The Public Health Problem of Vaccine

Hesitancy

Walter A. Orenstein, M.D.

Professor of Medicine, Pediatrics, Epidemiology, and Global Health
Associate Director, Emory Vaccine Center
Director, Emory Vaccine Policy and Development

Vaccine Boot Camp

National Press Foundation
August 3, 2020
No conflicts to disclose
 Summary of Costs

Societal Costs
  Direct costs
(Direct + Indirect)

Costs averted by
immunization program 20,267 76,360
(Million $)

Immunization program 6,740 7,532

costs (Million $)

Net Present Value (net

saving) (Million $) 13,527 68,828

Benefit-cost ratio 3.0 10.1

3
Zhou F., et al Pediatrics, published online 3/3/14; DOI: 10_1542/peds_2013-0698
 Community Protection

A B
Poor Vaccination Coverage Good Vaccination Coverage
Transmitting Case

= Susceptible

= Vaccinated/Protected

= Infected

Outbreak Infection Contained

Orenstein WA, Ahmed R. Simply put:  Vaccination saves lives.  PNAS 2017;114(16):4031-4033
 Society Obligations to Individuals and Individual Obligations
to Society with Regard to Vaccines
• Minimizing barriers to vaccine access (e.g. cost)
• Ongoing Monitoring of Safety and Effectiveness
• Change Recommendations for Vaccines as Appropriate
• Mandates for Immunization
• Vaccine Injury Compensation Program
 Defining Vaccine Hesitancy
SAGE Working Group

Vaccine hesitancy refers to delay in acceptance or

refusal of vaccines despite availability of vaccine
services. Vaccine hesitancy is complex and context
specific, varying across time, place and vaccines. It is
influenced by factors such as complacency,
convenience, and confidence

From: Daniel Salmon, Johns Hopkins University

6
http://www.who.int/immunization/sage/meetings/2013/april/1_Model_analyze_driversofvaccineConfidence_22_March.pdf
 Does Hesitancy Matter given Most Parents Vaccinate their
Children?

• Need to uniformly maintain extremely high coverage, perhaps

indefinitely
• Refusal associated with diseases and outbreaks
– Measles
– Pertussis
– Haemophilus influenzae type b
– Varicella
– Pneumococcal

Modified from: Daniel Salmon, Johns Hopkins University

CDC, MMWR, 2008; Glanz, Arch Pediatr Adolesc Med, 2010; Glanz, Vaccine, 2011; Parker, JID, 2010; Salmon, JAMA, 1999; 7
Glanz, Pediatrics, 2009; Omer, AJE, 2008; Omer, JAMA, 2006; Atwell, Pediatrics, 2013
 Continuum of Vaccine Hesitancy between Full
Acceptance & Outright Refusal of all Vaccines
Vaccine Hesitancy and Demand Continuum

From: Daniel Salmon, Johns Hopkins University 8

http://www.who.int/immunization/sage/meetings/2013/april/1_Model_analyze_driversofvaccineConfidence_22_March.pdf
DPT VACCINE Roulette -1982 1982
https://www.youtube.com/watch?v=VDkeQKAnas8

Started the modern anti-vaccine movement in the US

Led to formation of Dissatisfied Parents Together (DPT), now

the National Vaccine Information Center (NVIC)

Massive increase in law suits against DPT manufacturers

Vaccine shortages

National Vaccine Injury Compensation Program

Increased resources for vaccine safety monitoringUUSS

.com/watchhttps://www.youtube?v=VDkeQKAnas8
 2019 National Survey about Parental Hesitancy Regarding
Vaccines
• Nationally representative sample of families with children
• Hesitancy prevalence was 6.1% for routinely recommended
childhood vaccines and 25.8% for influenza
• 12% strongly and 27% somewhat agreed they had concerns about
serious side effects of childhood and influenza vaccines
• Thus, almost 1 in 15 US parents are hesitant about routine vaccines
and >1 in 4 were hesitant about influenza

• From Kempe A et al. Pediatrics 2020;146(1):e20193852

Pre-licensure activities form the foundation of vaccine safety *

11
*source: https://www.cdc.gov/vaccines/parents/infographics/journey-of-child-vaccine.html Provided by Frank DeStefano, Director, Vaccine Safety Office, CDC
Vaccine Safety Continues to be Monitored

