**FTS-CDC-NCHSTP**

**Moderator: Dale Babcock**

**June 12, 2008**

**11:00 am CT**

Coordinator: Welcome and thank you for standing by. At this time all
participants are in a listen only mode.

During the question and answer session today you can press star 1 to ask
a question.

Today's conference is being recorded. At this time I'll turn the call
over to Dr. Andrew Kroger. You may begin sir.

Andrew Kroger: Thank you. Good afternoon. And welcome to Current Issues
and Immunization. A CDC Net Conference.

I'm Dr. Andrew Kroger, a Medical Officer in the Education and
Information Partnership Branch of the National Center for Immunization
and Respiratory Diseases. And I will be the moderator for today's
session.

To participate in today's program you need a telephone connection and a
separate Internet connection.

The learning objectives for this session are one, list a recent
immunization recommendation made by the Advisory Committee on
Immunization Practices or (ACIP). And two, describe an emerging
immunization issue.

Today is June 12, 2008 and we will have two presentations that address
vaccine communication with parents. First Dr. Kristine Sheedy, Director
of Communications for the National Center for Immunization and
Respiratory Diseases at CDC will give a talk entitled Why It Takes More
Than Science To Address Parental Concerns About Vaccines - Confessions
Of A New Mom.

Then Patricia Stinchfield the Director of Infectious Disease/Immunology/
Infection Control at Children's Hospitals and Clinics of Minnesota, and
an (ACIP) Member will discuss how to effectively address parents'
concerns about immunization.

Please make a note of the following information. If you have technical
trouble please dial star 0 on your telephone. If you'd like to ask a
question please press star 1 on the phone.

Continuing education credit is available only through the CDC ATSDR
Training and Continuing Education Online System at
[www.cdc.gov/tceonline](http://www.cdc.gov/tceonline) or t-c-e-online.

You must have a verification code specific to this program to apply for
CE credit. The code will be revealed during the course of the program.
CE credit for this activity will expire on July 14, 2008.

CDC, our planners and our presenters wish to disclose that they have no
financial interests or other relationships with the manufacturers of
commercial products, suppliers of commercial services or commercial
supporters.

Presentations will not include any discussion of the unlabeled use of a
product or a product under investigational use.

So I'm happy now to turn the mike over to Dr. Kris Sheedy. Kris?

Kris: Thank you to all of you who dialed in today. There are so many of
you out there. I think we have over 200. Maybe close to 300 who've
dialed in.

So that's understandable that there's tremendous amount of interest in
this topic given the heightened attention that vaccine safety issues
have received over the past month.

We've heard from many providers who see that they see parents daily who
have concerns about vaccines and others who want to delay or differ
vacations. And we know this is a challenging time for many of you on the
front lines.

So we're excited to be able to do this Net Conference today. And we look
forward to hearing your questions and your comments.

I gave this presentation in March at the National Immunization
Conference. And it was suggested that I present it again today. And I'm
really happy to do so.

Like all of you, I wear several hats in my life. Normally in a forum
like this I would put on my professional hat and speak to you as a CDC
Public Health Communication Specialist.

But today I'm putting on my mommy hat. And will speak to you as someone
who has recently had a baby. My second of two feisty and energetic boys.
And who of course has recently had that baby vaccinated.

Now I know I don't represent all moms out there. But by taking a few
minutes to share my story I hope to shed a little bit of light on why we
moms worry about vaccine risks. And how open, honest and empathic
communication can really help to alleviate those concerns, and empower
moms to make informed decisions.

So let me begin by introducing my sweet 11 month old Conner. He was born
in July. Like so many moms-to-be, I was vigilant during my pregnancy
about taking my vitamins.

I didn't drink a drop of alcohol or caffeine. I ate right. I did what
all the doctors and books tell you to do during pregnancy. Always
thinking about the baby everyday several times a day.

Even before they're conceived, we moms start obsessing over keeping our
babies healthy and safe. Then they finally arrive.

When my first son was born I really couldn't believe just the
overwhelming real love I instantly felt for him. And with Conner it was
the same way.

As babies do, he came into the world wrinkly and gooey - looking a bit
like an alien. But to me, he was the most beautiful thing I had ever
laid my eyes on.

