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Pressure Points in Pediatric Vaccines: The Critical Role of Advanced Practice Professionals for Lasting Progress in Vaccine-Preventable Diseases

Dr. Mary Beth Koslap-Petraco (Stony Brook University School of Nursing): Well, welcome everyone. We're really thrilled to be here. And I'm just going to open the program by reading off this first section for you. So messaging does matter.

And if you've heard any of us speak before, you know that this is one of our big issues. So we're going to be talking about following the science behind effective vaccine recommendations.

So Jen, can you take over from here and tell us a little bit about this topic?

Dr. Jennifer Walsh (George Washington University): Absolutely. Thank you, Mary Beth. As Mary Beth mentioned, we - we all know the evidence base, right? But now we are going to examine the evidence-based messaging that's so important to connect with our families about vaccination hesitancy.

The Vaccine Hesitancy Continuum

So, as we know, the vaccine hesitancy continuum really is a spectrum. Where we have the most impact is this large area of vaccine hesitancy, right? Those that are - except some may be confused, maybe refuse some, etc. This is where we can have the most impact and the most fluctuation occurs in this area as well.

Factors Contributing to Vaccine Hesitancy

So two things to address first. We have both misinformation as well as disinformation when it comes to contributing to vaccine hesitancy. So misinformation - we see both on social media. But misinformation is incorrect information that's spread inadvertently, accidentally, right? We think about maybe a study came out and it has a correlation. And it's - it's pushed forward as if that's the cause or, you know, we think about, you know, vaccines that were made from aborted fetal tissue or mercury and vaccines.

That is misinformation, false, inaccurate, and spread inadvertently, versus the disinformation, which is the deliberate spreading of false information, intentionally trying to deceive the public and discredit vaccines. And we think about this with COVID, with information that it was implanting microchips or with the measles, mumps and rubella vaccine, that it was a cause of autism.

How to Speak to Vaccine-Hesitant People

All right. So how to speak to vaccine-hesitant people? So first of all, we need to make sure that we are taking a presumptive approach, where we're framing vaccination as the expected standard of care and we're assuming parents and patients are ready to vaccinate, right? So this might be something like your child is due for the hepatitis B vaccine, versus would you like to talk about vaccines that are available today?

So having that presumptive lead-in is very, very essential. And it's what's recommended by both the CDC, AAP, NAPNAP, etc., because we know that that's the most impactful for uptake of vaccination.

Some other key things. Kill them with kindness. We want to listen to their concerns. We want to listen in order to - to understand, not listening to respond. Remembering that convincing may sound coercive, right? We have - we have some history in the medical - in the medical arena, in the healthcare arena of unethical type of issues, right?

We've got Tuskegee Syphilis study and the Willowbrook hepatitis studies. Many people still remember that, right? So we want to make sure that we are partnering with them as - as experts on pediatric health and vaccination and - and creating that partnership. If we alienate them, we've lost them. Right?

We want to work on that malleable middle, that vaccine hesitance, encourage questions if they're hesitant. And again, don't - don't give up if they refuse. It's a marathon, not a sprint. They may refuse today, but maybe in a couple of weeks we can get - we can get them vaccinated.

And then leading by examples. Behaviors really can change attitudes much faster than attitudes change behaviors. And stare - share stories of vaccines that you've received or why you've received it. My grandfather's two-year-old brother died of influenza, and ever since I learned that as a young child growing up, I always wanted a flu vaccine. So share those stories of how vaccination or non-vaccination can impact your family - has impacted your family or your patients.

Attention Economy

And so it's important to examine that attention economy, and we can really see this with social media, right? Attention is limited. It's very valuable. We know it can be captured, studied, traded for profit. We think about all of those influencers that are making multimillions or billions each year by grabbing that attention. And remembering that even a short pause on that information on social media or even a dislike is feeding into that algorithm.

So we know - we do know from psychology that people accept information that supports their pre-existing beliefs. And people also ignore information that contradicts their beliefs. And we can see this when we - you know, our family members, what news station maybe they watch, right, when we think about what's supporting our beliefs.

Attention Economy: Shaping Vaccine Beliefs

So we know that the attention economy is - is very influencer - influential in shaping those vaccine beliefs. We're going to talk a little bit more about this later in the webinar. But the research shows that there's only about 12 people that originated most of those vaccine hoaxes. They're well known to reacher - researchers and social networks alike, including, you know, anti-vaccine activists, alternative health entrepreneurs, and even physicians.

Some can often run multiple accounts promoting natural health. Most of them have some type of selling something, you know, being supplements or books, charging exorbitant the speaker fees. But what we know above all else is that 90% of our parents do vaccinate their children. However, this disinformation and misinformation may really drown out some of those majority voices.

Attention Economy: Strategies to Support Parents and Caregivers

So when we're thinking about the eco - attention economy, we know that it rewards emotional high click content. We've all seen those posts. It really opens the door to overwhelm individuals, creates false narratives that stick with them, right, tugging on their emotions.

Provider strategies, validate the overwhelm. Ask them what they've seen on social media. What platforms they've gotten information from? Ask what they've read online.

Poll 3

So we've got a quick poll. Two truths and a myth: Spot the myth!

1. So immunity conferred by vaccination is generally longer lasting than immunity conferred by natural infection;
2. Hepatitis B is recommended with shared decision-making - hepatitis B vaccine, pardon me; and
3. Appealing to rational facts is one of the most powerful approaches to guide decision-making.

All right. So we'll go ahead and close that. All right. So kind of mixed. What we know is - the truth is that immunity conferred by vaccination is generally longer lasting than that with natural infection. And appealing to rational facts is one of the most powerful approaches.

The myth is that hepatitis B vaccine is recommended with dis - shared decision-making. We're going to dive into that and some of the controversy related to that a little bit later in the webinar.

Why Behavioral Economics Matter for Vaccination

Now, we know that rational decision-making is what we all claim to base our behaviors on, right? But why do people deviate from that? It's a lot of different factors, emotions, social influences, cognitive biases. All of these can impact why individuals may choose to not vaccinate even when the rational evidence is - is in front of them.

Behavioral Economics Principles

So we're going to talk about some behavioral economic principles that influence decision-making and touch on each of these.

