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ApproachingtheVaccineHesitantParentusingCASE

RobertMJacobson,MD,FAAP

ProfessorofPediatrics,MayoClinic

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Disclosures

Potentialconflict

PrincipalInvestigator

AdultPCV13Prevnar13vaccine(Pfizer)

MenveoMCV4vaccine(Novartis)

SafetyReviewCommitteeMember

GardasilHPV4vaccine(Merck)

DataandSafetyMonitoringBoardMember

15valentPCV(Merck)

Noofflabelusediscussion

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LearningObjectives

Relateanewapproachtovaccinehesitancy

Identifyeachofits4components

Describehowitworksin3commonscenarios

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TheStateofVaccination

Theantivaccinemovementisthriving

Successfulvaccinationmakesitsvalueinvisible

Mediaseekstoportraycontroversy,bothsides

Americansculturallyopposedtopublichealth

Vaccinehesitancymajorissue

Notjustamongexemptorsanddelayers

Even25to30%ofthoseuptodate

Educationorinformationtransferinsufficient

Bothclinician

and

parent

struggle

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TheClinicianintheOffice

Haslittletimefordiscussion

Suffersasenseofrejectionaswiseadvisor

Feelssenseoffutility

Recognizesproblemofhealthilliteracy

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TheParentintheOffice

Wouldliketobeheard

Wishestoberespected

Seekscredibleinformation

Wantscontrol;wantstomakedecision

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StudiesofParents

Wanttheirchildrentobehealthy

Seektomakerationaldecisions

Weighbenefitsandrisks

Respecttheclinicianastrustedsource Drawfromtheavailableevidence

Theirownexperiencewiththediseases

Theirownexperienceswiththevaccine

Whattheyhearfromthemedia,family,friends

Whattheyhearfromtheclinician

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WhattheCDCRecommends

Taketimetolisten

Solicitandwelcomequestions

Acknowledgerisksandbenefits

Havebothscienceandstoriesavailable

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TakeTimetoListen

Eyetoeyecontact

Notjustasyouspeak

Butalsoasyoulisten

Letthe

parent

finish

speaking

Resisttheurgetomultitaskduringconversation

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SolicitandWelcomeQuestions

Askforquestions

Conveythatyouhavetimetoanswerthese

Giveshortenoughanswersthatmoreiswelcome

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AcknowledgeRisksandBenefits

Whileseveresideeffectshappen,theyarerare

TheVISlistsknownsideeffects

OKtonotethatnotvaccinatingisalsorisky

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HaveBothScienceandStories

Available

Whileyoumayfeelsaferwithscientificinfo

Mostparentspreferexperiencesyoucanshare

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TheC.A.S.E.forVaccines

Anewmodelfortalkingtoparents

Amnemonictoorganizearapid,usefulresponse

DrawsfromAristotelianteachingonrhetoric

CreatedbyAlisonSinger,MDPresident

AutismScienceFoundation

Lackspublishedstudiesofitsefficacy

Nonethelesshasfacevalidity,historicalroots

Lackscompetingalternatives

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TheCASEAcronym

Corroborate

AboutMe

Science

Explain/Advise

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TheCASEApproach Corroborate:

Acknowledgetheparentsconcernandfindsomepointonwhichyoucanagree;setthetoneforarespectful,successfultalk

AboutMe: Describewhatyouhavedonetobuildyourknowledgebaseandexpertise

Science: Relatewhatthesciencesays

Explain/Advise: Explainyouradvicetopatient,basedonthescience

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BreakUpinTwos

Corroborate:

Acknowledgetheparentsconcernandfindsomepointonwhichyoucanagree;setthetoneforarespectful,

successfultalk

WHAT PHRASING HAVE

YOU FOUND HELPFUL

WHEN A PARENT

HESITATES ABOUT

ANYTHING?

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Corroborate

Whatisyourmainconcern?

Dontpermitavaguerefusal

Maketheparentgetspecific

ThenThat'savalidconcern

WhenIheardthat,Isoughtoutanswersmyself

Webothwantyourchildtobefreeofillnessandinjury

Webothwanttoavoidunnecessarymedications

andtheirsideeffects

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BreakUpinTwos

AboutMe:

Describewhatyouhavedonetobuildyourknowledgebaseandexpertise

DO YOU EVER TALK

ABOUT THIS SORT OF

THING WITH YOUR

PARENTS? WHAT HAVE

YOU SAID?

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AboutMe

Imcommittedtoyourchildshealth,andIve

dedicatedmycareertothatwork

Ivebeenstudyingmedicineandpediatrics

nowforXyears

OneoftheareaswhereIread agreatdealis

aboutinfections,immunity,andvaccination

Vaccinationsrepresentamajorpartofmyprofessionaleffortasyourchildspediatrician

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BreakUpinTwos

Science:

Relatewhatthesciencesays

DO YOU TALK ABOUT

THE SCIENCE TO YOUR

PATIENTS PARENTS?HOW DO YOU

INTRODUCE THAT?