We took him home and entered that new baby universe that, you know, all
of you parents out there are familiar with. It's a combination of severe
sleep deprivation and constant feeding, burping and changing, and
rocking the baby.

I was on maternity leave and at that point Conner and I were attached
all of the time. And life was all about keeping him comfortable and
content around the clock.

Just before Conner's 2nd month birthday, I started to develop a bit a
knot in my stomach thinking about the fact that in a few days I would
have to take him for his doctor's appointment.

I knew he'd be getting five vaccines and I was already feeling a little
bit anxious about it.

That afternoon a rare event occurred. The baby and my 3-year-old both
napped at the same time. Which is a great thing for a new mom. So hooray
for me.

I decided to ignore the laundry and ignore the dirty dishes and put on
Oprah. She was introducing her guest for the day, Jenny McCarthy and I
thought to myself, okay I like Jenny McCarthy.

During my first pregnancy someone gave me Ms.McCarthy's book Belly
Laughs which was about her pregnancy, and I thought it was honest and
funny. So, at the time I didn't know that she had written another book.
Like I said, I was on maternity leave and in my own world.

So I sat and watched Miss McCarthy tell an emotional and really
horrifying story about how her son, (Evan) suffered a series of seizures
and was ultimately diagnosed with autism.

When she told Oprah that she learned most of what she knows about autism
from the Internet, I just knew where the conversation was going and I
was right.

After the next commercial break, Oprah asked Miss McCarthy about the
cause of her son's autism. And then she said it - vaccines.

And by the time the show was over I was honestly feeling a mix of
emotions. I was angry that Oprah didn't have an actual autism expert on
the show. I was disappointed that the CDC statement that was read on the
show sounded so inappropriate and flat. Particularly compared to Jenny
McCarthy's story.

But in addition to the anger and disappointment, I have to confess that
that knot of anxiety in my stomach about taking (Conner) in for his
shots was yes, a little bit bigger.

Now many of you may be saying, come on Kris didn't you listen to what
Jenny McCarthy said? There are holes and contradictions in her story.
She herself stated that the signs that her son was different were always
there.

And I do know that. And having worked in the Immunization Program at CDC
for many years, I also know the epi(demiology) studies that we and
others have done related to vaccines and autism. And I know how strong
those studies are and how reassuring that science is.

And I most certainly know that CDC has never covered up any vaccine
safety findings. And that when we say we care about the health and
well-being of children, it's not just a media talking point it's the
truth.

I know all of that. I know the facts. I've written many of the CDC
questions and answers and talking points and Web content.

So how could I, someone who promotes CDC's immunization recommendations
for a living have even the slightest seed of doubt or slightest concern
about vaccinating my own child?

Well, there are several reasons. Like many of you, over the years I've
spoken to so many parents who are convinced that vaccines had something
to do with their child's autism.

As the mother of a baby, their stories scare me. And their stories stay
with me. I do remember them.

When she told her story on Oprah, Jenny McCarthy mentioned her mother's
intuition several times.

She and other moms talk about how they just know.

Again, this resonates with mothers including me. Because I too feel very
in-tuned to my kids. And while intuition can be wrong, it can also be
right.

So I don't easily dismiss a mother's intuition.

I also know that truth changes as science advances. And that while the
biggest and best population-based studies have found no association
between vaccines and autism, they don't rule out the possibility that
maybe vaccines somehow contributed to some of these kids conditions. We
just don't know for sure.

So I do say a little prayer before Conner gets his vaccines that he will
be like the vast majority of babies who get vaccinated, enjoy the
protection that it affords him and have no problems following vaccines.

And worries about autism aside, it's just heart wrenching to have to
take your precious, delicate baby - lay them out on an exam table and
watch as they get multiple shots.

When I first went through this with my oldest son, I really wasn't
expecting it to be as traumatic for me as it was. But those needles
looked so big next to his tiny legs, and I had never heard him cry out
in pain like that before. So it was very emotional for me. And it's
memorable event for parents.