What is essential is that we remember empathy, which - with every single interaction we have that we - the vast majority of our families want to do what's best for their child, but they - but they're - they've been confused, right? There's a lot of information out there and they've been confused. And often that misinformation, disinformation is louder than our evidence-based information.

Present Bias

So present bias is one of those behavioral principles. So that's when immediate cost and benefits outweigh those occurring in the future. So now feels bigger than later. We think about this, you know, I'm - I'm nervous to get this vaccine because then my child may have a fever tomorrow. I may miss work, I may miss the family reunion, etc. That present bias. So overcoming that is making the benefits feel immediate and real. So saying things like protection begins the moment the vaccine does and then risk of vaccine - pardon me, risk of preventable disease complications far outweighs any adverse - any low adverse side effects - adverse effects or side effects.

Status Quo Bias

Then we also have the status quo bias. And this is when individuals choose to do what they've done, always done, or choose to do nothing if they have not done that, right? Those of us that have been getting flu vaccines for decades will most likely continue to do that, right, versus those that have not will most likely continue to do that.

So overcome the status quo bias by making vaccine acceptance the default or the new - neutral choice, right, with that presumptive approach and opt out type of clauses. So these are the vaccines that your child is due today. These are the mandatory school vaccines making - opting out more challenging than accepting the vaccines. And then prescheduled appointments that are routinely done. And we have that in pediatrics, right, set up along with our well-child visits.

Availability Bias

And then we have the availability bias. This is when individuals estimate the probability based on examples or stories, right? What they've heard, what they've seen. We all know that individuals are more likely to vaccinate when they've got a personal - personal family friend or neighbor, or they've read something that's concerning, right? And a teenager dies of influenza in our county makes you much more likely to go and get vaccinated and get your kids vaccinated.

So to overcome that availability bias, using short, relatable stories to anchor that risk, right? So up to one in five children are susceptible to measles due to the age group - age gap or due to the gap in vaccination under the age of three. And measles is one of the most contagious diseases known to man. One in five children who contract measles are hospitalized. These short little sound bites about some of the risk and redefining that.

Loss Aversion

And then loss aversion. Again, when people prioritize preventing loss over that equal or greater gain. So again, what if I get an adverse effect - adverse effect? What if a side effect is significant? What if I'm not able to go to work for a few days, versus that equal or greater gain of vaccinating. So talking about, you know, don't leave them unprotected, give them that vaccination so they can walk out safer than they came into the office.

Social Forces

And then social forces. We cannot underestimate this peer pressure. We know it impacts behavior. And social media can really act as an echo chamber and - and feed you more and more and more to - to scare you, right? To make you question. So normalizing vaccination as that community standard. This is what the community does. Most families in our practice vaccinate today. We are a family that vaccinates, etc..

Ensuring Consistent Messaging

And then we think about ensuring consistent messages, right? Getting everyone on the same page, but also involving the entire staff and ensuring consistent communication. So it would be things like your - we follow at this practice, we follow the AAP vaccination schedule that your schedulers that are booking the appointments, if anyone asks about vaccinations, they say we follow the AAP vaccination schedule, versus, “Well, when you come in, you can talk to your provider and you can decide which vaccines you want to give your child, right?” We need to make sure that the entire practice is on the same page and that we're having that unified voice.

Also establishing a social presence, right? Putting out that information, utilizing behavioral nudges. It's time for flu vaccine, flu bye boo[?]. Those type of little wording that is so important.

And then using positive framing. I can tell that you are a mother that really cares about the health and keeping your child safe, right? Positively framing that, emphasizing the benefits over potential risk. And then knowing when to use narratives. Know when statistics are not going to reach that individual, but narratives are much more impactful.

Connect With People’s Values

We also want to connect with people's values, right? Those that value well, you know, that value the medical system or authority, you know, the - the doctors, the nurse practitioners, the nurses that have dedicated their lives to patient care, saying well qualified doctors and nurse - nurses endorse vaccination.

Also thinking about liberty, appealing to that value of liberty. Take personal control of your family's health. Vaccination can help your child live to be free - live a free and help - happy and healthy life.

And then values of purity. Boost your child's natural defenses against vaccines. Keep your child pure of infection. Vaccinate. These are all evidence-based messages that can really change behavior.

Micromessages That Stick

And then more micromessages that stick. Short little informations, short little sentences. Most families choose to vaccinate at this visit. You're in good company. Vaccines are what parents trust. Don't leave them unprotected. Strong kids, strong futures.

Case 1

And now…

Patricia Stinchfield (National Foundation for Infectious Diseases): Well, great.

Dr. Walsh: Turn it - turn it over to my colleague.

Patricia Stinchfield: Great, Jen. Thank you so much. That was so good. I really love those last list of soundbites. Really important. Well, I'm going to take us into a case. This is a real life case from my practice back in 2017. But it really started back in - in the 2008 or so. And this is related to the Somali community in Minneapolis. You may have heard of this. It ended up on the front page of the Washington Post.

But there have been a longstanding vaccine hesitancy in this community. It is still a problem today. But in 2008, there were some concerns about the - actually started even earlier with - with concerns about Somali kids having a greater rate of autism. And it was raised initially by the Minneapolis public schools. And there was in fact a very good researcher, University of Minnesota, who looked at and said, “You know, these kids who are coming into kindergarten have never been diagnosed and never had early intervention. And they - they do have autism or they do have some - some delayed learning and they live in, in a household that is in a world that's bilingual.”

They maybe went for care and said, you know, had the questions we all ask is your child looking at you? Are they - are they babbling? Are they starting to make sounds? Are they starting to talk? And in - in the Somali community, your child is a gift from Allah. And so your child is your child. And - and whatever your child is - is - is not a problem to be sought for specialists or to be given treatment or interventions or whatever. That is just how your child is.

And so many families just would say, “My child is fine.” And so they were noticing this in the schools that the kids were coming far, far, far too late and un - without early intervention.

So in - in 2017, a measles outbreak occurred in this same community in the Somali Muslim community in Minnesota. We ended up with that case lasting about four, five months, 75 confirmed cases. Almost all of them were in preschoolers. The median age was 21 months. And the main problem was that they just had not had their MMR vaccine.

Vaccination Rates Fell Following the Rise of Misinformation

And so how and when did this happen? You can see that Somali children initially back in the early 2000s, they - when they come to the United States, primarily Minnesota, a very welcoming state, largest Somali community outside of Somalia, they're highly vaccinated. In fact, look at that higher vaccinated than the other children in Hennepin County, which is the county Minneapolis is in.

