Robert M Jacobson, MD, FAAPProfessor of Pediatrics, Mayo Clinic

President, SEMICMed Dir, Mayo’s Primary Care Immun ProgramPresident, MN Chap Amer Acad of Pediatrics

Working with Vaccine Hesitant Parents using the

C.A.S.E. Approach

Disclosures

• Potential conflicts– Safety Review Committee • Male HPV4 Gardasil® vaccine (Merck)

– Data and Safety Monitoring Board• Adult and infant PCV15 (Merck)

• No off-label use discussion

Disclosures

• Potential conflicts– Jacobson v Massachusetts– Reverend Henning Jacobson– Martin Bror Johan Jacobson– Robert Bror Jacobson

Learning Objectives

• Relate a new approach to vaccine hesitancy• Identify each of its 4 components• Describe how it works in 3 common scenarios

The State of Vaccination

• The anti-vaccine movement is thriving– Successful vaccination makes its value invisible– Media seeks to portray controversy, “both sides”– Americans culturally opposed to “social health”

• Vaccine hesitancy is a major issue– Not just among exempters and delayers– Even 25 to 30% of those up-to-date

• Both vaccine provider and parent struggle

The Vaccine Provider in the Office

• Has little time for discussion• Suffers a sense of rejection as wise advisor• Feels sense of futility• Recognizes problem of health illiteracy

The Parent in the Office

• Would like to be heard• Wishes to be respected• Seeks credible information• Wants control; wants to make the decision

The Back Fire Effect

• Nyhan et al 2014• 1759 parents 18 years and older• Two waves of online messaging• Randomized 5 different interventions– Info explaining the lack of evidence re autism– Info re dangers of diseases prevented by MMR – Images of children w/diseases prevented by MMR– Dramatic narrative re infant almost died of measles– Control group

The Back Fire Effect

• Results– None of 4 interventions increased intent to

vaccinate– Info re autism improved expressed knowledge but

decreased intent to vaccinate– Images and narrative worsened fears re autism

Clinician Recommendation Matters

• Many studies across many vaccines and ages– Gnanasekaran 2006– Nowalk 2007– Guerry et al 2011– Brewer et al 2011– Ylitalo et al 2013– Darden et al 2013– Jacobson and Darden 2014

• Clinician recommendations increase rates

Hey, lady! Where do you want this

health care delivered?

Information Transfer Not Enough

Hey, lady! Where do you want this

health care delivered?

Rhetoric

Rhetoric

Logos

Rhetoric

Logos

Ethos

Rhetoric

Logos

Pathos Ethos

Persuasion

Information

Passion Standing

The C.A.S.E. for Vaccines

• A model for talking to vaccine-hesitant parents • A mnemonic to organize a rapid, useful response• Created by Alison Tepper Singer– Formerly, NBC and CNBC television producer – Mother of an autistic child– Quit Autism Speaks over its anti-vaccination stance– Founding CEO of Autism Science Foundation– Strong advocate of science and routine vaccination

The Case for C.A.S.E.

• Provides more than just information• Has historical roots in Aristotelian rhetoric• Lacks published studies of its efficacy• Nonetheless has face validity• Lacks competing alternatives• Preserves the relationship

The C.A.S.E. Acronym

• Corroborate• About Me• Science• Explain/Advise

The C.A.S.E. Approach

• Corroborate:– Acknowledge the person’ concern – Find some point on which you can agree– Set the tone for a respectful, successful talk

• About Me:– Describe what you have done to build your knowledge base and

expertise

• Science: – Relate what the science says

• Explain/Advise: – Explain your advice to patient, based on the science

A Hesitant Parent

We want to pass on the MMR vaccine

today. The others are fine.

C for Corroborate

Please tell me why you want to pass on the MMR vaccine.

The Parent’s Specific Concern

I’m worried that it might cause autism.

There’s just too much in the news about it.

More Corroboration

If the MMR vaccine caused autism, I wouldn’t want your child to get it

either. Just like you, I want to do whatever I can

do to keep your child healthy.

A for About Me

I have been studying this claim for many years now and have read the studies that tested whether the MMR vaccine

causes autism. I’ve also been reading the studies about the

autism itself.

S for Science

Dozens of very large, well-done studies have shown that

the MMR vaccine does not cause autism.