Finally I have to say that my own mother, whose input I trust and value
contributed to my worries, because I spoke to her the evening the Oprah
show aired. And she asked me if I really thought it was a good idea to
have - let Conner get all those shots. And I think a lot of moms out
there hear the same thing from the grandmas.

Naturally I did take Conner in to get his vaccines. Unlike some moms out
there I am familiar with vaccine preventable diseases by virtue of my
job. I do hear about those cases and those outbreaks.

So my very strong belief in vaccine benefits, and frankly my fear of
diseases like Pertussis and measles and influenza are far greater than
my worries about vaccine safety.

The doctor's visit itself was unpleasant as expected. I mean, let's face
it five vaccines is a lot. But Conner calmed right down after just a few
minutes. I took him home and he slept and ate and was fine.

Until later that day. And I don't remember exactly how many hours it was
after he'd been vaccinated, but he started crying. And he continued to
cry. And it wasn't his hungry cry or his tired cry, or any other cry
that I had heard come out of him before.

And I just couldn't console him. He cried and he cried and it wasn't
just the crying that scared me. He was arching his back and at times he
was so tired that he fell asleep, but never for more than a few minutes.
And then he sort of jerked himself awake and the crying would start
again.

I tried telling myself that this happens sometimes and he would be fine.
I even got the DTaP VIS out of the diaper bag just so I could confirm
for myself that persistent crying for a few hours or more is a known
side effect.

And I'll confess that even though I've looked at that VIS hundreds of
times, it made me feel better to see it in that moment.

Just as I started digging through my things to find the phone number of
one of my CDC pediatrician friends, Conner stopped crying and he slept.
He woke up hungry after a good sleep and he was fine. I was exhausted,
but he was fine and of course I was relieved.

I want to fast-forward to November and Conner's four month doctor's
visit for a moment. After our experience following his previous round of
shots, you can imagine that I was more nervous then before about brining
him in for another five vaccines.

But I bundled him up and we headed to the Pediatrician's office. That
day we saw a Pediatrician who was new to the practice. I didn't mention
to her anything about where I worked or what I do.

So she examined Conner and when she was done examining him, she said to
me - well Conner's going to be getting several vaccines today. And I
told her I know.

Her reply to that was a bit unexpected. She said to me - you seem a
little bit concerned about that. Is there anything on your mind?

So I told her about what happened after Conner's last round of
vaccinations. When I told her that he cried for a long time and was
inconsolable, she asked me exactly how long he cried for and questioned
me about how he was crying.

When I told her that Conner would fall asleep for a moment, but then
have, you know, have twitching motions that woke him up - she again
asked me questions to get more specific information about what happened
and what I observed.

Was the jerking repetitive she asked. No I told her. Her eye contact,
her posture - all of her non-verbal communication made me feel like she
was really listening closely to me.

I have to emphasize how reassuring this dialog was to me. I really felt
like this is a doctor who truly cares.

After questioning me about Conner's crying episode, she said to me -
well that must have been very scary for you. I can understand why you're
concerned about vaccinating Conner today.

But based on everything you've described to me - she said it doesn't
sound like Conner had seizures after his last round of vaccines. And I
would feel very comfortable giving him all his shots today.

But she said, if you are very worried about this we can talk about
giving him some of his vaccines today and bringing him back for the
rest.

Again, I am wearing my mommy hat speaking to you now. And I have to say
that the empathy this Pediatrician expressed to me, and her willingness
to give me some control over the decision really helped to put my mind
at ease.

On the next slide you'll see a number of talking - points and tips that
I have shared with many audiences over the years about
risk-communication.

The advice may seem elementary, but really is a big deal. And it applies
to communication that takes place between a provider and a parent and an
exam room. As well as the public communication that we do at CDC at the
national level. And that's done at state and local levels as well.

Good, open, transparent communication is critical to building trust.

But, back to my story. Though I was given the option of delaying some of
Conner's vaccines that day, I did choose to have him fully vaccinated
that day.

He had another little bit of a crying episode, but it wasn't nearly as
intense and didn't last as long. I will make sure that Conner is fully
vaccinated. I know the danger the vaccine-preventable disease, and I
know the safety profiles of our vaccines.