But you can see that degradation over time. Slowly, there was this conversation about, you know, the schools raising some concerns. And then Andrew Wakefield got wind of that and came here twice and started talking in - interestingly to the imams, the head of the religious communities and in private closed door gun bearing person at the door, no one else, no public health allowed to come in, no clinicians allowed. Just told the imams, do not vaccinate your children. The vaccines - MMR vaccine causes autism.

And so then you could see this plummet over time, dropping from higher than the community of right around 90% all the way down to 42%. And remember, with measles, we need to have vaccine coverage at 95% or greater to prevent outbreaks.

Impact of Measles

So this is what happens. These are why we don't let a child just walk out the door and say, “Okay, well, I'll see you next time.” We have to make sure we keep an image like this in our mind of why we keep having these hard conversations. This is one of the children from one of our measles outbreaks at Children's Minnesota on a ventilator for 15 days. And they were - he was part of a family who travelled to Somalia and back, and all of the family got their travel vaccines except this kiddo.

And the mom - he was nine months old, and the mom said, “You know, he just fell asleep. I just don't want to wake him up. He'll do okay. We'll get it when we get back.” And the travel provider really pushed hard, but the mom said no. Got infected. Travelled back to Minnesota, infected on the plane, infectious to the community, and then ended up coming straight to the hospital very sick.

And as I took this picture, she asked me to take this picture and she said, “You know, get all of those pumps in the machines and the wires. Look at how sick he is. You have to show this to people so they know this is what measles can do.” And she asked me to take this picture and gave me permission to share it with - with you.

And she said, “You know, that fateful decision I made, I didn't want to wake him up that day. And now I stand in his bed praying that all I want him to do is wake up.”

So keep this story in mind when you're tired. It's Friday at 16:00 and you don't want to have one more dang immunization conversation. This is what we're - we're trying to prevent.

Working With the Somali Community: Culturally Competent Care

So what did we do? Well, we worked directly with the Somali community. We - the message is important. The messenger is also important, not only just that they're coming from that the same community, but they are well informed. And so this partnership of clinicians and some - and imams and spiritual leaders and community leaders in the Somali community was really important. So I pulled together a dinner of Somali clinicians from all of the hospitals in the Twin Cities area.

We had a listening dinner. We had meetings with imams. We had our Somali employee resource group was super helpful. We did a Ramadan Eid meeting and dinner and we're welcomed in and - and did panels with both Somali leaders and clinicians like me who were measles or vaccine experts, and we had some autism experts.

So it’s - it took a lot of intervention to get that vac - that vaccine coverage up. But some of the parents would say things like, “I didn't know that MM and R. When you said MMR, I didn't know that the M was measles.” That's where the listening comes from, really listening. If I had known it was measles, my sister died of measles in Somalia. I would not have skipped it.

And so even simple things like making sure when we not - don't just whip over MMR, that they know what that stands for. So it was a difficult time. And the rates are not where they need to be at 95% in Hennepin County, but we learned a lot from this.

Case 2

And then case two, I'm going to turn it over to you, Jen.

Dr. Walsh: Thank you. I - I love that reminder to list out the - the illnesses that we're hoping to prevent with vaccination. Really excellent.

So case. We've got a first-time mother, identifies as a crunchy mom, prioritizes natural living, low-tox choices, homemade remedies. Follows natural health influencers on Instagram and TikTok. And she says to you, “I'm not antivax. I just want to make the most informed, natural choice. But every time I look something up, my feed fills with stories of moms whose kids had reactions.”

I'm wondering what Patsy and Mary Beth think about this.

Dr. Koslap-Petraco: Well, first of all, I would ask the mom. I would thank her for sharing that information with me. And then I would ask her specifically, what were the concerns with the parents following the vaccines? And then I would address those one by one. Because the other thing that I always advise folks to do too, is make sure you tell the parent the baby can get a fever, the baby can be fussy. The things that we - the baby can have a sore red leg.

And what I say to parents is when we see these things, what that says to me is your child's immune system is kicking into high gear to protect them. So I think it's how - how we approach those - those - those issues. I saw someone here in one of the questions say lack of education, but it's how we ask those questions.

And the other thing too is - and Patsy and I are old enough to remember all of these diseases. Parents have no recall of the diseases years ago. And then that one - and that was just so important when Patsy talked about that mom who - she says, “I didn't know M was for measles, I would have - because my sister was so sick or my sister died in Somalia from measles.” You know, spelling those words out for them, asking them, “What other questions do you have?” Asking for permission to answer those questions.

Patsy, what do you have to think about that?

Patricia Stinchfield: Yeah, I - I think - I - I like talking to these parents when they are talking about natural because it gives me the opportunity to talk about my favorite thing, which is the power of the human immune system. And I'll talk a little bit more about that later. But in this case, I would say I hear you about really wanting to serve your family healthy food and, you know, with as little extra things as possible. And I think that's the same thing we're doing with vaccines.

There's nothing more natural than your body's ability to see, recognize a germ or an antigen and then build an antibody, store it away in an amazing file cabinet that circulates constantly looking for - if it ever sees a germ that looks just like this, the measles virus or the pertussis bacteria that file cabinets going to open up that - that those antibodies are like an army and they will come out and protect your child.

It is this beautiful, wonderful, natural way that we are made. And the vaccines are simply the easiest way to give your body a little hint of what those serious diseases are so that you're well protected in the event that you ever come in contact with that disease. So it's about as natural as anything I can think of.

Dr. Walsh: Absolutely. I agree with all of that. I think also reframing the risk for the - for the mother is important as well in addition to all of these questions. You know, asking her, you know, what - what those reactions were. And as you mentioned, that's - that's our immune system doing what it's designed to do. That's the healthiest way we can protect your child versus coming in contact with that potentially debilitating, life-changing, potentially fatal disease that has consequences.

Vaccines Are the Safest Way to Acquire Immunity

So reminding them that vaccine prevent - preventable illnesses can cause serious complications, right? We all know that as providers, but - but they may not know that or may not remember that about the risk of pneumonia with many of our vaccine preventable. Heart muscle damage, liver failure, encephalitis with measles. Right? That scares anyone when they think about encephalitis, right?