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Science

Vaccinesarebetterstudiedthananyother

medicineIprescribeortestIorder

EachvaccineissaferthananymedicineI

prescribe

Vaccinesarenotfoolproofbuttheyarethe

mosteffectivemeanstopreventcertain

injuriesandillnesses Thedecisionwhattogivewhenisbasedon

thevaccineseffectiveness,safety,andspecific

needforthechildatthatparticularage

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BreakUpinTwos

Explain/Advise:

Explainyouradvicetopatient,basedonthe

science

WHATS YOUR BOTTOM

LINE? HOW DO YOU

PHRASE YOURRECOMMENDATIONS?

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Explain/Advise

ThatswhyIamrecommendingthisvaccine

Ifthisweremychild,Iwouldbevaccinating

hertoday

Igot

this

vaccine

Imadesuremychildrengotthesevaccines

ThatswhyifIwereyou,Iwouldbegetting

thesevaccinesforyourchild

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CisforCorroborate

YouandIultimatelywantthesamethingfor

yourchild.

Wewantyourchildhealthandfreeof

diseaseandinjury.

Iknowyouareworried,scared.

Itismyjobtohelpyouwithyourconcerns.

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AisforAboutMe

Iamaprofessionalnotonlycommittedto

that,buttrainedandeducatedinthescienceofhealthandmedicine.

Thatincludesvaccination.

Myexpertiseiswhyyoucametoseeme.

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SisforScience

ThevaccinesIamrecommendingarethe

vaccinesIbelieveyourchildneeds. Thesevaccineshavebeenprovenboth

effectiveageaswellassafeforchildrenyour

child'sage.

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EisforExplain/Advise

Hereismyadvice:getthisvaccinetodayits

safe,itseffective,andyourchildwillbenefit

Ifyourchildweremine,Iwoulddothis.

Infact,

doing

somay

be

more

valuable

toyou

thananythingelsewedointhisvisit.

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ThreeCommonConcerns

Vaccinesmaycauseautism

Toomanyvaccinestoosoonisharmful

Thevaccine(s)isnolongernecessary

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TheCASEagainstAutism Corroborate:

TherescertainlybeenalotonTVandtheinternetaboutvaccinesandautismsoIcanunderstandwhy

youhavequestions

AboutMe: IalwayswanttomakesureImuptodateonthe

latestinformationsothatIcandowhatsbestformy

patients,soIveresearchedthisthoroughly. Infact,Ijustreturnedfromaprofessionalconference

whereexpertsreviewedtheactualevidence

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MoreAgainstAutism Science:

Theevidencedoesnotsupportthatmeaslesvaccine,theMMR,oranyvaccinecausesautism.

TheCDC,theAAP,theNIH,theIOM,andothers

haveallreviewedthedata

Allreachedthesameconclusion.

Dozensofstudieshavebeendone.

Noneshowalink.

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FinishingtheCASEagainstAutism Explain/Advise:

Vaccinesarecriticaltopreventingdeath,disease,anddisability.

Theypreventdiseasesthatcauserealharm.

Choosingnottovaccinatedoesnotprotect

childrenforautism,butdoesleavethematriskfor

disease.

Childrenneedthesevaccines.

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TheCASEagainstVaccineOverload Corroborate:

Childrentodaycertainlygetmoreshotsthantheydidyearsago.

AboutMe:

OurpracticefollowstheCDCschedulebecauseit

iscarefullydesignedtoprotectchildrenatthe

timetheyaremostvulnerabletodisease.

Ivereadthroughtherecommendations

carefully

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MoreagainstVaccineOverload Science:

Althoughchildrengetmoreshotstoday,theyactuallyreceivefewerimmunereactiveantigensthan

whentheygotfewershots,becausetechnologyhas

enabledustomakevaccinesthathaveonlythepartofthecellthatinducesimmuneresponse.

Plus,theimmunologicalchallengefromavaccineis

nothingcomparedtowhatkidsfightoffeveryday.Anearinfectionisabiggerimmunological

challenge.

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FinishingUpagainstOverload Explain:

Wewantallthekidsinourpracticetobeimmunizedsothattheyhavethegreatestchance

fora long,healthylife.

Ifyourdaughterweremydaughter,andIwassittinginyourshoes,holdingherinmylap,I

wouldbegettinghervaccinatedtoday.

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TheCASEagainstUnnecessary Corroborate:

Icanunderstandwhyyoumightfeelthatway.

Mostofthetimewhenourchildrengettheflu,

wedonttestforit,andsoparentsdontknow

whentheirchildrenhavehadtheflu.