12
 Causes of Vaccine Hesitance
• Vaccines as victims of their own success
• Coincidental temporal relationships
• How people make decisions
• Other contemporary factors

Modified from: Daniel Salmon, Johns Hopkins University

13
Number and Vaccination Status of Measles Cases,
by Age-Group – U.S., January–May 2019*

Provided by Manisha Patel, CDC

 Other Contemporary Issues Impacting
Vaccine Safety
• Trust in corporations and government low
• Fear of ‘pharmaceutical industrial complex’
• Growing interest in natural products - “green our vaccines”
• Changing medical model
– Shared decision making > paternalism
– More patients in less time
• The role of the media
• Internet

From: Daniel Salmon, Johns Hopkins University

 77% of Parents Reported Vaccine Concerns

• 38% - painful to receive so many shots

• 36% - too many vaccines at one doctors visit
• 34% - too many vaccines if first two years of life
• 32% - may cause fevers
• 30% - may cause learning disabilities, such as autism
• 26% - ingredients unsafe
• 17% - not tested enough for safety
• 16% - may cause chronic disease
• 11% - unlikely to get diseases
• 9% - not enough vaccine supply
• 8% - diseases not serious
From: Daniel Salmon, Johns Hopkins University
Kennedy A, et al. Health Affairs 2011; 30(6): 1151–1159
Clusters of underimmunization, Kaiser Permanente Northern California,
2010–2012

Underimmunization was defined as not having received all recommended vaccines by 36 months of age. Colored areas
represent the counties included in the study, with darker colors representing higher rates of underimmunization.
County underimmunization rates: crimson, 16.29%–17.93%; light red, 13.65%–16.28%; dark orange, 13.54%–13.64%;
light orange, 10.02%–13.53%; light yellow, 9.24%–10.01%
Lieu TA et al, Pediatrics, 2015; 135(2):280-289
 Summary
• Vaccine Hesitancy is a problem
• Vaccines are victims of their own success
• Trust in government and industry can be low
• People lack an understanding of how to determine whether an
adverse event following vaccination is causally related or
coincidentally related
• The media have an important role in addressing this problem
Extra Slides
 How Providers Initiate Conversation May Matter
• Observational study of provider-parent vaccine discussions,
oversampled vaccine hesitant parents
• Majority of providers (74%) used Presumptive Format (well, we have
to do some shots) rather than Participatory Format (what do you
want to do about shots)
• Participatory format more common with vaccine hesitant parents
(41% vs. 11%)
• Resistance to following recommendations higher with participatory
rather than presumptive format

From: Daniel Salmon, Johns Hopkins University

21
Opel DJ, et al. Pediatrics, 2013; 132(6):1-10
 The line indicates the predicted
number of annual measles cases in
US children (ages 2-11 years) and the
associated public sector costs across
a range of prevalences for vaccine
hesitancy (i.e., nonmedical
exemptions).

The shaded area provides the 90%

prediction interval.

The vertical dashed line indicates

the predicted annual measles cases in
children for present day (2%
prevalence of vaccine hesitancy).

The datapoints represent the

observed number of annual
cases in recent years.

We estimated the consequence of

increasing national nonmedical
exemptions from 2%to 10%
prevalence, and the removal of
nonmedical exemptions (0%
prevalence).

Lo NC, Hotez PJ. JAMA Pediatr. 2017;171(9):887-892. doi:10.1001/jamapediatrics.2017.1695

Published online July 24, 2017.
 Effective Messages in Vaccine Promotion
• Randomized trial among 1759 parents testing interventions
• 5 Groups
1. Control: No Intervention
2. Correction: CDC information explaining lack of evidence that MMR
causes autism
3. Risks: VIS text information @ dangers of disease prevented by MMR
4. Narrative: Dramatic narrative about infant who almost died from
measles (CDC fact sheet)
5. Images: Pictures of children with MMR disease