And then things like deafness or even testicular cancer with mumps infection. And as Patsy mentioned, vaccines train the immune system to defend against those infectious organisms. So they don't - they don't risk those illnesses, those long-term complications, those death - deaths.

And I love this statistic. I'm a big statistics person that almost 30 years. And we've estimated that vaccines have prevented 508 million illnesses and 1.1 million premature deaths. Like that's just astounding and really shows what a success vaccination is in our world.

Strategies to Overcome Vaccine Fears

So as we go back to that mom that was concerned about toxic - tox - toxicity and wanting to - to feed healthy foods and whatnot. Some of the behavioral economics that are at play are social norms, right? What she's reading in her online groups. And then that attention algorithm reinforcement. Once she clicks on one of those post about a reaction after a vaccine, she's going to get hundreds more, right? You just see that – that vicious cycle that just revs up.

So the goals of our interaction are to reduce fear, re-anchor risk and to shift the norm. So affin - affirming identity, as we mentioned. You are obviously a - a mother who really values the health and safety for your child. I can tell your baby girl is so lucky to have you as a mother.

And then making positive norms. This is what most parents do. This is what 90% of parents do. And then reframe that risk.

Case 3

And now I will turn it over. I believe Mary Beth, is this you?

Dr. Koslap-Petraco: Yes, that's me.

Dr. Walsh: Alright.

Dr. Koslap-Petraco: Okay. I just had a couple of comments, though, on that last case that we did. You know, sharing family stories as well. My own sister's immune system was permanently damaged by – by measles. And those very personal stories like Patsy has talked about that - that one mom who talked about her sister not knowing it was measles. Those are the things that I have found in so many of us have - have found, which is also backed up by the data are really what makes a difference.

Sometimes just going over numbers and what can happen. But when you can connect those personal stories, Patsy's got those wonderful stories about those terrific Somali families and how terrible they felt because they just didn't know. Somebody mentioned - and one of the questions was lack of education, the cause of vaccination refusal.

I think that's a combination of things. I think it's they don't know about the diseases because vaccines have been a victim of their own successes. And they also have not had the opportunity for people to explain to them what the vaccines do and how they affect the immune system. That's why Patsy's story is about how the immune system is such a strong and wonderful thing and couldn't be more natural, are such important stories to - to share with parents and with the children themselves?

Okay, we’re going to told -

Patricia Stinchfield: Mary Beth, I would add - can I add to that - the person's question about our - is lack of education an issue? I'm going to really agree with that strongly, because I think we are lacking in science education from early - early childhood all the way through high school and into to college years and beyond that, having a good appreciation for science, a good understanding of how the human immune system and the human body works.

Like I was shocked in clinics sometimes where children didn't even know what, you know, their body did or - or what all these holes in their bodies were for. And, you know, our job is to teach them early and have them appreciate science and be able to be good science consumers.

So if you read Andrew Wakefield's paper in “n of 12”, you know, that is - you should just not even read one sentence on any study that has a such a small n. So I do think science illiteracy is a problem in America and I think that is feeding into some of our anti-vaccine stuff that we're dealing with.

Dr. Koslap-Petraco: Great points, Patsy. Those were terrific points. I could not agree with you more. Okay, let's talk about case three.

During a routine office visit for her two-year-old child, a mom states she's confused about the vaccine recommendations from CDC. And I think this is going to address some of the - one - one or two of the questions we have in the queue here. She's expecting her second child and believes that the new CDC recommendations mean that her future child will now get fewer shots, which she is very happy about. She's concerned about the recommendations about the hepatitis B vaccine changing and doesn't know who to trust. “Oh wow, is that a can of worms?”

So Jen, you want to open us up with that - discussion with that?

Dr. Walsh: It is a can of worms, Mary Beth, for sure. It is confusing. I mean, for decades, I would recommend that parents look to the CDC as a reputable source. And that has changed in the past couple of years. I think it's important to know why the recommendations changed and that it was not based on any science that the science overwhelmingly supports universal vaccination.

And - and so that's why the American Academy of Pediatrics, NAPNAP, etc., all of the medical and nursing organizations support that universal recommendation because that's where the evidence lives about how impactful that vaccinate - that hepatitis B vaccine has been.

Changing CDC Recommendations

Dr. Koslap-Petraco: Yeah, I think that's - I think those are very important points. And what we're saying is, regardless of what ACIP is saying, that's not evidence. And we also - what I say to parents too, is there has been a stay or those implement - recommendations are not to be put in place because they were not scientifically based. It's in the court system now.

And again, like Patsy says, we need to do that science education. Patsy, do you want to add a word or two before we move forward?

Patricia Stinchfield: No, I just think that we should all keep our eye on - on the AAP lawsuit and what's happening there. And unfortunately, the people that work at the CDC are kind of held hostage right now. The CDC recommendations are, you know, really not evidence-based. And so we are leaning on NAPNAP and the American Academy of Pediatrics schedule, which is evidence-based and actually has been being published by AAP for 90 years as opposed to CDC, which has been since the last 60 years.

Dr. Koslap-Petraco: Right. Well, it's - when I started my career - and I'm the public health nurse. And when I started my career in public health, we didn't have a harmonized schedule. AAP had their schedule and ACIP had their own. And then they used science to come together so that everybody was going to be on the same page.

So I'm just going to move on with this. The shared decision-making is now recommended for vaccines, including the birth dose. We are not following that. That is not the science. And that's what I tell parents all the time.

It's very confusing to providers. I'm not sure whether the providers have even heard that the - the - the cases has been found to hold all of those recommendations from ACIP. But the person - again, educating yourself, talking to your provider. And then later on in the talk, we have some really good evidence-based websites for you to use as well. So let's move on to the next slide.

Risks of Not Vaccinating Against Hep B

So what are the risks of not vaccinating against hepatitis B? I can tell you a story about that right here in Suffolk County where I live. And when - when we were taking the thimerosal out of the vaccine, we were holding off on the hospital birth doses. And this is going back many, many years.

And I remember a physician saying to me, “Oh, I'm not worried about that because I'm so sure all of my mothers are hepatitis B negative.” And I said, “But you can't guarantee that.” “Oh, yes, I'm so sure.”