I've had the honor of getting to know moms like Julie Moisey who lost
her precious baby boy to a vaccine-preventable disease. So I would never
consider not vaccinating Conner.

Still, before every immunization visit I will have that knot of anxiety
in my stomach. But now I will make a point of scheduling his visits with
that caring doctor who was able to loosen that knot a bit.

I want to thank everybody for listening and I'll pass it back to Andrew.

Andrew Kroger: Thank you Kris for that personal and informative account.
Next, we are going to hear from Patsy Stinchfield on how to address
parental concerns about immunization. Patsy?

Patricia Stinchfield: Good afternoon and thank you so much for the
opportunity to speak to you today about effectively addressing parents'
concerns about immunizations.

So much of our risk communication is really based on our own experience
and our own values. So in the spirit of true transparency I thought I
would start with what drives my risk communications based on my
experience.

I've been a nurse for 30 years in Pediatrics. I've been a nurse
practitioner for 21 years. Some in primary care, but most of it in
infectious disease and immunology.

Working at a children's hospital we do care for the sickest of sick. And
I have in my career taken care of and been participating in the care of
children with Pertussis, measles, influenza, severe varicella including
a 15 year old child who died at Children's Hospital here a couple of
years ago after being a totally healthy teenager. And then succumbing
with a couple of days.

We've seen severe rotavirus, pneumococcal meningitis, Hib and
meningococcal meningitis.

I've held parents in my arms whose children have died from influenza and
these diseases.

I've talked with grandparents who can't understand why anyone would not
get vaccinated.

So in the spirit of transparency, I will let you know that yes I do have
a bias and it's a strong bias in favor of vaccination.

Because one of the issues we are dealing with today is that parents and
many providers have never seen these diseases. So the benefit of
vaccines is invisible.

And I do think that is probably getting to the bottom-line first is
what - why we have these conversations today. And why they seem so
complicated. Is that the diseases don't seem real to a lot of people.

So let's just talk a little bit more about that. The vaccine debates do
have a big impact on parents. The Oprah show, the newspapers, the
Internet conversations.

These national vaccine debates cause great vaccine communication
challenges at the patient care level.

Parents can be confused. They can be misinformed and fearful because of
a story that they read or see.

These cause vaccine communication challenges and they are many. And we
will talk about those in a moment.

The interesting thing is sometimes the perspective can often be skewed.
For example, the media may say well we're going to have a balanced story
on an immunization concern. And we'll have one parent who has vaccinated
their child. And we'll have one parent who chooses not to vaccinate
their child.

Well those two parents represent two very different sizes of population.
We have to keep in mind that the majority of parents do vaccinate their
children. For 98% of parents - by the time a child gets to
Kindergarten - that child is fully vaccinated and fully protected.

And we're glad to see some of the lowest levels of vaccine-preventable
disease that we've ever had.

But that 2% - and it's roughly 2 to 3% and it varies by state, but we
are concerned about that number growing.

It does not take much for that number to grow to have outbreaks and
problems.

So what about providers? We have an impact on this discussion as well.

When you look at the literature, about 40% of providers surveyed by
Davis did not mention vaccine risk with patients.

Research supports that physicians say little to parents about
immunization. And that parents say that they do want to hear from their
providers, more so than their mothers or the person next door. They want
to hear from their trusted advisor at their clinic.

Nurses reported the most education in risk-benefit communication, but
they may not always have that responsibility to do the patient
education.

So with recent media attention to the topic, more and more providers are
spending considerably more time discussing immunization concerns at the
clinic level.

So what are some of those concerns? Let's talk about a few of them.

Here's one that I'm sure many of you are hearing more and more lately.
An infant's immune system is too weak for vaccines.

Well, working in immunology I daily think about the power of the human
immune system.

And I think it's good for all of us who are clinicians to refresh our
minds on how exactly the immune system works.

And break it down into simple English to discuss this with new parents
especially.

If you can take a moment early on in that baby's life, they won't feel
like they have to keep them in a bubble and protect them. Or that these
will be too many vaccines or that will harm the baby's system in some
way.

The fact is that there are tens of thousands of T&B lymphocytes. They're
abundant in a lock and key fashion. Ready for individual antigens to
individually lock up with those B cells to make antibodies.

