This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.

Heading Off Misinformation and Disinformation

So, in order to kind of try to head off this misinformation and disinformation, we think about things called pre bunking, inoculation, right? Just like our vaccinations, we're priming individuals to recognize when there's misinformation or disinformation. Just like that vaccine primes the immune system to respond to an actual virus or infection.

So, we're teaching people about how fake news works before they're exposed. And teaching media savvy, right? Not just science knowledge about studies and the population and, you know, all those things that are important, but also to be media savvy, you know, where is this coming from? Is this a closed website? Is there a marketplace icon on that website which shows that they are selling something, right? They've got an ulterior motive to sell their product. And are the posts - do they have no personal post? Are there no comments on them, right? Are they chat bots, etc?

So, really important that we talk about, you know what they might see going forward and how to respond to that.

Prebunking Tactics

So, things like, you know, addressing fear amplification, some post scaring parents or fake experts, right? You see someone posting, they look like an expert, but then when you dive a little deeper, they have no education, no background in pediatrics or immunization, the false balance where it looks like it's - it's split 50/50 about a vaccine, when really the overwhelming evidence is on one side of giving that vaccination. And then conspiracy framing where post make you feel like it's a hidden agenda that there's - the health care system is out to make money from you and harm you and - and all of that. We've got another agenda. Letting them know, watch out for these. You're going to see these, watch out for these.

Effective Vaccine Recommendations: Presumptive Recommendations

So, let's talk about some effective vaccine recommendations. These presumptive things. When Patsy mentioned earlier when they come to the office, how many vaccines would you like today? The thing we want to say to them is, "Your child is due for hep B, whatever else you're going to give today. What questions do you have? And then let's give those vaccines."

I always make sure I ask the parents for questions so that you want that strong, clear, presumptive recommendation. And there's the examples down there. Your child needs whatever vaccines, instead of are you interested? One of my students said, "Are you interested?" I almost had a heart attack. So, I said, "No, you don't say that." Well, we're giving. I said, well, you don't say it that way. You - you tell them what they are due for, and then you have a discussion about why. Okay.

RULE: Motivational Interviewing Principles

So, motivational interviewing. Motivational interviewing is our only evidence-based paradigm for talking about vaccines. But it takes a long time. Usually, when I use motivational interviewing, that's when I booked a half an hour appointment to do nothing but talk about vaccines.

So, we are going to review this, but we have a couple of what I call down and dirty quick ways to talk about vaccines that you can get a lot of points across without spending this large chunk of time, because time is money in the private offices. Let me tell you, I've heard from some of my private pediatrician provider colleagues about how it's so expensive to spend this amount of time that it takes to do this vaccine counseling.

So, you know, these are the four principles, you know, resist the righting reflex. You want to make sure that you that you listen to the vaccine-hesitant parent. You don't want to commit to the status quo. You want to understand what their motivations are. Listen - listen - listen. If you get nothing from this program, please remember, listen to what the parents say. And then address their questions. And that's very empowering for people to even to just, oh, she wants to hear what I have to say. Okay, let's move on to the next one.

The AIMS Approach

All right. So, this is the AIMS approach. This is another paradigm that you can use. Announce the vaccination. Inquire what the concerns are. Mirror the patient's response. Like I hear that you are concerned about the what - how many vaccines the child is getting. And that's - if that's what the parents - and make sure that that's what their - their question is. Secure their trust and mutual respect. Again, this is done on a one-to-one basis. It's not done with videos.

The CASE Model

This is one of my favorites is the CASE model. It was developed by Alison Singer who's the president and the CEO of the Autism Science Foundation. Alison has  an autistic brother, and a child with autism. So, she came up with this. The C is for corroborate. Acknowledge what you both want. Yes. We both want your child to grow up safe and healthy. About me. How did you get to this point? I took courses. I asked a lot of questions. I learned how to evaluate the best scientific methods. And then you might - I always mention here all my family members. My mother had polio. My sister almost - two sisters almost died from measles. We had another family member with the HPV related cancer. My grandmother died in 1955 from cervical cancer. Share those stories.

Then talk about the science. And like we've - we've given you tons and tons of information about the science and then explain and advise. That's where you come up with your presumptive recommendation. Have I answered all your questions that the parent says, "Yes." Then you say, "Okay, let's give those vaccines today and get that immune system kicked into gear to protect your child."

