Canadian Immunization Guide
Seventh Edition - 2006

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Part 1
General Guidelines

Communicating Effectively about Immunization

Public concern regarding vaccine safety can reduce vaccine coverage and result in resurgence of vaccine-preventable diseases. As trusted information sources, health care providers have a vital role in the continued success of immunization programs. To be most effective, providers must have skill and expertise, not only in the principles and practices of immunization but also in risk communication. This section outlines the general principles of risk communication and identifies additional resources for providers and the public.

Principles of risk communication

The goal of effective risk communication is the development of an informed decision-making partnership. The process involves both education and advocacy, and is facilitated through advance preparation by all participants, clear messaging, and an open and respectful atmosphere. An individual's perception of risk is influenced by experience as well as personal, religious and cultural contexts. Furthermore, events that are familiar, involve a natural process, seem to be under an individual's control, are of a voluntary nature or involve a decision to forgo something are generally perceived as less risky than those that are unfamiliar, involve a man-made process, involve loss of control, are mandatory or involve a decision to do something rather than avoid something. A decision to become immunized or immunize a child clearly falls into the latter "high risk" category regardless of the true odds. Framing the risks in the right context is very important. Countering an individual's concerns by citing the greater dangers of a familiar event, like driving a car, while true, may be counterproductive.

For effective risk communication, physicians and other health care providers should attempt to do the following:

1. Communicate current knowledge, taking into account what an individual already knows and the level of detail requested. The process need not be time-consuming. It is useful to have varied information formats (visual, audio, printed material, Web sites) tailored to a range of educational levels and languages as appropriate to a given practice/clientele. Given the volume, accessibility and variable quality of material available on the Internet, it is also helpful to provide guidance on how to assess Web site reliability. Several excellent resources are listed at the end of this section.
2. Respect differences of opinion about immunization. Some individuals will express reluctance or refusal to accept immunization for themselves or their children. It is important to both gauge the strength of this stance as well as discover its underlying reasons.
3. Represent the risks and benefits of vaccines fairly and openly. Contrast the known and theoretical risks of vaccine with the known risks associated with the vaccine-preventable infection (see at the end of this Guide for a table on Comparison of Effects of Diseases and Vaccines). It is also important to counter the notion that vaccine-preventable diseases are gone (see box).
4. Adopt a patient-centred approach. Effective decision making is best done in a partnership between the provider or vaccinator and the parent or patient. Central to this is the acceptance that individuals have input into the decision to immunize and retain responsibility for their own or their child's health. A decision to do something rather than to avoid something may cause greater concern when it comes to immunizing children. It may be helpful to present the facts and then ask those responsible to consider what the child would choose, were he or she old enough to do so.
5. Make the most of each opportunity to present clear, evidence-based messages regarding vaccines and immunizations (see box). Encourage questions, address misinformation, and provide valid and appropriate resources, including authoritative Web sites, for those who want more information.

Conclusion

As long as the diseases that vaccines prevent are rarely seen by the general public today, vaccine safety concerns will continue to have a high profile. Careful and timely counselling can help people to weigh the benefits of vaccines and the risks of the disease that the vaccine will prevent, as well as the small risk posed by the vaccine itself. By providing vaccines in a climate of appropriate informed consent, including discussion of commonly held misconceptions, health care providers can help ensure that immunization will maintain its status as one of the most effective preventive measures in the history of medicine.

Immunization Truths Immunization is the best protective strategy against vaccine-preventable diseases. The vaccines used in Canada are both effective and safe. Health authorities worldwide take vaccine safety very seriously. Expert committees in Canada investigate reports of serious adverse events following immunization. Vaccines do not weaken the immune system. Rather, they harness and train it to defend, rapidly, against vaccine-preventable pathogens before illness can occur. Vaccine-preventable infections are far more dangerous than vaccines (see the Table on Comparison of Effects of Diseases and Vaccines at the end of the Guide ) . The bacteria and viruses that cause vaccine-preventable diseases are not gone. Diphtheria, pertussis, polio, measles, mumps, rubella, varicella, hepatitis A and B are well adapted human pathogens that, to a greater or lesser extent, are contagious and are still occurring in parts of the world. Tetanus is a soil organism - it will never be eliminated. Haemophilus influenzae type b, Streptococcus pneumoniae and Neisseria meningitidis can survive in the nose and throat and will likely never be completely eliminated. Unvaccinated individuals have a much greater chance of getting a vaccine-preventable disease than those who have received the vaccine. This is true even in countries where high levels of immunization provide some degree of protection to susceptible individuals (i.e., herd immunity). Three examples: An outbreak of rubella occurred in 2005 among unimmunized individuals in Ontario. Children in the United States who did not receive measles vaccine were 22 to 35 times more likely to get measles than immunized children. Children in the United States who did not receive pertussis vaccine were almost 6 times more likely to get whooping cough than immunized children. When vaccine coverage drops, vaccine-preventable diseases return: In Japan, pertussis vaccine coverage dropped from 90% to less than 40% because of public concern over two infant deaths that followed DPT immunization. Prior to the drop in coverage there were 200 to 400 cases of pertussis each year in Japan. From 1976 to 1979, following the marked drop in vaccine coverage, there were 13,000 cases of pertussis, of which over 100 were fatal. In Ireland, measles vaccine coverage dropped to 76% following allegations of a link with autism. The number of measles cases increased from 148 in 1999 to 1200 in 2000, along with several child deaths due to the complications of measles.

References and Web resources for immunization risk communication

A. How to communicate

Spier RE. Perception of risk of vaccine adverse events: a historical perspective. Vaccine 2001;20:S78-84.

Stoto MA, Evans G, Bostrom A. Vaccine risk communication. American Journal of Preventive Medicine 1998;14(3):237-39.

Summary. Workshop on Vaccine Communication, October 5-6, 2000, Arlington, Virginia. URL: <http://www.dhhs.gov/nvpo/pubs/vcwsummary.pdf>.

Tenrreiro KN. Time-efficient strategies to ensure vaccine risk/benefit communication. Journal of Pediatric Nursing 2005;20:469-76.

B. What to communicate

Canadian Coalition for Immunization Awareness and Promotion. Addressing patient concerns. URL: <http://www.immunize.cpha.ca/english/links/hlthprv.htm> (English); <http://www.immunize.cpha.ca/francais/hcprovdf/provresf/provparf.htm> (French).

Canadian Paediatric Society. URL: <www.cps.ca>

Children's Hospital of Philadelphia Vaccine Education Center. URL: <http://www.chop.edu/consumer/jsp/microsite/microsite.jsp?id=75918>.

Gold R and Canadian Paediatric Society. Your child's best shot: a parent's guide to vaccination, 2^nd ed. 2002. URL: <www.cps.ca/english/publications/Bookstore/YourChildsBestShot.htm>.

Immunization Action Coalition. URL: <www.immunize.org>. (Information in several formats, including video.)

National Network for Immunization Information. URL: <www.immunizationinfo.org>. Communicating with patients about immunization. URL: <http://www.immunizationinfo.org/healthProfessionals/resource_kit.cfm>.

C. How to evaluate Web site quality and reliability

Centers for Disease Control and Prevention. URL: <http://www.immunizationinfo.org/parents/evaluatingWeb.cfm> (tips on how to assess vaccine Web sites).

World Health Organization. URL: <http://www.who.int/immunization_safety/safety_quality/vaccine_safety_websites/en/>. Vaccine safety net - lists sites with information related to vaccine safety that meet criteria related to credibility, content, accessibility and design.

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