Therefore, this immune system overload concept doesn't match what the
way that our immune system works.

And I'm not even sure where it originated from.

I like Dr. Paul Offit's analogy of the ocean analogy. So describe to
parents that the immune system's like an ocean. And that at that first
two month visit for example, they're going to have eight antigens added
to that immune ocean.

Think of it like eight cups of water being added to an ocean. It's far
from overload and far from being too weak to accept those.

When I think about our neonatal intensive care unit here at Children's
Hospital in Minnesota, even premature babies have that immune capacity
to respond to inactivated vaccines - with very few exceptions.

When those babies in our NICU are 60 days old, they are started on their
immunization series. And they do make protective measurable level of
antibodies.

And I remember one mom saying to me from the NICU, how terrible it would
be if they survived this prematurity - this long NICU stay, this open
heart surgery only to go out into the world and have their baby get
Pertussis and die from that. She said she was very happy to have her
baby immunized within the NICU.

Another topic we might be hearing about is it's so many vaccines. So
soon. Or so many vaccines at one visit.

And therefore, can we change the immunization schedule? Can we spread it
out? Or make a new schedule?

Well I think what we need to know is the schedule isn't just made up.
It's recommended schedule that's been thoroughly reviewed by experts and
with lots of scientific thought taken into it. Of when are babies ready
to start on immunization schedule?

And most of us experts who are recommending these schedules are parents
as well. And we've gone through the experience in a very similar way to
what Kris described.

So, there is not a physiologic reason to design an alternative
immunization schedule. And there's no biological rationale for splitting
up a dose, giving an (M) and an (R.) (instead of MMR).

When you do that, essentially we're delaying the schedule. And to choose
to delay is to choose to take a risk.

We're preventing and prolonging the prevention. And that can cause harm.

So, if avoidance of harm is the goal. To prolong prevention is to delay
protection.

And I think that's something that we have to communicate with families.

Choosing to not vaccinate, not only potentially endangers this baby in
this clinic at that day that you're having the conversation, but others
as well.

Another topic that seems to be continuing in our conversations is
thimerosal. Is thimerosal the problem?

We know that the preservative thimerosal has been removed from vaccines
with the exception of the multi-dose influenza vaccines. Multi-dose
vials of influenza do contain thimerosal, and this does sometimes cause
us to have conversations in clinics about thimerosal.

Even in mass influenza vaccine settings as we experienced here a couple
winters ago. Giving multiple doses of flu vaccine in the middle of a
crisis - we were discussing thimerosal surprisingly. But it's a topic
that we do need to discuss.

When you look to the literature for answers, there are numerous studies
on this topic.

Danish cases of autism for example, rose substantially after thimerosal
was removed in 1992. Again, unproven relationship.

We know that there's this theoretical and unproven risk with thimerosal
versus what we know is real and considerable risk of the disease.

And so again, balancing our communication with the risk and benefit of
vaccines.

So education on the lack of scientific support for thimerosal as a
causative agent of autism is as necessary as ever.

We also have the concern more specifically to autism. Do vaccines cause
autism?

We know that the Institute of Medicine has reported that there is no
correlation between thimerosal content in vaccines and autism.

We do not yet know the cause of autism. And resources would be best
spent understanding this better.

More and more science is talking about the genetic basis of autism. But
one of the saddest things to me is that we have spent so much time down
the wrong road.

And I do talk to parents of children with autism. Some of them are my
colleagues right within my own department who say we need this topic to
go away. Because we're spending too many resources on the wrong issue.
We really need resources to go to find a better understanding to autism.

We know there's been epidemiologic studies in different parts of the
world that have shown no relationship between vaccines and autism.

For example, the Danish study. Looking at 500,000 children over a seven
year period found no association.

And the Danes have this amazing electronic medical record where they can
look at essentially every child in their country, every vaccine they've
got and every disease. And so it's an enormous helpful database.

In the U.S. we also use the vaccine safety data link which is a large
network of HMO information. And you can queue up questions. Does X cause
Y. This safety data link did not show a relationship between vaccines
and autism or other neurodevelopment disorders.