The 4 A's

This is the four A's. This is the voices for vaccines paradigm. Another very simple, easy-to-use paradigm. Ask what are the questions? What is the specific questions the person has? Acknowledge, recognizing that person already is bringing a lot of knowledge. Hey, looks to me like you've done a lot of research, and I'm so proud of you for looking these things up. And then you want to affirm. Reassure that the patient, it's okay to have questions. We encourage questions and then answer ask permission again. That's so empowering for you to say, do I have your permission to tell you what I know about the vaccines? So, get permission to share the facts that you have.

Responding to Arguments Against Immunization With Facts and Evidence in a Respectful Manner

And then you always want to be respectful. Responding to arguments against immunization with facts and evidence in that respect - in a respectful manner. So use paradigms that don't belittle. And I think we've showed you a few. Ask parents make sure you listen to their concerns, ask permission for addressing those concerns and keep that conversation going even if they are - if they're - they're pushing back today. Like Patsy said before, there's always tomorrow. Okay.

Effective Communication With Parents

 Messages that we want to be sharing with folks is, this is what I choose for my child. You want parents to choose those things. We don't force anybody to vaccinate. We always ask for permission. And that's the message we want to get across.

I tell them what vaccines my children have had. My grandchildren are all fully vaccinated. My kids have said to me, we wouldn't send our children to school without being vaccinated. We're not just worried about our kids. Suppose there was a teacher in the classroom who had cancer and -and that teacher got sick because I didn't vaccinate my child. I've heard that message from my own children. We're partners. We're all doing this together to keep your children healthy. And I can provide you with evidence to make this decision easier for you.

And now I'm going to turn it back to Patsy.

Case 4

Patricia Stinchfield: Very good. So, we're going to close out with three quick cases and then get to your questions. This one is a mother of an infant son, is unsure whether her baby needs all the recommended vaccines. She'd like to know if she could skip some vaccines or if the vaccine schedule could be modified.

Reasons to Adhere to AAP Recommended Vaccine Schedule

And, you know, we really don't want to skip vaccines. We definitely don't want to spread them out because we don't need to. Your immune system is ready and waiting. Whether it's the pain that baby's brain sees one vaccine in four pokes the exact same. There's really no reason. You increase the risk when you delay vaccines. You increase the risk of getting the disease. You increase the risk of the number of times you're getting in the car and driving to the clinic of other potential harms happening to your family.

So, we do know that alternate vaccine schedules are not evidence-based. And so we do recommend that people always follow that AAP schedule.

Responding to Requests to Alter Vaccine Schedule

And then, responding to those requests to - to alter the schedule. We - I - there was a question here I'll address on this. My clinic did not turn families away because they refused to vaccinate. We tried to see them on a Friday afternoon where there weren't newborns or other families. I feel like if we turn them away, where are they going to go? They're going to go to someone who's not going to vaccinate them. And I don't work for the parent. I work for the child. And that child needs to be protected. And their greatest chance of getting protected is if they stay with me.

And so, I do think that altering the vaccine schedule is not a good idea. But if it's - if they're going to get vaccinated and they're just, you know, hell-bent on spreading them out, then if we can get it done, and that's what it's going to take, then I will do that. It does cause errors and some other safety problems. So, I do try to talk people out of doing that.

Case 5

Okay. Case five that's over to you Jen.

Jennifer Walsh: Thank you. I think another thing that I like to tell my family is, you know, if they're - if they're going to spread out the vaccines, know that we don't know what's going to happen tomorrow, right? We don't know if that vaccine is going to be available tomorrow. We don't know, you know, what may happen. There may be a supply chain issue. There may be, you know, something that happens. So, you know, do today what you - you're not guaranteed to do tomorrow, right?

So, case five parents of a four year old come in. They've read that vaccines are harmful and have harmful side effects. They'd like to stop all vaccines for their daughter.

Vaccines Are Held to a Higher Safety Standard

I think it's important to remind parents about vaccination and the higher safety standard, right? They have a higher safety standard than all other medical interventions and medications because they're given to healthy individuals. The tolerance is lower for adverse effects for products that treat the sick versus vaccinations are given to healthy individuals.

The serious adverse effects are very rare, but side effects are universal for other medications that we utilize. And they're tested in tens of thousands of individuals. And the risk is much, significantly, lower than the risk of complications for that vaccine-preventable illness.

Responding to Safety Concerns

And the other thing, too, that I point out to parents is when they delay the vaccine, I learned this from Dr. Bill Atkinson, who Patsy and I, he was mentor to Patsy and me at the CDC many years ago, Bill used to say that vaccine doesn't work as long as it stays in the jar. It only works when you get it in the children. So, the longer you take to get the vaccine into your children, the longer your child goes unprotected.