More Science

In fact, the studies about autism show that children who are going to get autism show

the signs of autism long before they receive the MMR vaccine.

More Science

On the other hand, the MMR vaccine prevents measles

disease, and I have seen how serious measles disease can be. 1 in 3 children have been

so sick they had to be hospitalized. Some die of

measles.

E for Explain

We both want your child healthy. Your passing on the MMR will not protect your child from autism,

but it will leave your child at risk for diseases that can result in

hospitalization or worse. As your child’s doctor, I urge you to have your child get the MMR vaccine.

Another Hesitant Parent

It’s just too many shots at once. I just want to spread them out and give them

one at a time.

C for Corroborate

We do give more injections now in the first few visits. What specifically worries

you about that?

More Specifics

Won’t it overload her immune system? How do we know it’s really

safe?

More Corroboration

You are not the first parent to ask that question. My own

spouse asked me about that at our first baby’s two-month

check-up.

A for About Me

So I read through the recommendations carefully and the discussions among experts about the safety of

giving all these vaccines together.

S for Science

Although kids get more shots today, they actually receive fewer

antigens than when they got fewer shots, because technology has enabled us to make vaccines that have only the part of the cell that induces immune response.

More on Science

Plus, the immunological challenge from a vaccine is

nothing compared to what kids fight off every day. An ear

infection is a bigger immunological challenge.

E for Explain/Advise

We want all the kids in our practice to be immunized so that they have the greatest

chance for a long, healthy life. I made sure my own children

got all the vaccines recommended on time.

A Hesitant Mother-to-Be

I don’t want a Tdap, I just had one after I had my baby two years ago. It just

doesn’t seem safe.

C for Corroborate

I too wondered about the frequency

of getting Tdap during every

pregnancy. We used to say only one Tdap

ever.

A For About Me

So, I went to the recommendations that were

just published to better understand the reasoning and

the data a Tdap for each pregnancy.

S For Science

Pertussis can be most severe in infant who have started

their vaccination. The majority of deaths occur in infants less

than three months old.

More on Science

I learned that the recommendation was made to take advantage of the mother’s

ability to pass on pertussis protection to the baby so the

baby is protected until they are old enough to get vaccinated.

More on Science

Because the level of protective antibodies declines after the first year of vaccination, it won’t protect babies from

future pregnancies.

More on Science

Meanwhile studies show the Tdap is safe to pregnant

mothers and their fetuses. That’s why they’ve made this

recommendation.

More on Science

So far what experts have observed is swelling and

redness at the injection site. It won’t cause you harm and it

just may save your baby’s life.

E for Explain/Advise

Protecting your baby against pertussis in the first couple

months is so important that I recommend that you get the

Tdap today.

Other Forms of Corroborate

• I’ve heard that too• I first thought that as well• Lots of parents wonder about that• We both want your child healthy, safe, and

free of disease

Other Forms of About Me

• This is one of the most important things I do• I’ve been studying this topic for years• I’ve dedicated my life to this work• I lose money on vaccines but I don’t regret it

Other Forms of Science

• Let me tell you a story about a patient of mine…• No vaccine is 100% safe but studies show…• I asked a leading expert the same question…

Other Forms of Explain/Advise

• That’s why I got the vaccine myself• That’s why I made sure my baby got this vaccine• If I had children, I’d get them this vaccine• If I were in your shoes, I’d choose to vaccinate• I feel more strongly about this than I do about

antibiotics for ear infections

C.A.S.E.

• Not just information• Not scare tactics• But your advice

• You have more than the science• You have your connection with the parent• You have your standing with the parent• You have the passion you hold for your advice

The C.A.S.E. Approach

• Corroborate:– Connect emotionally with the parent

– About Me:– Buttress your professional standing with the parent

• Science: – Summarize the science

• Explain/Advise: – Passionately advise given your status or standing and the

science

Practice

• Pair up in twos• Have one play the role of a hesitating parent • Have one play the role of vaccine provider• Work through all four steps of C.A.S.E.– Corroborate– About Me– Science– Explain/Advise

Summary

• Relate a new approach to vaccine hesitancy– Passionately advise using science and standing

• Identify each of the 4 components of C.A.S.E.– Corroborate – About Me– Science– Explain/Advise

• Describe how it works in 3 common scenarios