We know that temporal association between things is not the same as a
causal association.

So, just because things happen around the same time - my baby got MMR
and then I noticed he wasn't as social, it does not mean that it's cause
and effect.

You look to the fact that when you do autopsies on people who have died
in car accidents. Almost all of them have bread in their stomach. Well
is that because if you eat bread you'll get in a car accident?

That's a temporal association, but that doesn't mean it's cause and
effect. So we have to be careful in how we think and talk about these
things.

So back to our challenges. Those of you who are clinicians on this line
know that one of your biggest challenges to taking the time to
communicate about these things is time itself.

You may only have 15 minutes for a well-check and you have as many
topics to cover in that time. And immunization is just one of them. So
time is difficult.

Prevention. We do all of this vaccination and nothing happens. We have
no disease. We have no outbreaks. So prevention in itself is sort of a
difficult topic.

This is also a very complicated science. As I said, T cells, B cells,
antigens. These are cellular level things that people just don't think
about on a day-to-day basis.

And as we discuss diseases and their difficulties and the vaccines and
potential side effects, sometimes you can see the parents eyes just
glaze over. And we have to make sure that we're being very clear about
talking about the disease versus the vaccine.

And then of course as we all know this can be an emotional topic. There
can be fear and anxiety and that knot in the stomach that Kris
described.

Multiple languages can be challenges. And we sometimes speak medicalese.
We need to try to not do that. To try to speak as clear and concisely
and using interpreters as needed.

Perceptions are also challenging. Someone may perceive that these
vaccines themselves are much more dangerous than the disease is. Or the
perception that these diseases are gone. When was the last time we saw
polio?

Well they may be gone in the Northern Hemisphere, but they are but a
plane ride away.

And then we'll have people of course in our clinics who have their mind
made up. And they really don't want to talk about it.

And sometimes that can be two ways. We have parents who are - bring in
their fifth or sixth child and they say, you know, I've read all that. I
don't really need to look at the VIS. I just want you to give them all
the shots they need today. And they really don't want education at that
time.

And then the opposite. Where they have decided that they don't believe
in vaccines, and all the talking and communicating may not help. I say
never give up. Continue to communicate and do the best you can.

And last, one of our challenges is information resource challenges.
Where do people learn from? Are they going on the Internet? Of course
they are. Are they listening to Oprah? Of course they are. Are they
reading the Washington Post? Of course they are.

And these all have information in them that may or may not be accurate.
So what do we do? What are our strategies to reduce myths and
misperceptions?

Well, Kris nicely described the Pediatrician. The first thing we do is
listen. We try to find out what is the root of the misunderstanding, or
of their fear. Is it a fear-based issue? Is it an attitude? Do they have
a knowledge deficit?

Sometimes we'll find parents that say well I came in at two months and
they got a bunch of shots. I thought that was all that they needed.

What's their experience? Maybe they have a person in their family who
has had a significant side effect to a vaccine. What are their emotions?
What are their beliefs? Try to determine that.

And then of course the media is difficult in that they try to be
balanced, but is it even possible? How do we even represent that 98% of
parents effectively who are choosing to immunize their child?

When we talk about a vaccine story that may have only affected a very
small percentage of children.

One of the things we can do as clinicians is model. We can have our flu
vaccines. We can have our Hepatitis B vaccine. We can talk about the
importance of keeping up on our tetanus and Pertussis booster by getting
our one time Tdap.

Vaccinating healthcare professionals and we talking about how we
ourselves have been vaccinated because we know it's the right thing to
do.

And then of course story telling. I have so many stories of children
I've taken care of over the years. I don't even know where to begin.

But I thought I would share with a most recent one. And this is a story
that was on our local television here in January of 2007.

This family shared their son's story. He was an 8-year-old named Lucio
who was an otherwise healthy, baseball playing, adorable kiddo who died
of influenza A.

And his parents wanted other parents to know that you can die from
influenza. This is dangerous. It's around.

This went on the news the next day. Public Health Clinics, the State
Health Department, Children's Hospital, and private clinics faced droves
of parents, who called providers concerned asking for influenza
vaccines.