Okay, let's talk about this last and final case. A healthy 16-year-old boy is making plans to go to college. Before he and his mother - both he and his mother, are hesitant about the meningococcal vaccines. They question why a healthy young person would need to be vaccinated. After all, isn't this a disease that mostly affects babies? Well, let's clear that up for them.

Specific Age Groups Are at Increased Risk

Okay. Well, the thing that we want to tell them is, because of behaviors at this age group, you see that high bar in the beginning, that's babies. But then, when you look over here to the adolescents, that bar kicks up again. And I have to say, Dr. Michael Osterholm came up with the best way to describe why we want to vaccinate these adolescents is because they share spit, and that, you know - that's their big risk factor. They share water bottles. They - they share vapes. They share chewing gum. I saw kids in a - in a mall once sharing a wad of chewing gum. And that's why we want to protect them. Okay.

Counseling Strategies

Okay, so what are the counseling? We want to tell them how serious it is. I mean, Patsy and I have both met mothers who've lost their children to invasive meningococcal disease before we had a vaccine. I mean, I have two very dear friends who run a - they're the executive directors of the National Associa… National Society for Meningitis Prevention. Both of those lovely ladies lost their girls to - to meningitis two years before we had a vaccine.

So now, my goal is to make sure no other mother has to go through that again. I share that story. Adolescents and young adults are at risk. And I told you because Dr. Osterholm says they share spit. Exposure to that bacterium is very difficult to avoid. The disease is very unpredictable. But honestly, from my experience, and I'm sure Patsy will tell you too, she's seen this. I have never seen a child fully recovered from meningitis. There's always something left over.

And routine vaccination is the only way that we can protect these children. And if you look, we don't see meningitis caused by the four strains A, C, Y, and W-135 in this population because we vaccinate them all. So, it makes perfect sense that that's why we want to get the meningitis B into them.

Additional Resources for Discussing Vaccines

All right. So, you've heard us talk about a lot of these associations and societies in between here. AAP is a terrific resource. NAPNAP has great stuff. CHOP I cannot say enough stuff about Dr. Paul Offit's Vaccine Information Center at the Children's Hospital of Philadelphia. It's one of my go to places. And CHOP also has parents packs. Dr. Offit does these terrific talks at least twice a year.

And then, Patsy, with the National Foundation for Infectious Diseases voices for vaccines. We told you about them because we used their paradigm for how to speak to parents. We also want to mention immunize.org. I'm a nurse consultant for them. Anything you want to know about the mechanics of giving vaccines, what the diseases look like, immunize.org is the great place to go. And Dr. Kelly Moore does these great little two-minute vignettes to talk about different issues with vaccines.

We also want to mention vaccinate your family because they also have stories and they're - it's right organized all down if you're pregnant, if you've got young children, older children, there's a tab that you can click for any things on there.

And of course, Patsy and I are real - real proponents of parents - grandparents for vaccine because that's where you're going to hear the stories from those of us who have seen and - and experienced these different diseases.

Q&A

And let me turn this back over to our panel for a Q&A session.

Patricia Stinchfield: Well, thanks so much, Karen. I'm going to just combine a couple of questions here that were asking about health care workers and vaccination. And there isn't like an overall rule for clinics and hospitals. I think the Joint Commission does have some things around looking at your immunization rates and, or processes at your hospital, but it's up to the institution, it's up to your individual clinic. It's up to your health care system.

At Children's Minnesota, where I worked when I worked there, it was a clear rule that vaccinated individuals was a condition of employment. And in fact, when we posted our jobs, it said, if you want to work at Children's Hospital, please do. We, you know, expect that everyone who comes to work here are all fully immunized.

And the reason is, is we could not protect our premature babies, our kids with cancer, our rheumatology kids who were on severe immunosuppressive drugs in the cafeteria, in the hallway, in the parking lot from some, you know, maybe a facilities guy who says, well, I don't take care of patients, but you go in their room and you change their lights. And there was just too many ways to slice and dice it.

So, it was just a clear rule. And that helped us so much in times where we had measles in the hospital, pertussis, RSV, you know, those kinds of things where we could just say, you know - or measles and pertussis, at least these people are all vaccinated. I think that should be a standard of care in your - your clinics as well.

Mary Koslap-Petraco: Yeah. I see a question here from somebody who's been practicing for 50 years. And this person is concerned because she has young RN colleagues who are vaccine-hesitant. Well, my answer to that is that these young RN are subjected to the same online garbage that everybody else is. So, we have to kill them with kindness as well and ask them, can - do I have your permission? Ask me specifically what question - what questions do you have specifically? And ask them if you can answer them.  I've had a few like that, and when I approached it in that method, I have gotten them to change their minds.

