptive counseling were not significantly increased among those exposed to the HPV vaccine when compared with unexposed patients (adjusted incidence RR =1.29; 95% CI, 0.92-1.8).

In another study published in 2014 in Pediatrics, Mayhew and colleagues found that baseline risk perceptions were not associated with subsequent sexual initiation 6 months after HPV vaccination among 339 females aged 13 to 21 years. Moreover, those aged 16 to 21 years who reported a lower perceived risk for other STI were less likely to initiate sex (OR = 0.13; 95% CI, 0.03-0.69).

“I remain optimistic that we will see an increase in HPV vaccination rates,” Alexander said. “How we will get there is a complex issue. I think what will ultimately drive the increase is twofold. We need to begin looking at other opportunities to administer the HPV vaccine, such as during sick visits in the pediatrician’s office, offering HPV vaccination at school or the YMCA, for example.

“We need to also change our messaging about the vaccine. Stop talking about the vaccine as preventing a sexually transmitted disease and instead talk about the vaccine as cancer prevention. Tell the parent that what we are trying to do is ensure their child’s health in the future. Ask the parent if anyone in their family has had cancer, and if so, what was it like for them? Make them realize that with this vaccine, we can reduce the risk of their child having a cancer experience later in life.”

Meningococcal B vaccine

In July 2015, the CDC’s Advisory Committee on Immunization Practices voted to issue a Category B recommendation for the use of two serogroup B meningococcal vaccines in patients aged 16 to 23 years for short-term protection against the disease.

Previous recommendations included administration of Trumenba (Pfizer), given as a three-dose series, and Bexsero (GlaxoSmithKline), given as a two-dose series, only for those aged 10 years and older who are at high-risk for serogroup B meningococcal disease. High-risk groups include those with persistent complement component deficiencies and populations at risk due to outbreaks.

However, experts have most recently expressed concerns about the efficacy of the vaccine and say it is hard to know how to aggressively promote the meningococcal serogroup B vaccine.

In December 2013, students at Princeton University were vaccinated with two doses of meningococcal serogroup B during a campus outbreak. According to findings examining the outbreak, published in July in the New England Journal of Medicine, students experienced a lower level of immunity than expected.

“Although the incidence has been declining, in part because of the routine administration of meningococcal A, C, W and Y vaccines in adolescents, the prevention of serogroup B disease has presented particular challenges; it is possible to use the meningococcal B polysaccharide as a vaccine antigen owing to its similarity to human glycoproteins, the presence of which could lead to an autoimmune response,” Nicole E. Basta, PhD, assistant professor of epidemiology and community health in the School of Public Health at the University of Minnesota, and colleagues wrote. “Meningococcal B vaccines that are derived from the outer-membrane vesicles of specific outbreak strains have been developed, but these vaccines have not provided broad protection beyond the outbreak strain.”

Despite the data indicating the vaccine would potentially control the outbreak as isolates expressed antigens that were closely related to the vaccine antigens, immune response rates against the actual circulating strain were between 50% and 60%.

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Mark H. Sawyer

“This was disappointing and until we learn more about how variable its effectiveness is, it is hard to know how aggressively to promote the meningococcal serogroup B vaccine,” Mark H. Sawyer, MD, professor of clinical pediatrics and director of the pediatric residency program at the University of California San Diego School of Medicine, Rady Children’s Hospital-San Diego, said during an interview with Infectious Diseases in Children. “We have not used this vaccine as much, and there are still some lingering concerns with it.”

Because the protein antigens used in both vaccines vary among different serogroup B meningococcal disease, neither FDA-approved vaccine is expected to protect against all strains of serogroup B meningococcal disease in the U.S.

“This is a very challenging and emotional situation because, of course, when the research started on the vaccine, we saw a lot of meningococcal group B disease,” Alexander said. “However, meningococcal disease is just like the tide, it goes in and out. Right now, the tide is out, but eventually the tide will come back in, and we will be glad that we have a vaccine. Every pediatrician should have the discussion about this vaccine with every family, and if the family has coverage, the adolescent should get the vaccine.”

Pediatrician’s role

Data from the 2009 Health Styles survey indicated that approximately 80% of surveyed parents reported that their decision to vaccinate their child was positively influenced by their primary care provider.

“Health care providers have a positive influence on parents to vaccinate their children, including parents who believe that vaccinations are unsafe,” the researchers wrote. “Physicians, nurses and other health care professionals should increase their efforts to build honest and respectful relationships with parents, especially when parents express concerns about vaccine safety or have misconceptions about the benefits and risks of vaccinations.”

Alexander said that moving forward, pediatricians should make the case for vaccination more emotional and less technical.

“There has been a belief by a lot of people in the past that if we just give parents enough data and education, then they will make the right decision,” he said. “I would contend that the decision to immunize is 90% in their heart and 10% in their head. What we should capitalize on as immunizers is parents’ desire to protect their children.”

The public health community has been through 15 years of crescendo and de-crescendo in vaccine hesitancy, vaccine refusal and concern, Marshall said.

“However, I do believe the tide has turned. I do not hear so much about boycotting vaccines or flat-out vaccine refusal anymore,” he said. “For the parents who have concerns about vaccines, it is our job to make the argument that nothing is 100% safe, but absolutely beyond a doubt, vaccination trumps getting the disease the vaccine protects against.” – by Jennifer R. Southall

Disclosures: Alexander, Diasio, Marshall, Sawyer and Wolf report no relevant financial disclosures.

Click here to read the POINTCOUNTER, "Are HPV vaccination rates in the pediatric office reflective of the quality of adolescent care that an office gives?"