Telling those real stories makes a difference. We're not sure why it
takes a crisis or an outbreak to have people moved to do the vaccination
as they should. But story telling does help move parents.

So other reasons that parents may give to not immunize, I kind of lump
in four categories. Maybe they have true medial contraindications. For
example, they might want an intranasal influenza vaccine, but they have
a significant egg allergy. That would be a medical contraindication.

A precaution may be something to make that clinician pause, think about
the risk and benefit of vaccinating today or not. Safety side effects
may be the thing that really drives parents.

They might have some philosophical issues of individual rights and
freedoms. Or alternative health beliefs. Or there may be some religious
issues that give them pause and want them to not immunize.

The Washington Post this week - the quote was there I believe that "good
health is achieved through seeking God". And therefore someone did not
believe that vaccines were necessary.

So, if we don't get to the bottom of where they're thinking is coming
from it will be difficult to know how to best communicate.

The other thing I'm noticing in taking care of families is that people
really want safety for their children. Of course we all do. Those of us
who have children. Those of use who work in healthcare, in the vaccine
business. We want our children to be safe. That's why we do all of this
work.

But what is safe? Is safe no harm? We live in a world of harm. I have
two teenagers. I think about harm all the time.

And so, when it comes to vaccine is vaccine no harm meaning that the
vaccine is 100% safe? Well we can't really say that.

Does safety mean that no harm from the disease? That the vaccine is
going to be 100% effective? We can't say that either.

We know that people who get, for example, influenza vaccine may in fact
get influenza. Hopefully they'll have a lesser case and not have it as
severe.

But, do we communicate realistic expectations when we immunize? We need
to make sure that we're talking about the percent of effectiveness. The
side effects to watch for. That local redness and induration that they
might get on their leg is to be expected. That's a local reaction - you
can observe the immune system working there on those antigens. To be
expected.

So communicate that safety and effectiveness of receiving vaccines is
far less risky than being un-immunized. To do nothing is to take a risk.
And we have to remind people of that.

So here are some practical thoughts on how we reduce these challenges.
Establishing that rapport. Even in Kris's case that she shared so nicely
with us, one may just meet a provider for one time. And you can
initially show the empathy, have a listening skill, show that you've got
trust and that you can be listened to and relied upon.

Determine the understanding. What have their experiences been? Ask them.
Have you had a problem with vaccines before? Break down that emotional
barrier.

Make sure it's two-way conversation, not just a lecture or reading off
the VIS and the parent doesn't get to say anything else.

Give that personal provider experience with vaccine safety issues that
you personally have had, that you're state has experienced or that we've
experienced nationally.

Talk about that we have emerging measles outbreaks that are happening
all across the country right now.

Encourage those questions. Give that life perspective and real examples.
Provide supporting information. We have a nice brochure that we give out
with reliable resources that you can look up on the Internet yourself.
And you will find wonderful information. But make sure that they know
it's a reliable place to go.

You want to keep the conversation focused. You want to control without
being controlling. And sometimes that's difficult to do when emotions
rise high.

You want to enhance our vaccine communication by first of all
recognizing we are in a challenging business. There's no two ways about
it.

We want to meet our parents and patients and where they are answer their
concerns.

Share those goals of informed decision-making in a partnership.

Engage in a dialog with trust and open understanding.

And be evidence-based. As definitive as the science allows. We don't
want to say anything less because that would be risk compression. And we
don't want to say anything more which may not be truthful.

But we need to help parents be guided to the answer together.

We wouldn't say to a parent, well your child needs open heart surgery,
but that's up to you. You can choose if you want to do that or not.

So I'm not sure why we say that when we're talking about vaccines.

We want to individualize the message and methods of communication.

And of course, always using current information and vaccine information
statements. And looking at the date and recording those dates
appropriately.

Making sure we communicate in clear, plain language. Visual aids,
helping by drawing pictures. Using analogies like the ocean analogy.
Keeping it interactive.

To try to get at the time factor, some clinics are going to group
teaching. Where they'll have a Tuesday and Thursday night vaccine
education class. Where you can come and sit down with a provider, watch
a video, have your questions answered.