From: Daniel Salmon, Johns Hopkins University

23
Nyhan B, et al. Pediatrics, 2014; 133:e835–e842
 Intention to Give MMR Vaccine
Least Favorable Toward Vaccines

Proportion Very Likely to Vaccinate

P<0.05

Study Arm
From: Daniel Salmon, Johns Hopkins University 24
Adapted from Nyhan B, et al. Pediatrics, 2014; 133:e835–e842
 Take Home Messages
• Pro-Vaccine messages don’t always work
• Corrective information
– decreased misconceptions that MMR vaccine causes autism
– reduced intent to vaccinate with MMR vaccine among parents with least
favorable vaccine attitudes
• Messages @ risk of measles through narrative and images increased
misperceptions about MMR vaccine
• No interventions increased intent to vaccinate among parents with
least favorable vaccine attitudes

From: Daniel Salmon, Johns Hopkins University

25
Nyhan B, et al. Pediatrics, 2014; 133:e835–e842
 Healthcare Providers
• Widely considered best source for vaccine
information
• Often lack the tools to effectively communicate with
parents
• Reimbursement for vaccine risk communication
inadequate

From: Daniel Salmon, Johns Hopkins University

26
Nyhan B, et al. Pediatrics, 2014; 133:e835–e842
How School Immunization Requirements Work in US

• All State Laws (not Federal)

• Wide Variability in Implementation
– Antigens required
– Process for adding antigens or making changes
– Applicable Populations
– Who provides documentation

From: Daniel Salmon, Johns Hopkins University

Nyhan B, et al. Pediatrics, 2014; 133:e835–e842

 Ease of Exemption Classification Standards

b
States were classified as easy if they required at least 1 standard from the easy list and nothing from the medium or difficult list.
c
States were classified as medium if they required at least 2 standards from the medium list in addition to things from the easy list.
These states did not have requirements from the difficult list.
d
States were classified as difficult if they required at least 3 standards from the difficult list in addition to anything from the medium or
easy list.
Omer SB, et al. Open Forum Infectious Diseases, 2018, DOI: 10.1093/ofid/ofx244
State Non-Medical Exemption Rates
by Ease of Obtaining Them
2011-2012 and 2013-2015 

Overall Average
Difficult 1.84%
Medium 1.77%
Easy 2.97%


Omer SB, et al. Open Forum Infectious Diseases, 2018, DOI: 10.1093/ofid/ofx244
 Summary
• Most vaccine-preventable diseases are person-to-person spread
• Getting vaccinated provides both individual and community
protection
• Failure to get vaccinated leads to personal and community risk
• Vaccines may be victims of their own success
• Public may not understand how we determine whether an
adverse event that follows vaccination is causal or coincidental
• More research is needed on how best to overcome vaccine
hesitancy
THANK YOU
extras
 DTP Vaccine Litigation 1988

• Largely assumed to
be result of the
enactment of the
National Vaccine
Injury Compensation
Program of October
1988
• The decrease in
lawsuits has been
associated with
stabilization in the
prices for DPT

Orenstein WA, AJDC 1990; 144:517

From: Daniel Salmon, Johns Hopkins University
34
Lieu TA et al, Pediatrics, 2015; 135(2):280-289
 Parental Vaccine Attitudes, Beliefs & Practices

• 376 parents of children 1-6 years from 2010 HealthStyles Panel

Survey
• 83% vaccinated with recommended schedule
• 11% planned to vaccinate with recommended schedule
• 5% vaccinated with some but not all vaccines
• 2% intended to not vaccinate at all

From: Daniel Salmon, Johns Hopkins University

Kennedy A, et al. Health Affairs 2011; 30(6): 1151–1159

 How Providers Initiate Conversation May Matter

• When parents resist, half of providers pursued original

recommendation and 47% of parents ultimately accepted
recommendation
• Is the goal informed decision-making or vaccine uptake?
• What about long-term patient/provider relationship?

From: Daniel Salmon, Johns Hopkins University

36
Opel DJ, et al. Pediatrics, 2013; 132(6):1-10
 Vaccine Hesitancy and Demand Continuum

GVAP definition of demand

generation: “Individuals
and communities
understand the value of
vaccines and demand
immunization as both their
right and responsibility.”