And then also telling them about that the other thing too, is they're not afraid of the diseases because they haven't seen them. So, relating to them, what the - what happens when we don't vaccinate is so very important as well.

Jennifer Walsh: And I wanted to add about why does the US recommend a hepatitis B vaccine at birth, when other countries may recommend waiting until the child's older. We have a vastly different health care system and public health system than many of those countries that may have the ability to test and see every pregnant individual repeatedly through pregnancy. We don't always have that. We know that maternal health outcomes are dire in our country, and many individuals do not get care.

So, when we started vaccinating with hepatitis B, we would do it for the moms that were testing positive. And then we realized that we were missing so many infants. And so, that's where universal vaccination came from. Maybe one day we'll have a different health care system and public health system. But right now, this is the best evidence that we have to protect our individuals.

Mary Koslap-Petraco: And in those countries that don't give the vaccines, like for RSV and some of the other - the other vaccine preventable diseases, those countries see those diseases. But again, like you mentioned, Jen, they have a better health care system. So, they're really right there to take care of these children. Whereas in this country, the child could go without health care if they're not, you know - if they don't have it.

So that - that affects this whole issue as well. It's the same thing with why we give everybody HPV vaccine. We started out just vaccinating the girls, and that didn't do it, and we didn't - and then we found out when we started vaccinating folks, it was preventing head and neck cancer, not just in women, but in boys as well. And that was another thing that the CDC came up with. And they said, well, we only want you to give one dose of HPV vaccine. There is some data that shows one dose prevents cervical cancer, but there's no data that says only one dose is going to prevent head and neck cancer.

Patricia Stinchfield: Right. How long do you keep encouraging parents like how many visits or when do you give up? I never give up. I don't think we should ever give up. I think that is our job.

And I think, Mary Beth, on your example about HPV, let's take that, for example, you would start with the presumptive conversations. Maybe you added a half an hour to do the motivational interviewing. They're still uncertain about HPV, their kids, you know, 10, 11. And so as they are getting older, you'd say, I see that we're still not vaccinated against HPV. And what I'd like to do today is show you some photos. Is that okay? They're difficult to look at, they’re genital warts. And it's - it's not only just cancer that we're trying to prevent, of course, that's our main goal, but having genital warts is a really difficult thing. And this is not something that your child's going to want. Can I show them to you? As the child gets older, can I show them to the child? The child's going to go home and say, mom, I want that vaccine.

And so, you just keep trying different approaches, different tactics, and know that what drives you is the severity of the disease. And if you are a young provider and you don't have experience with this, you know, look at some movies about polio, about - about measles, look back at some textbooks on the - the photos of this. Really try to get a sense of the emotional and physical and public health impact of these diseases, so that you've got some sound points that you can share with families as well.

Jennifer Walsh: And Mary also said, please discuss transmission of hepatitis B from other family members that it's definitely a route of transmission. So, it's not just only maternal to the baby, but it is also family members. It's day-care settings. It's schools. It's camps, it's all different ways of transmission. Any type of secretion that has blood in it could potentially transmit that hepatitis B virus.

Mary Koslap-Petraco: There's a question here.

Mary Koslap-Petraco: Some people have been tested and do not appear to have protective antibody levels despite knowing they've been vaccinated. Now, that's an especially good question about hepatitis B because we know that vaccine has immune memory.

Now, I was vaccinated, God knows how much long ago, probably if you tested me now, my antibody levels would be pretty low. But if I stuck my finger with a dirty needle and was exposed to hepatitis B, my antibody levels would go back up again. I mean, our protocol is to give one more dose if you're fully vaccinated, but that's what happens. And again, it's like Patsy keeps talking about this amazing immune system that we have that remembers all of these things to protect us. And I think that that's the message we have to get across also.

But it's also like - with - with the live virus vaccines, they're the ones that offer longer term protection like measles, mumps and rubella and chickenpox. But things like whooping cough, that's why we have to revaccinate and give boosters, because over time that immunity does wane. And that's why we give pregnant people a dose of Tdap with every pregnancy, because we know that that vaccine is the most effective within the first two years that it's given. So, we want to protect that baby.

We lost two babies in New Orleans from whooping cough. We lost two children from Hib disease. Hib. Oh my God. I don't ever want to see epiglottitis again in my whole life. And I'm so afraid I'm going to see it again. So, you know, it's - you have to know which vaccines you're talking about to be able to tell the parents whether or not they got to be revaccinated, or like something like hepatitis B, you're still immune, even though it doesn't look like you're immune. Because if you're exposed, your wonderful immune system is going to kick in and protect you.