Again, provide reliable Web sites. Have parent-to-parent sessions. A
phone call to a parent who has children that immunize and why they did
that.

And taped phone messages work really well when parents are on hold -
hopefully not too long, at your clinic. They can listen to messages that
have been thoughtfully put together about vaccines safety.

You want to use the five C's of effective communication. Have good
chemistry. Have clarity. Be consistent. So every time that parent comes
in and says, you know, I really don't think they need the chicken pox
vaccine - that you bring up the chicken pox vaccine. That you really
mean that consistently - this is an important vaccine and I want to talk
more about it.

Have the credibility. And also of course, be caring and compassionate.

Keeping your message simple. Keeping it simple is definitely better. A
one sentence description of the disease. And this is why working off the
vaccine information statements is so helpful. All that you need is on
there.

A word about its prevalence or dangers in your own community in the
world can be added to the VIS. Describing that vaccine benefits.
Describing the vaccine risks and the risks of not immunizing.

Advising about what to expect. What normal, local responses are actually
good. And what to expect.

Inform what to do in the event of a severe adverse reaction. Who do they
call? What should they do?

And then emphasize the return visits, so they keep on the recommended
schedule.

And then I think another thing we can do is really emphasize that
on-going safety monitoring.

We don't just vote on a vaccine at the Advisory Committee on
Immunization Practices and then move on to the next vaccine. We're
constantly monitoring vaccine safety in a number of ways that are listed
here.

From (VAERS) to post-marketing surveillance. And so going through and
describing to parents how these are always being looked at.

And we have good examples where we have found errors or problems with
vaccines and we've removed them from the market.

So in summary, we have many vaccine communication challenges that exist
in our practice settings today.

We really need to determine the origin of those concerns. And address
concerns with effective risk benefit communication strategies.

And also, really emphasizing that the risk of the disease far outweighs
the risk of the vaccine.

Underscore safety is a top priority for all of us. For those who are
developing vaccines. For those who vote on the policy of vaccines. For
those who give vaccines in their clinic. And for parents who choose it.

We all have the same goal. And that is safety of our children. That
safety is monitored in an on-going strategy - in an on-going way. And
then we have multiple strategies that we can consider using to make our
communication more clear.

And in the end, keep our communication clear, compassionate, yet
confident. So we want to keep these quarantined pictures in black and
white - like they used to be.

And not see these diseases rise back up in our communities. And keep our
digital photos only of healthy, happy children. Thanks a lot.

Andrew Kroger: Thank you very much Patsy for those communication and
clinical pearls. I am going to need to move on to closing information -
some housekeeping information.

For continuing education credits, please go to
[www.cdc.gov/tceonline](http://www.cdc.gov/tceonline). The course number
for this Net Conference is EC1268. And the verification code is CR248F
and I will repeat that CR248F.

And please keep in mind that CE credit will expire July 14, 2008.

Once you to become familiar with the online system, you will find it
easy to use and a great way to keep track of CE credit earned from CDC
training programs.

If you're having any difficulty or you are new to the system, you can
get assistance by phoning 1-800-41-TRAIN or another number 404-639-1292.
Both numbers during business hours from 8 am to 4:30 pm Easter Time.

To get help by way of email, you can contact <ce@cdc.gov>.

If you were unable to ask your question today, or if you have other
questions related to this Net Conference or in general you can contact
us at our email question and answer service at the address nipinfo -
[n-i-p-info - \@cdc.gov](mailto:n-i-p-info@cdc.gov).

If the question is related to the Net Conference, please write the word
Net Conference in the subject line. And we do definitely look forward to
receiving feedback as well.

Another way that you can ask us a question is to call the CDC hotline.
That's at 1-800-CDC-INFO - CDC I-N-F-O. This is a general hotline
service that handles immunization-related questions in addition to other
public health-related questions. The hotline is staffed 24 hours a day 7
days a week.

So I'd really like to thank everyone for joining us today. With a
special thanks to our subject matter experts Christine Shetty and
Patricia Stinchfield.

And thank you very much from Atlanta and have a great day.

Coordinator: Thank you. And this does conclude today's conference. We
thank you for your participation. At this time you may disconnect your
lines.

END