Public health officials must find better ways to communicate with parents about the risks and benefits of childhood vaccination, researchers and public health officials agree.

That task is particularly challenging in the absence of a national, or a provincial, vaccine surveillance registry because, to target messages effectively, accurate and timely information about vaccination rates and trends is critical.

Primary health practitioners can also play a key role by engaging parents in non-judgmental discussions about vaccination at key moments during the course of having children and early development.

The call for better information and better communication is prompted by the re-emergence of vaccine-preventable illnesses, such as whooping cough and measles, the outbreaks of which are associated with a drop in vaccination rates.

In Ontario, parents can obtain exemptions from school-entry vaccination laws for medical reasons and for “sincerely held convictions based on the parent’s religion or conscience.”

While the overall exemption rate is less than two per cent, there’s been an  “increased propensity” towards non-medical exemptions for children born in 1998 and later, according to a 2010 study, Compulsory School-Entry Vaccination Laws and Exemptions: Who is Opting Out in Ontario and Why Does it Matter.

The study compared exemptions before and after 1998, which was the year that a widely publicized (but now thoroughly refuted) report, published in The Lancet, linked the Measles Mumps Ruebella vaccine to autism.

Exemption trends may create barrier to vaccination targets

Parents “may be increasingly weighing perceived personal risk over personal and population benefit,” states the report, and the “exemption trend constitutes another barrier to achieving the levels of immunization coverage required to prevent disease transmission.”

Concern about lack of safety—in particular the possibility of adverse reactions— was the top reason cited by parents who choose not to vaccinate, conclude the authors of Parental Views on pediatric vaccination: the impact of competing advocacy coalitions, a 2008 study of Ontario parent coalitions, based on focus groups conducted in Toronto. The second most cited reason was doubt about the effectiveness of vaccinations.

Those parents also cited the (discredited) research that incorrectly linked the MMR vaccination to autism, and concerns about the unproven risks posed by vaccine components such as thimerosal (ethylmercury).

Polarization of viewpoints

“We’ve observed an increasing polarization of viewpoints,” between pro-vaccine public health officials and anti-vaccine groups, Kumanan Wilson, lead author and a physician and researcher with the Ottawa Health Research Institute, said in an interview. “There’s been no effective dialogue between the two.”

But average parents  “can hear a lot of rhetoric and get scared off from vaccinating. . . it can dissuade them, at least temporarily,” he said. Vaccination schedules begin when infants are two months old and it can be a difficult time for parents to make a decision—parents can feel overwhelmed, he said.

“And with more vaccines added to the schedule, it can all seem like too much for some parents,” Wilson said.  (In the past several years, an injection of federal funding—some of it temporary—has led to a rapid expansion of immunization programs.)

Effective messaging is critical

The study concludes that parents who vaccinate “appear to have weaker belief systems” than anti-vaccine groups, and are therefore potentially susceptible to change. Effective messaging to this group is critical and “if trust in public health falters, many who currently support vaccination may re-evaluate their positions,” he said.

While exemption rates appear to be low among school age children, there is an information vacuum about pre-school children, since Canada and Ontario lack a vaccine registry system. Parents concerns can’t be effectively addressed without accurate information, Wilson stresses.

A 2006 study by the Institute for Clinical Evaluative Sciences estimated, based on doctors’ billings, that only 75 per cent of two year olds in Toronto—pre-schoolers not covered by vaccination legislation unless registered in day care or nurseries— were up to date for age-appropriate vaccines and four percent had received no vaccines.

Natasha Crowcroft, chief of communicable diseases at Ontario Public Health, says public health officials “need to be really creative—no one has the perfect answer—about how to sustain confidence in the system when things are going well.”

Crowcroft was the guest on a CBC radio phone-in show about vaccination last month, and the majority of callers were opposed to vaccination. Parents, for example, argued that keeping children healthy with good nutrition is the best defence against illness.

During the program, Crowcroft acknowledged that such views are widespread, but gently suggested parents who have lost a child to a vaccine-preventable illness would feel differently about the protection afforded by good nutrition.

“Victims of our own success”

There’s been a global trend among parents to think a healthy lifestyle will protect their children, she said in an interview. “Time and again such thinking has been proven to be wrong . . . people nowadays have the luxury of thinking they won’t see these diseases again. We are the victims of our own success.”

But not every country benefits from vaccination rates high enough to protect the population. The World Health Organization is a major partner in the Decade of Vaccine Collaboration to bring the benefits of effective vaccine programs to all parts of the world, including low income countries where coverage rates for vaccination are typically low and associated disease and death are predictably high. Hundreds of millions of cases and millions of deaths can be averted through well-orchestrated, country-level commitments, plans and resources.

Crowcroft said ideally education about vaccines would start in schools, with students learning basic science about how the human body works, about antibodies, and the history of the chickenpox vaccine. People who rely on Internet research often find “nonsense and lies,” but it’s not effective for public health officials to “scare people” in an effort to promote vaccination, she adds.

However, as an opinion piece in the CMAJ argued, the popularity of Internet research for health issues can’t be ignored, and public health officials have to adapt.

Journalist Seth Mnookin’s 2011 book, The Panic Virus, examines modern day fear of vaccines, bogus research, and the role of media in fostering parental fears. But he is also concerned about the role of public health officials.

Scientifically trained people who look at some unsupported, but popularized research are “astounded” that anyone would believe it and can “respond accordingly,” he said in an interview.

Parents “just want to take care of their kids”

But that’s a mistake, he argues, because when public health and medical workers mock parents opposed to childhood vaccination, they spark negative reactions even among parents who support vaccination.

It can alienate parents who hear, in that attitude, authority figures insulting other parents who “just want to take care of their kids,” says Mnookin.

But such responses fail to understand that, for example, anxiety about vaccinations can be a proxy for young parents’ anxiety about how to protect children. “And parents who chose not to vaccinate can feel that by making that choice they are exercising control in a chaotic world.”

Mnookin believes that one way to address the misunderstandings is to have information about vaccination presenting to parents during pregnancy, for example in prenatal classes, rather than at an infant’s first appointment when the doctor “may have a needle in hand.”

Public health does have a social media presence—both the Public Health Agency of Canada (PHAC)  and Public Health Ontario are on twitter and PHAC is on Facebook. But Doug Sider, Ontario’s associate chief medical officer of health, says the agencies still need to communicate more effectively with parents—and with physicians—through social media.

It’s not helpful to be judgmental

Susan Phillips, a physician and professor at Queen’s University, says in her experience the vast majority of parents don’t question the need for vaccination. Those who choose not to follow the vaccination schedule “have given it a huge amount of thought” and fall into two general categories—those who oppose vaccination, and those who delay having their child vaccinated.

She says that as a clinician, it’s not helpful to be judgmental, but she does sometimes initiate a discussion about the risks and benefits of vaccination.

Canada appears to be dropping the ball when it comes to building a vaccine registry and surveillance system to give public health timely access to comprehensive information about vaccination rates and trends in the population.

The lack of that information jeopardizes public health’s ability— not only to tackle outbreaks of vaccine preventable illnesses— but also to communicate effectively with parents and to counter misinformation that can easily be spread through the internet.

At the same time, it may be time to rethink how and when health care providers stage the ‘encounter’ with families and children on vaccination. A more focused, deliberative, non judgmental engagement with parents may be called for during the major milestones of  pregnancy, childbirth, early preschool years, and primary and high school.

This is part two of a  series on vaccine related issues. The first ‘Absence of vaccine registry hampers ability to track vaccine-preventable outbreaks’ is available here.