Well, guess what? It was one of the moms from his practice that that baby went on to be hepatitis B positive because we weren't vaccinating the baby. That physician came to me later and he says, “I should have listened to you.” So we can never guarantee that the mom is going to be hepatitis B free because she's continuing to have sex. She might be exposed to blood somewhere. We cannot do that.

90% of infants who contract hepatitis B go on to develop chronic hep B. And people with chronic hep B are at a higher risk of liver failure, cirrhosis and hepatocellular carcinoma, and about 25% of untreated patients with hepatitis B are going to die from liver cancer. This - I sell this vaccine to parents as this is an anti-cancer vaccine. So I think we're going to move on now. And Patsy, you're going to take over from here.

Strategies to Overcome Vaccine Confusion

Patricia Stinchfield: Yeah. I'll take it from here. All right. So what do we do? Strategies to overcome our vaccine confusion. The really and truly it is listening to their concerns first. And as Jen said, listen to understand, not listen to convince, but really stop and listen.

So ask those questions, probing questions, open-ended questions and make sure they know your expertise as a healthcare provider and your personal experience too. I have two children. They are fully vaccinated. My daughter was one of the first ones to get a COVID vaccine at her pregnancy right after it became available. I - I knew the science and I trusted the science with what we had at the time.

So vaccinating your child will really prevent long-term consequences of hep B, of COVID, of other things. So it's important to just share and listen.

Myths and Mixed Messages: Championing the Benefits and Safety of Pediatric Vaccines

So I'm going to take us into some myths and mixed messages here on champ - championing the benefits and safety of pediatric vaccines.

Poll 4

So this is our poll. Two truths and a myth. So A - spot the myth here.

1. Increases in the number of vaccines means children today are exposed to more antigens than in years past;
2. Studies have definitely shown that MMR vaccines do not increase the risk of autism; and
3. The third one is the majority of US children are vaccinated according to the recommended schedule.

Which two are true and which one is a myth? All right, let's see what people think. Okay, a little bit of a spread there. But the increased number of antigens is what we're going to talk about in a minute here. So let's just go on, then we'll close that out.

Myth: “It’s Too Many Shots At Once”

Because this is a myth, it's too many shots all at once.

A Child’s Immune System Has the Capacity to Respond to Multiple Vaccines at Once

And I want to just talk about this for a second. As I said, I - I worked in immunology at children's for 35 years, ID and immunology. And I love talking to six year olds about how their immune system works. Believe it or not, you can do that, you know, have them imagine the fighter guys and their immune system, the army that's there always in the background ready to fight disease. It's amazing. They get all excited about it.

Dr. Koslap-Petraco: Pac-Man chewing up things.

Patricia Stinchfield: That's right. Back when Pac-Man was good. I - that was common. I did use that one for sure. We are dating ourselves there. But - so I think one of the things is that vaccines use up a tiny, tiny part of our immune system, less than 0.1%. It does not overwhelm the immune system, whether you give one, two, four, five injections at the same visit. Your immune system is like bring it on, I can handle it.

Those newly licensed vaccines are tested alone, and in combination with other vaccines, are tested in animals first, then a small group of people, then a larger group of people, then the general population. So even when vaccines come out, they are not new. They've been around for a long, long time and being studied intensely.

So I think it's important people know that vaccines do not weaken your immune system. They do not overwhelm your immune system. They protect children from vaccine preventable diseases. And like our - our colleague and friend, Paul Offit describes the immune system like an ocean. So if you're talking to a parent about MMR, measles, mumps, rubella, that's three antigens or three germs we're going to try to build up antibodies, the good guys, the fighter guys.

And if you imagine your child's immune system like that ocean, and you want to put in a measles, a mumps and a rubella antigen, it's like three spits in the ocean. It absolutely will not overwhelm it. So - and combination vaccines, whether you give them individually or together, your immune system sees them as individual antigen. It's like a lock and key. It goes in as an antigen. It gets into that lock, turns it becomes that antibody and fits one-to-one. So you're not going to have any changes whether it's in combination or individually.

Current Pediatric Vaccine Schedule Has More Vaccines but Fewer Antigens

And I think to that first question, that was actually a myth. When you look back at – at the - it's - I think it's about antigens versus pokes, alright? So as we say in Minnesota, pokes. In - in 1980, there was fewer - there were fewer pokes for sure. But the number of antigens or those biological proteins that your immune system is recognizing and working with was about 3,000. Whereas in 2021, you can see the number of pokes has increased quite a bit, but the number of antigens has dropped substantially - thank you science - down to around 320.

So the protein chemistry, the purification, the recombination, the realizing, we don't need necessarily whole cell. For some things we can use acellular vaccines. There's lots of reasons why we have more numbers of vaccines today, but less antigens. And I think it's really important. What is this? You know, this number 72 kind of got in the - the misinformation disinformation crew. And that's been going around with terrible looking memes of 72 needles poking in a child. That's getting at people's fear. And I do think it's getting at one of our biggest problems with immunization is pain. So whether it's a baby or an adolescent, you've got to have your distraction that's going on at the time of injection.

So if it's an infant, they should be breastfeeding. If it's a toddler, they should be having bubbles or feathers that they're blowing. If it's a school age kid, let them look at an iPad. If it's a teenager, put on their headphones and rock out. Whatever it is that they have some distraction to that - that pain, rub with a nice cold alcohol wipe really vigorously and then your - their brain picks up pressure and not pain.

Myth: “Vaccines Might Cause Autism”

All right. So Mary Beth, I'm going to turn it over to you, this next myth.

Dr. Koslap-Petraco: Okay. Thanks very much, Patsy. That was really a terrific explanation for that.

MMR Vaccine Does Not Cause Autism

Okay. So MMR vaccine does not cause autism. So there - this is going to be a bit of a history lesson for you. In 1998, this was the original theory - and I'm old enough to remember this. I was a relatively new nurse practitioner at this point, and I was beside myself. And the first thing I did was - and like Patsy mentioned before, eight people. And these are the things that we have to talk to folks about.

Eight children. It wasn't approved by any of scientific board. He just went and did this and he was - and also always talk about the money. He was being paid money to do this by a group of parents whose children had autism and he was also looking to discredit the currently licensed MMR vaccine because he was going to make his own.

So then in 2004, 10 out of 13 co-authors pulled their names from the - the research study and The Lancet pub - published a retraction. But look how many years. And, you know, like our good friend Dr. Paul Offit says, you cannot unring a bell. In 2010, Wakefield lost his license. I do not even ever refer to him as doctor. He doesn't deserve the title. So he can't practice medicine in England or practice here. And he was reprimanded by the British Medical Board.

