Physicians Play Key Role in Educating Patients
Public Health Feature — January 2014
Tex Med. 2014;110(1):31-36.
By Crystal Zuzek
In 1998, The Lancet published a case report by English physician Andrew Wakefield, MD, that linked the measles, mumps, and rubella (MMR) vaccine to a new syndrome of autism and bowel disease. The report set off frenzied media coverage, and some critics say it led to thousands of unnecessary illnesses. The Lancet ultimately retracted the report.
Fast forward 16 years, and the rescinded report has forever altered the dialogue physicians have with their patients about immunizations. Despite a 2011 British Medical Journal (BMJ) investigative report that alleged Dr. Wakefield falsified data in his study and had a financial conflict of interest, some devotees continue to follow Dr. Wakefield and cling to his findings. (Read "Bad Science," March 2011 Texas Medicine, pages 27-32.)
Physicians say there's no doubt Dr. Wakefield's report and the subsequent media firestorm influenced patients' comfort level with vaccinations.
An accompanying editorial in BMJ also charged that unbalanced media reporting, along with an ineffective response from government and medical professionals, contributed to harming the public's health as fewer people around the world received the recommended vaccines.
Litjen (L.J.) Tan, PhD, Immunization Action Coalition (IAC) chief strategy officer, says that in the aftermath of the initial report, physicians and other health practitioners were ill-prepared to inform the public of the safety of vaccines. The Minnesota-based IAC receives funding from the Centers for Disease Control and Prevention (CDC). It promotes immunizations by distributing educational materials for health professionals and the public on the delivery of safe and effective immunization services.
"Health professionals and public health advocates did not do a good job informing the public about vaccine safety and chose to rely solely on the provider conversation. We chose to believe that in the absence of a broader action, sane minds would prevail," Dr. Tan said.
Physicians on the front lines of disease prevention say inaccurate information about the safety and efficacy of vaccines complicates their efforts to immunize adults and children against deadly diseases.
Jason Terk, MD, a Keller pediatrician and member of the Texas Medical Association Be Wise — ImmunizeSM Advisory Panel, says he commonly encounters vaccine-hesitant parents in his practice. Reasons for their caution include the alleged connection between vaccines and autism spectrum disorder, as well as concerns about the safety of vaccine ingredients such as aluminum adjuvants and about the number of vaccinations on the recommended childhood vaccination schedule.
Dr. Terk has a strategy for refuting unfounded resistance from parents.
"The first thing I do is ask for specific reasons a parent has concerns and what resources the parent used to create the concern or reinforce it. Requiring specifics is important because it allows me to understand what information I might need to call upon to answer the concern. It also requires the parent to cognitively clarify what may be a nebulous fear," he said.
Once he understands the underlying concern, Dr. Terk says it's easier to be a reliable resource for the parent. Plus, if the parent has consulted an unreliable, non-evidence-based source, he can point out that the foundation underlying vaccine recommendations is "usually much stronger than what the parent was using to research the concerns."
Countering Vaccine Resistance
Vaccine-preventable disease outbreaks are making headlines. For instance, as of October, 2,652 pertussis cases had been reported to the Texas Department of State Health Services. That number surpasses the 2,218 cases of the disease reported in 2012.
Physicians like Deborah Fuller, MD, a Dallas obstetrician-gynecologist and past chair of the TMA Council on Health Promotion, hope new tetanus, diphtheria, and pertussis (Tdap) vaccine recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP) will help thwart the spread of pertussis and save lives.
ACIP now recommends all pregnant women be vaccinated with Tdap during each pregnancy. Since implementing the recommendation in her practice, Dr. Fuller says all of her obstetric patients receive the vaccine in their third trimester. She reports that so far none have refused the Tdap vaccine.
"I inform patients of the benefits of Tdap vaccination, and I hand out copies of articles from local newspapers about the pertussis outbreak. I think that combination helps sway patients," she said.
Dr. Fuller says many of her patients rely on her for primary care.
"I have some patients who see me once a year but don't see an internist or family physician. It's my job to provide the whole package of preventive health services," she said.
Immunizations are part of the package. In her practice, Dr. Fuller says pregnant women and those who plan to become pregnant are the most vaccine compliant.
"I educate these patients by providing them with factual brochures about flu and Tdap vaccines. Once they realize these shots will protect their babies from potentially deadly diseases, they get them," Dr. Fuller said.
Unfortunately, she encounters vaccine resistance more commonly from her gynecology patients. These women tend to be more likely to decline the influenza vaccine, for instance.
"In my experience, women are willing to get the flu shot to protect their unborn babies. I don't know why, but they're not as willing to get the vaccine to protect their own health," Dr. Fuller said.
She estimates only about half of her gynecology patients consent to the flu vaccine. She says Tdap compliance among these same patients is much higher.
"That could be because Tdap is recommended to be given every 10 years, not every year like the flu vaccine," she said.
Dr. Terk says flu vaccine is a victim of the urban myth that the shot actually causes influenza.
"And the risk of influenza disease has always been inappropriately minimized unless we are experiencing a pandemic," he said.
Erica Swegler, MD, a Keller family physician and member of the Be Wise — Immunize Advisory Panel, also runs into resistance when trying to persuade adults to get vaccinated against flu. She hopes approval of a new flu vaccine made without eggs, called FluBlok, will increase vaccination among adults with egg allergies. ACIP voted last year to recommend the vaccine for use in adults aged 18 to 49.
Dr. Swegler vaccinates more adults than children. In her experience, the reasons for vaccine resistance among each population vary.
"Parents are still concerned about whether MMR vaccine causes autism. They worry about exposing their children to mercury, even though mercury was removed from children's vaccines in 1999, with the exception of multidose flu vaccine," she said.