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MoreagainstUnnecessary AboutMe:

Iusedtothinkthatchildrennevergottheflubutthestudiesarecompelling.

Inretrospectthosesorethroatswithfeverwith

negativestreptestingwereoftentheflu.

Samethingwiththevirusesleadinguptoear

infections

Samethingwithfeversandcoughsthatmadeus

worryaboutpneumonia.

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MoreagainstUnnecessary Science:

Thehospitalizationratesininfantslessthan2duetotheflurivaltheratesintheelderly

Morethan40%ofschoolchildrengetthefluon

averageeveryyear

Thevaccineworksreallywell;itreducestherisk

by45to90%dependingontheyear

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FinishingUpagainstUnnecessary Explain:

Wecareaboutourpatientsanddontwanttopracticesubstandardcare.

Allourpatientsneedtobevaccinatedagainstthe

flu.

Mychildrenarefullyvaccinated.

Iamtoo.

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TheCASEApproach Corroborate:

Acknowledgethe

parents

concern

and

find

some

point

on

whichyoucanagree;setthetoneforarespectful,successfultalk

AboutMe: Describewhatyouhavedonetobuildyourknowledgebaseandexpertise

Science: Describewhatthesciencesays

Explain/Advise: Giveyouradvicetopatient,basedonthescience

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ClassicAristotelianRhetoric AristotletaughttheCASEmethod

Topersuadeoneneedsmorethanjustevidence

Needthreethings

Logos(theinformationandreasoningyouhave)

Pathos(yourpassion,compassion, andconviction)

Ethos(yourprofessionalstandingw/theparent)

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Rationale Informationaloneinsufficient

ItsanemotionalinformationtooOneneedstofeelgoodaboutthedecision

Onehastofeelstronglyaboutthedecision

Yourroleismorethanjustatechnicians

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TheCASEApproach Corroborate:

Acknowledgetheparentsconcernandfindsomepointonwhichyoucanagree;setthetoneforarespectful,successfultalk(PATHOS)

AboutMe: Describewhatyouhavedonetobuildyourknowledgebaseandexpertise(ETHOS)

Science: Describewhatthesciencesays(LOGOS)

Explain/Advise: Giveyouradvicetopatient,basedonthescience(PATHOS)

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YourSourcesofInformation Parentswantmorethaninformation

Wantstotrustyoubecauseofwhoyouare(ethos)

Expectsyoutohavepassionforwhatyouadvise(pathos)

Youontheotherhandwantdatayoucantrust

Whataretheactualrecommendations?

Whatarethedatathatsupportthese?

WherecanyoufindinformationtosupportyourCASE?

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SourceofRecommendations AdvisoryCommitteeonImmunizationPractices(ACIP)

Groupofvolunteerexperts

Meetsthreetimesayear

OrganizedbyCentersforDiseaseControlandPrevention(CDC)

Solesourceoffederalvaccinerecommendationsforcivilianpopulation

ThefederalgovernmentdoesnotrequirevaccinesSchoolanddaycaremandatesarestatebased

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ACIPRecommendations 2012Child&AdolescentImmunizationSchedule

UpdatedatleastannuallyinJanuary Providescatchupscheduletoo

Publishedwidelyindozensofjournals

AvailableonlinefromtheCDCVaccinessite

www.cdc.gov/vaccines

AAPandAAFPharmonizewithCDCACIP AlsopublishestheAdultSchedule

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VaccineSpecificDetails ACIPpublishesitsrecommendationsinMMWR

Theseprovidedetails

Doseandroute

Timingvariationsandexceptions

ContraindicationsandprecautionsOtherissues

Basisforrecommendations

Wellreferenced

KnowhowtofindthemstartingatCDCvaccines

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SpecificAdvicereParents UnderstandingVaccinesandVaccineSafety

Resources

for

Vaccine

Conversations Factsheetsprovideinformationaboutvaccine

testing,safety,monitoring,andtheprocessfor

establishingtheUSimmunizationschedule

Letsfinditandreviewitscontents

StartattheCDCvaccinessitewww.cdc.gov/vaccines

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CDCInformation

Dontplanonprintingandgivingtoparents

Dontplanonemailingthemthelinks

InsteadreadandremembertomakeyourCASE

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OtherSources

AAPProviderResources

www2.aap.org/immunization AAPParentResources

www.healthychildren.org

IAC

Provider

Resources

www.immunize.org

MNAAPwww.mnaap.org

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Summary Persuaderatherthaninform

CASE CorroborateAboutMeScienceExplain/Advise

AristotelianRhetoric

PathosEthos LogosPathos

Knowyoursourcesofinformation

ACIPanditsrecommendations

CDCanditsresources

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