So they did this large-scale study in Denmark, and they had over 65,000 - 650,000 children, including those with - with risk factors for autism and siblings with autism. And they looked at their data. So what they saw was that the MMR vaccine did not increase the autism link and didn't trigger autism in those who are susceptible. Even they weren't even associated with an increased risk of autism.

And now we have more studies coming out that say that there's a genetic link to autism and these developmental delays in children. We've also expanded the - the definition of autism. I'm a dinosaur. When I went to diploma school, children who had the - what we consider the classical features of autism, the stemmers, non-verbal, self-harm. That number of children with - with the classical autism has not increased. We've expanded the diagnosis and those are some of the things we need to say as well.

So we have repeated controlled population-based studies that show no link between autism and the vaccine.

Vaccines Do Not Cause Autism

And like I said, I'm going to point to my own kids. My children got that old whole cell DTP. And the kind of thinking that you use behind that is that parents are saying, “Well, that caused my child to get autism or developmental delay.” What I'm going to say is, jeepers, that old whole cell autism must have made my kids really smart because one has a PhD in quantum mechanics, and the other one is a computer engineer who helps me make slides, by the way. So that must have been that old whole cell vaccine that did that. But that's the kind of thinking that we're - that these folks are using and we need to explain that.

So the Institute of Medicine has repeatedly reported there's no correlation between the thime - the thimerosal content and vaccines and in autism. And the cause of autism isn't known yet, but we're certainly getting more and more data that show that there is a genetic link there. We need to spend our money on other things, like to find those links to help these children develop more - more - more interventions that can help these children.

And the epidemiological studies in different parts of the world have shown the same thing. There's no relationship between vaccines and autism. And the Vaccine Safety Datalink also did not show a relationship between the vaccines and autism or any other neurodevelopmental disorders.

So the take-home message here is there's a temporal association between things is not the same as causation. We start seeing features of autism right around when we're giving vaccines. But quite frankly, every child I have ever cared for with autism, I saw things when they were infants. I have it in my own family. Lack of eye contact, social smiles, those kinds of things show up very early and it never failed me in all my years of practice, that when that child went on to have autism, I saw features at one to two months of age.

Patricia Stinchfield: And Mary Beth, can I add? I think, you know, we - when I said the CDC is - is been changed. They did take down a statement on the CDC website.

Dr. Koslap-Petraco: On the banking, Patsy.

Patricia Stinchfield: Yes. That said, you know, vaccines do not cause autism and listed all those great studies that you just mentioned. And because the Secretary of Health and Human Services has a personal mission to, you know, vilify vaccines, he made the CDC staff take that down. So it's no longer on their website, which is why, I mean, we - we are all encouraging people to use the NAPNAP website, use AAP for their vaccine guidance.

[00:56:02]

Myth: “My Child Doesn’t Need This Vaccine Because This Disease Is Mostly Gone”

Dr. Koslap-Petraco: Thank you so much for remembering to bring that in, Patsy. Now with that, I'm going to turn it back over to Jen for the next myth.

Dr. Walsh: Thank you, Mary Beth. Excellent. Excellent comments by my colleagues. So another myth is my children doesn't need this vaccine because this disease is mostly gone. So because vaccination has been so unbelievably successful in reducing and almost eliminating many, many of these disease - diseases, it's made it difficult for the public to appreciate that. Right?

The public health has basically, with vaccination, created an invi - indivi - invisible, pardon me - invisible shield against disease. So we are needing to look at how can we make the invisible visible for our families.

Perspective Is Needed

So perspective is really needed. Again, overwhelming number of parents, over 90% vaccinate their kids and the majority of American children, over 70% follow that American Academy of Pediatrics vaccination schedule.

However, we do know that that number of completely unvaccinated is rising. So in 2001, it was at 0.3%, rose to 0.9%. And then again in 2017, 1.3%. You might say this doesn't look that impressive. This - this is, you know, very close, right? But when you think about the fact that out of 3.9 million children, this number went from about 10,000 to over 50,000 American children un - completely unvaccinated. Right?

And you think about how significant that number is when it comes to, you know, not just lowering or increasing their risk, but increasing everyone's risk when we think about herd - herd immunity.

Dr. Koslap-Petraco: I think we also need to point out, Jen, that this can be down - I mean, we - we always go down to the communities, and this can be community - I mean, look at Patsy's community. It was the Somali community. It wasn't the entire state. You know, in my - here in New York, it's the - it's - we have our - our - our Hasidic religious community who've been scared to death about the vaccines. So that's where these things start.

So when we look at these numbers, they're very misleading because if you go and look in those - I mean, you saw the numbers that Patsy brought up about how low the numbers were in her community. And I could show you the same thing in New York with the - how low the numbers are in some of our religious communities.

Patricia Stinchfield: I think that's a great point. And it does tend to - you know, it's the Mennonites in Texas, the Hasidic Jews in New York, the Somali Muslims. And it is not the religion. That is - that is just what brings like-minded people together. They meet often. They - they're in close proximity. They spend a lot of time. So if a disease gets into a closed community with low immunization rates, then it spreads within that community. So it's not what their religion is because there aren't - aren't major religions that have any - any disagreement with vaccines. It's that like-minded –

Dr. Koslap-Petraco: Like no religion as opposed to vaccinations. None of them.

Patricia Stinchfield: Yeah, absolutely.

Dr. Walsh: Yeah. So important to remember that about the different pockets around, right, where these numbers - you know, we're concerned about in general, the entire US, but even more so with those pockets of higher percentages of unvaccinated individuals. Excellent point to remember.

Cumulative Measles Cases Reported in the United States by Yr

So our cumulative measles report, we can see how this has been rising over time, particularly in the past couple of years, we've seen a huge spike. And - and, you know, we - we do have to think about, you know, HHS and CDC and some of the information that came with that and how that impacted these numbers as well, as well as the misinformation and disinformation that we have going on right now.

But look at 2026. We are on record for an absolutely devastating year for measles in the US and - and getting close every year to losing that - that - my mind is blanking.

Dr. Koslap-Petraco: Measles free status.

Dr. Walsh: Thank you. Losing that measles free status. Thank you very much.