To tackle resistance to vaccines, Dr. Swegler often shares Vaccine-Preventable Disease: The Forgotten Story with their patients.
The publication is available for purchase from The Center for Vaccine Awareness and Research at Texas Children's Hospital. It tells the story of people whose lives have been affected by vaccine-preventable diseases and can assist physicians in helping parents understand the importance of vaccines. (See "Resources to Spread Vaccine Facts.")
In addition to sharing personal accounts, using a presumptive approach toward childhood vaccines shows promise. A study published in the November 2013 issue of Pediatrics reports that only 26 percent of parents resisted vaccine recommendations when physicians used a presumptive approach, which assumes parents will immunize their children. Eighty-three percent resisted, however, when physicians used a participatory approach, which invites room for parental debate about vaccines.
Dr. Terk says the presumptive approach is the gold standard in pediatric practice.
"I think it is terribly important to approach the provision of vaccines as what we are supposed to do and not something that is optional or up for discussion. It should be an assumption that we get our vaccines unless there is a true contraindication," he said.
A participatory approach presumes safe room for deviation from the recommended vaccine schedule, Dr. Terk says, adding that delaying vaccination or deviating from the recommended schedule enhances the risk a patient will contract a preventable disease.
Dr. Tan says many physicians haven't been appropriately trained in communicating vaccine risks to patients, most of whom haven't witnessed the effects of smallpox, polio, or other forgotten but deadly diseases.
"In the absence of disease, the perception of and acceptance of risk changes. There comes a tipping point when parental concerns about adverse events outweigh what they perceive as benefits from vaccines," Dr. Tan said.
When communicating about vaccine risks to parents, Dr. Tan says physicians need to realize many parents have a limited understanding of vaccine science.
"Data disprove the link between autism and vaccines, but some parents continue to give weight to that claim," he said. "The anti-vaccine community tells a compelling story and has captured the attention of many people. That's why it's important for physicians to address the perceived risks and educate patients about the benefits of vaccines."
Carol J. Baker, MD, past ACIP chair and executive director of the Texas Children's Hospital Center for Vaccine Awareness and Research, has advice for busy physicians.
"Physicians must listen compassionately to identify concerns and establish early, open, ongoing, nonconfrontational dialogue. Most importantly, physicians should communicate that the infectious diseases prevented by the vaccines are much worse than the risks associated with vaccines," she said.
An article in the July 2004 issue of Pediatrics titled "Children Who Have Received No Vaccines: Who Are They and Where Do They Live?" examined the unvaccinated child population. Researchers concluded unvaccinated children are typically white, have a married and college-educated mother, and live in a household with an annual income exceeding $75,000. Their parents tend to express vaccine safety concerns and indicate that physicians have little influence over their vaccination decisions. Dr. Tan says the Internet is a haven for the anti-vaccination crowd.
"Anyone can pose as an expert and contribute their own content on anti-vaccination blogs and forums," he said.
Dr. Terk says when making important health care decisions for their children, many parents rely on the advice of a trusted friend or relative or an admired celebrity rather than data from epidemiologic studies.
"I always talk about the fact that I have provided these same vaccines to my children and that I would be happy to put parents in contact with other parents who have experienced loss as a result of vaccine-preventable diseases. Once you make it a real and personal issue, many parents will come around," he said.
Dr. Terk acknowledges that a few parents will never be persuaded to vaccinate their children, despite his attempts to provide respectful stewardship on the subject. He deems those noncompliant parents to be a poor fit with his practice and invites them to seek care from another physician. (Read "Firing Patients," May 2012 Texas Medicine, pages 37-40.)
Dr. Tan says physicians need to understand risk perception and learn to manage it among patients. And he advises physicians not to discount the impact of patients' emotions on risk evaluation.
"If feelings toward an activity are favorable, that activity's risk tends to be underestimated. If feelings toward an activity are not favorable, that activity's risk is usually perceived to be high," he said.
Be Wise — Immunize is a service mark of the Texas Medical Association.
Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Resources to Spread Vaccine Facts
The TMA Be Wise — Immunize physician toolkits for children and adolescents help physicians implement vaccination best practices in the office. The toolkits tell physicians and staff members how to use ImmTrac, the Texas immunization registry; join the Texas Vaccines for Children program; and talk to parents about conscientious objection. To access the toolkits, click here.
One of the Be Wise — Immunize program's main goals is to communicate that vaccines are important, safe, and effective. To aid physicians, the website features a variety of vaccination fact sheets, available in English and Spanish, regarding vaccinations recommended for children and adults. Physicians can request copies of these handouts from TMA and share them with patients as educational tools. To request the handouts, contact Tammy Wishard, TMA outreach coordinator, by telephone at (800) 880-1300, ext. 1470, or (512) 370-1470, or by email.
The TMA Foundation grants TMA funds for its Be Wise — Immunize program, thanks to major gifts from H-E-B and the TMF Health Quality Institute, and gifts from physicians and their families. The program began in 2004.
In addition, the vaccine safety webpage of the Centers for Disease Control and Prevention (CDC) has up-to-date information and resources. The CDC's Advisory Committee on Immunization Practices has the latest immunization recommendations and schedules.
The Immunization Action Coalition website features clinic resources, vaccine information statements, and a section devoted to talking to patients about vaccines.
The Texas Department of State Health Services (DSHS) also is active in educating Texas physicians and patients about vaccine safety and effectiveness through the Texas Vaccines for Children program. Information about vaccine education and safety is available on the DSHS website. The department works closely with the Texas Pediatric Society and TMA to educate medical professionals.