Report of the SAGE Working Group on Vaccine Hesitancy, 2014

From: Saad Omer, Emory University 37
 How School Immunization Requirements
Work in US
• All State Laws (not Federal)
• Wide Variability in Implementation
– Antigens required
– Process for adding antigens or making changes
– Applicable Populations
– Who provides documentation

From: Saad Omer, Emory University

Likelihood (Odds Ratios) of missing a vaccine
10

*
*
1

0.1

Haji B et al. BMC Public Health 2016; 16:152-160

From: Saad Omer, Emory University
Text Reminders in
Zimbabwe Caregivers (n=304)
of newborns in
Kadoma City
“Immunization protects your
child against killer diseases
such as polio, whooping
cough, diphtheria, measles,
pneumonia and tuberculosis. Text message
You are reminded that the Control (routine reminders and
vaccination appointment will health education) routine health
be due in 7 days time from education
today.”

“Your vaccination
“You are reminded that
appointment is due
the vaccination
tomorrow, visit the
appointment will be due
nearest clinic”.
in 3 days from today.”
Bangure B, et al. BMC Public Health 2015; 15: 137-147
From: Saad Omer, Emory University
Easy Exemption Process Associated with High Rates
Exemption Rate
Administrative Low Medium High
Difficulty (<0.5%) (0.5% - 1.0%) (>1.0%)
WA, ID, WI, MI,
Easy RI, OK, MO, HI, PA AK, AZ, VT, CA, MD
OR

ND, CT, IL, NC, AL, NY,

Medium OH, KS, NJ, LA
MA UT, SD, CO

WY, NH, MT, VA, IN, AR, IA, DE, CS, ME, NM,
Hard MN, KY, GA, TN TX, NV, FL, NE

From: Daniel Salmon, Johns Hopkins University

Rota et al AJPH, 2000

 Approaching Hesitant Parents:
Framing, Content and Culture
How you discuss and promote vaccines is as important as what you say

Framing Content Culture

Structure of What you recommend How you make
message delivery or endorse vaccination routine
From: Saad Omer, Emory University
Cook J. & Lewandowsky S., 2011
 Framing
Addressing a Myth
Sometimes addressing a myth is unavoidable – what should you do?

Clearly state that her assertion is a myth

State why the myth is not true

Replace the myth with the best

Think of it like a blank space where
alternative explanation
her belief in the myth used to reside

From: Saad Omer, Emory University

Cook J. & Lewandowsky S., 2011
 Framing
Addressing a Myth

Be confident
1

Do not argue counterproductive for your relationship

2 - Counterproductive for your relationship

Do not linger on the myth

3 - Focus on vaccine-preventable diseases

Key Point 3: Avoid lingering on a myth

From: Saad Omer, Emory University
Cook J. & Lewandowsky S., 2011
Evolution of Immunization Program and
Prominence of Vaccine Safety

45

Chen RT, Orenstein WA. Epidemiol Rev, 1996; 18(2):99-117

 Coverage of first-dose MMR in England from 1997–98 to 2011–12

Ramsay ME. Arch Dis Child 2013; 98(10): 752-754

The Beginnings of Modern Vaccine Hesitancy:
The Pertussis Vaccine Controversy in the UK
(1974-1976)
The introduction into public scrutiny: The case series from the
Hospital for sick Children at Great Ormond St.
• January 1974: the article described 36 children who authors believed had
suffered severe neurological complications after receiving the DPT vaccine
• Parents formed the Association of Parents of Vaccine -Damaged Children
which brought more public attention
• Led to severe drops in vaccine coverage. By 1977, coverage against
pertussis had declined from 77% to 33%; 9% in some districts. Led to 3
major epidemics of whooping cough
A House Divided: Medical professor Gordon Stewart
• Published a series of 160 cases of encephalopathy that he claimed were
linked to the pertussis vaccine.
• Public outcry led to the JCVI’s launch of the National Childhood
Encephalopathy study (NCES). Determined that although the vaccine was
associated with an increased risk of acute illness, the risk was very low.
Whooping cough notifications and mortality-
Baker JP, Vaccine 2003; 21:4003-4010 England and Wales, 1940-1998