Patricia Stinchfield: Elimination.

Dr. Koslap-Petraco: Yes.

Dr. Walsh: Elimination. Yes. Measles free elim - measles elimination status. Thank you.

Percentage of Reported Measles Cases in the US by Vaccination Status

So - and then we look at the, you know, percentage of reported measles cases in the US by vaccination status. And - and, you know, again, being a statistics kind of nerd, it's overwhelming about how - how at risk those unvaccinated or unknown are and how that is what's feeding the issue that we're having.

And now I believe we're turning it over to Mary Beth.

Reemergence of Previously Eliminated Diseases

Dr. Koslap-Petraco: I have Patsy. Patsy is next.

Dr. Walsh: Patsy. I'm sorry. Patsy.

Dr. Koslap-Petraco: No worries. That's alright. I'm here. Don't laugh. I need to see the - I'm making you all laugh because I need to see the slide number. So here I am with my - I give you a good laugh with my magnifying glass.

Dr. Walsh: Good for you.

Patricia Stinchfield: So let's just talk about a little bit about this elimination of diseases here. So there was a simulation model built with data from the US Census Bureau and the National Center for Health predicting that declining vaccination could lead to millions of preventable infections. Well, we're there, people. You know, three deaths from measles in the last year and a half. Two in children, one in an unvaccinated adult who never sought care.

Pertussis deaths across the country are increasing in young infants. And so we are seeing these diseases re-emerge and that parents and caregivers may not have that firsthand experience of the diseases, but that is where a wonderful new organization has started grandparentsforvaccines.org. You can go there and you can join. You don't have to be a grandparent, but basically, you know, people like Mary Beth and I that remember having chicken pox, having influenza severely. Having - I had hepatitis A. And so these stories are really important that mix of the stories and the - the data that tells us that vaccines are safe and effective.

We have to make sure that we're reaching people in lots of different ways, but we've got to get our vaccine rates up and - and keep them up every day. There's a new cohort born that we need to keep protecting. So vaccination is never over. We will have to maintain that herd immunity and protect the people who can't be vaccinated, including infants too young for the vaccines, the immunocompromised people on chemotherapy, pregnant women.

Debunking Vaccine Myths

So I think there's a lot to debunking vaccine myths. There - there is misinformation about vaccines that has proliferated on social media and “Oh, if we could just get rid of the bots.” There is so much misinformation and disinformation that is spread by - by not even humans. They're - they're bots.

And so we've got this misinformation online that we have got to be louder than. And going back to Jen's point, about 90% of parents vaccinate on schedule. And, you know, most kids who enter kindergarten are fully vaccinated. They may have spread out their vaccines, but they're fully vaccinated. We need that group of parents to be louder.

And so if you've got parents in your clinics that want to participate, we're going to give you a slide in the end that there's some organizations that they can join and - and get their voices out there. But making sure that we're using evidence-based strategies and trying to really get at those biases in misperceptions and misinformation.

Building Trust Is Important

And so building trust is really the - the most important thing. And trust is earned. Trust doesn't happen in one visit. Trust doesn't happen because of the initials behind your name. Trust happens because you have spent time with them. And I always tell people, clinicians, to think of that Venn diagram. The one circle is you. The other circle is the parent. What is the part that overlaps? And really, it's mostly safety. You want their child to be safe. They want their child to be safe. It's just that you are approaching it differently.

You want them to not get vaccine preventable diseases. They want to not have anything harmful from vaccines happening. And so that's the part that you - you work on together.

But we know that we can be those trusted voices. We are the influencers. And I think the best thing is to never give up. Like if they say, “I'm not doing that chickenpox shot. Chickenpox, it's such a cute name. It can't be a bad disease.” You know, it is a terrible disease. It can get into people's brains. I've seen patients that have lost limbs because of staph infection.

And so, yes, it's a very serious disease. It's one I saw a lot in my early career. And if you don't want to vaccinate today, let's talk about it next time. Here's some things between now and then to read. But the conversation should continue.

And then they're like, “Wow, she really cares.” You know, she really is saying the same thing every time that trust gets built up over time, your credibility, your knowledge, your concern, your compassion, your listening. And nurses, as we know, are the most trusted of all professions. And we need to continue to - to use our power in those conversations.

Building Trust With Parents and Caregivers

So building trust with parents and caregivers. Again, establishing that safe relationship, understanding where they're coming from. We might just assume they think that MMR causes autism and that's not on their mind at all. They might have had a relative who had a severe reaction. And is this going to happen - happen to my cousin? Is it going to happen to me and my kids?

Offer that information to build their knowledge. And again, it's sort of the statistics and the stories combination that's really important and trying to clarify and accept where they're coming from and give those relationships time.

Who and How to Debunk Vaccine Misinformation: Key Takeaways

So how - who and how to debunk those vaccine? The key takeaways are, again, use your trusted providers in healthcare, making sure that we're having facts alongside both what the long-term effects, what side effects may be, and what to expect.

I think one of the most important things that we, as clinicians, can do is say, “I'm giving you your MMR today. I want you to take out your calendar, and in about 10 to 14 days, put a little dot on there for rash, rash, rash, rash and write it down. Because this is a live vaccine. It may cause a little mini version of measles that gives you a rash. It's not contagious. It doesn't - it's not going to be harmful. But they may develop a fever and they even can have a rash with it.”

And so when that happens, it means the child's immune system has recognized this vaccine. It's seen it. It's building antibodies. And that's exactly what we expect. We expect some fever because that's your immune system's first response. We expect some redness. That's the inflammation and swelling. That's the immune system doing its job. So when those things happen, they aren't afraid. They aren't like, “Oh, I'm never going to vaccinate again.” They're like, “Oh, here's what they told me was going to happen. They think you're genius.”

So making sure that you describe in detail what they should expect for the next day. They're going to be sleepier. They're not going to eat as much. And so when those things happen, it's not that something bad happened, it's that their immune system is really working hard for their child. That's a good thing.

So that effectiveness and debunking can fade over time. So as I said, you mean you're never done with immunizations by age. You're never done with them by visit. Every visit is a vaccine visit. Those conversations, if they come in with a broken thumb, you fix their thumb and you look at their immunization record and you make sure that they get caught up. So continual efforts are always required.

Heading Off Misinformation and Disinformation

So I'm going to hand it off now. Back to you, Jen.

Dr. Walsh: Thank you. And I love how you mentioned about the grandparents for vaccination. Another thing that just sticks in my mind is that the vast majority of providers seeing children have not seen these vaccines. They learned about them, right? They took a test on them, but they've never seen them in real life. So thinking about that is concerning, right? Absolutely concerning. So thank you so much, Patsy.

So in order to kind of try to head off this misinformation and disinformation, we think about things called prebunking, 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 - are the posts, do they have no personal posts? 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 amplica - amplifi - amplification. I'm having trouble speaking. Some posts 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 - you know, the healthcare 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

And yes - and again, we already talked about presumptive…

Dr. Koslap-Petraco: Thanks, Jen. I'm going to take over from here.

Dr. Walsh: Thank you.

Dr. Koslap-Petraco: Thank you. Okay, 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? Your - the - the thing we want to say to them is your child is due for hep B - hep - 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.”

RULE: Motivational Interviewing Principles

Okay, 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 - 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 - 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 counselling. So, you know, these are the four - 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 the - 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 sister and an - excuse me, an autistic brother and an autistic - 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 - the - the best scientific methods. And - and then you might - I always mention here are my family members. My mother had polio. My sister - almost two sisters almost died from measles.

We had another family member with 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 advice. That's where you come up with your presumptive recommendation. “Have I answered all your questions?” If 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 are 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 - in a respectful manner. I'm just checking my slide number here. Okay, 65.

Okay. All right. 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.

Effective Communication With Parents

Okay. So this is -

Patricia Stinchfield: This is you.

Dr. Koslap-Petraco: Yes, this is my last one. Okay. 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. I mean, I hear all the time people are forced to vaccine. We don't force anybody to vaccinate. We always ask for permission. And that's the message we want to get across.

I would recommend this vaccine to - I tell them what vaccines my children have had. My grandchildren are all fully vaccinated. They - my - my – my - 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 and 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, who - 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.

Dr. 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 in the higher safety standard, right? They have a higher safety standard than all other medical interventions and medications because they're given to healthy child - 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, 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 - I'm sorry.

Dr. Koslap-Petraco: The new case.

Dr. Walsh: Last mine, my last one.

Dr. Koslap-Petraco: Yes.

Dr. Walsh: So being prepared to - you know, as - as Mary Beth said, may I offer my thoughts on this? Use presumptive messaging. Your child's due for the measles, mumps, rubella vaccination today and address concerns and offer reassurance. If this was my child, I would give the vaccination. I did give the vaccination to my child. My grandchildren got the vaccination.

And now I believe I'm turning it over to Mary Beth.

Case 6

Dr. Koslap-Petraco: That's me. Yes.

Dr. Walsh: There you go.

Dr. Koslap-Petraco: There we go. Okay. 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. Okay. Now, isn't that move?

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 you're in a wad of chewing gum. And that's why we want to protect them.

Counseling Strategies

Okay. Okay, so what are the counselling? 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 Association - National Society for Meningitis Prevention.

Both of those lovely ladies lost their girls to vaccine - to meningitis two years before we had a vaccine. So now my - 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 now we are - we have come to our additional resources where 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 PACK. 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 a 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 their - 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 Vaccines because that's where you're going to hear the stories from those of us who have seen and - and experienced these - these different diseases.

And I know that those resources are going to be sent - included in your final set of slides that you get.

Now, I think I'm going to turn it back to Karen, who's going to go over the post-test questions.

Posttest 1

Karen Straube-West: Thank you. We'll revisit the questions that I asked you at the beginning. Using motivational interviewing, what is the best way to respond to a parent who wants to reduce or space out their child's vaccines, owing to concerns that children today are exposed to too many vaccines?

1. Ask questions to ensure you fully understand their concerns;
2. Tell them that deviating from the vaccine schedule is not recommended;
3. Reassure them with information on vaccine safety;
4. Inform them of the risks of not vaccinating their child today.

Please go ahead and answer. Okay, let's close that one out, please.

Posttest 1: Rationale

And the majority of you seem to have gotten that one correct.

Posttest 2

Let's move on to second one. A young mother and her newborn are in for their first office visit. You can already tell that they like to get a lot of their information from social media. Using a prebunking technique, you should proactively:

1. Show her trusted social media sources;
2. Provide vaccine information statements prior to the vaccine - vaccination visit;
3. Counteract any social media misinformation by explaining the benefits and safety of vaccines at every encounter;
4. Explain that online debates imply that experts are split 50/50, when in fact the evidence is overwhelmingly on one side.

Please answer. Okay, let's close that one out.

Posttest 2: Rationale

And the correct answer actually was D, you should - you should explain to them that - that sometimes what they're seeing out there isn't quite - isn't quite the reality that sometimes - sometimes so-called experts out there are not really experts.

Posttest 3

Our final question. After completing this activity, I now have effective strategies to counter vaccine information.

1. Strongly disagree;
2. Disagree;
3. Neither agree nor disagree;
4. Agree;
5. Strongly agree.

Give you a minute to answer. Okay, let's close that one out. And thankfully, most of you agree or strongly agree.

Questions and Answer Session

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 we're asking about healthcare 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 healthcare 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 the 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, for 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.

Dr. 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's 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.

Dr. 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 is older? We have a vastly different healthcare 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 healthcare system and public health system. But right now this is the best evidence that we have to protect our individuals.

Dr. 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 healthcare system. So they're really right there to take care of these children, whereas in this country, the child could go without healthcare 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 getting - it was preventing can - head and neck cancer, not just in women, but in boys as well. And that was another thing that the CDC - this - this fake ACIP came up with. And they said, “Well, we don't - we - 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. And I'm going to tag - tag on to that with Sumaya’s[?] question about how long do you keep encouraging parents, like how many visits or when do you give up? I - I never give up.

Dr. Koslap-Petraco: I don't either.

Patricia Stinchfield: 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 - 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 their 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.

Dr. 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 daycare 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.

Patricia Stinchfield: And then…

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

Patricia Stinchfield: From Karen. I think that's the last one that we haven't addressed. Do you want to take that one?

Dr. Koslap-Petraco: Yes. Of Karen Weiss?

Patricia Stinchfield: Yes.

Dr. Koslap-Petraco: Yes. The parents appear to have - 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 get 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 - 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.