Vaccine Opposition and Hesitancy¶

Chapter 3 | Part 1: The Profession of Medicine

KEY CLINICAL POINTS¶

Vaccine hesitancy is defined as delay or refusal of vaccines despite availability and exists on a continuum from active demand to complete refusal
Herd immunity for measles requires 93-95% vaccination coverage; national rates of ~92% leave vulnerable pockets that enable outbreaks
The three C's of vaccine hesitancy are Complacency, Convenience, and Confidence - all modifiable through targeted interventions
A strong, unambiguous recommendation from a trusted healthcare provider is the most influential factor in vaccine acceptance
Presumptive/directive communication works best for most patients, while participatory/guiding approaches are needed for highly hesitant individuals

1. DEFINITION & OVERVIEW¶

Vaccines are recognized as one of the top public health achievements of the twentieth century, with dramatic declines in morbidity and mortality of vaccine-preventable diseases. However, vaccine opposition and hesitancy have existed since Edward Jenner introduced the first smallpox vaccine in the eighteenth century. The WHO ranked vaccine hesitancy as one of the ten greatest threats to public health in 2019. Modern vaccine hesitancy represents a 'crisis of confidence' manifesting as lack of trust in specific vaccines, vaccine programs, researchers, healthcare providers (HCPs), the health care system, pharmaceutical companies, academics, policymakers, governments, and authority in general.

1.1 WHO Definition¶

Vaccine hesitancy and opposition are defined by the WHO's SAGE Working Group on Vaccine Hesitancy as a 'delay in acceptance or refusal of vaccines despite availability of vaccination services.' The SAGE group describes vaccine hesitancy as 'complex and context specific, varying across time, place, and vaccines.'

1.2 Distinguishing Hesitancy from Access Issues¶

It is critical to distinguish persons who are hesitant and refuse vaccines from those who need assistance to access the health care system and successfully complete vaccination. An individual may be fully vaccinated but still be hesitant about safety and effectiveness, or an individual may be unvaccinated due to access issues but not be hesitant.

2. EPIDEMIOLOGY¶

Vaccination coverage rates provide an estimate of the proportion of children or adults who have been vaccinated but do not indicate the proportion who are vaccine hesitant.

Table 3-1: Measles Outbreaks in North America¶

Year/Place	No. of Cases	Reason
2010/Canada	70	Infected traveler to 2010 Winter Olympics transmitted to under- and unvaccinated local population in British Columbia
2011/Canada	776	Imported from France by unvaccinated returned traveler to Quebec; spread in nonvaccinating religious community; majority in under- and unvaccinated persons
2011/United States	118	46 cases in returned travelers from Europe and Asia/Pacific; 105 cases (89%) in unvaccinated persons
2013/United States	58	Imported by unvaccinated returned traveler from Europe; spread in nonvaccinating religious community in New York
2014/Canada	433	Imported from Netherlands; spread in nonvaccinating religious community in British Columbia
2014/United States	383	Occurred in nonvaccinating religious communities in Ohio
2015/United States	147	Multistate/multicountry outbreak linked to Disneyland; >80% in unvaccinated persons
2015/Canada	159	Imported from US (Disneyland outbreak) by unvaccinated traveler; spread in nonvaccinating religious community in Quebec
2017/United States	75	Occurred in undervaccinated community in Minnesota; 95% of patients unvaccinated
2018/United States	375	Imported by unvaccinated returned travelers from Israel; spread in nonvaccinating religious communities in New York and New Jersey
2019/Canada	31	Imported from Vietnam by returned traveler to British Columbia; spread in local schools; resulted in province-wide mass immunization campaign
2019/United States	1282	Outbreaks in 10 states; 73% (~935 cases) linked to nonvaccinating religious communities in New York

2.1 Coverage Rates in North America¶

National coverage estimates place one-dose measles vaccine coverage rates in 2-year-old children at 92% in both the United States and Canada. Despite these relatively high levels, numerous measles outbreaks have occurred in both countries since 2010. The vast majority (>80%) of measles cases occurred in under- or completely unvaccinated individuals.

2.2 Herd Immunity Requirements¶

Herd immunity occurs when enough individuals become immune (usually through vaccination) that transmission stops. Because measles is highly contagious, a coverage rate of 93-95% must be achieved for herd immunity. When herd immunity breaks (community immunity becomes too low), cases occur even in fully immunized persons.

2.3 Global Coverage¶

In 2022, only 34% of countries met the WHO goal of providing one dose of measles vaccine to at least 95% of their 1-year-old children - a decrease of 10% from prepandemic levels. Unvaccinated travelers are now likely to become infected in countries with active measles transmission and return home to spread infection.

2.4 Vulnerable Populations¶

Active measles transmission places individuals who rely on herd immunity at increased risk, including: - Immunocompromised persons - Young infants too young to be vaccinated - Individuals with waning vaccine protection - Those with individual-level characteristics affecting vaccine response (age, immunocompromise)

3. ETIOLOGY & PATHOPHYSIOLOGY¶

The roots of modern vaccine hesitancy and opposition vary depending on place and population. Multiple factors have converged to create a particularly potent form of hesitancy.

3.1 Causes of Vaccine Hesitancy¶

Pseudoscience and false claims about vaccine safety (e.g., unsupported link between measles vaccine and autism)
Real safety events (e.g., association of narcolepsy with Pandemrix pandemic influenza vaccine)
Failed health systems or state failures
Religious and cultural factors - fundamentalist religious groups and alternative-culture communities reflecting exclusion from and rejection of mainstream society and allopathic health care
Deep distrust of institutions and healthcare providers

3.2 The Three C's Model¶

Vaccine hesitancy can be influenced by three key factors: 1. COMPLACENCY: Self-satisfaction accompanied by lack of awareness of real dangers. Exists when perceived risks of vaccine-preventable diseases are low and vaccination is not deemed necessary. Influenced by actual or perceived vaccine efficacy/effectiveness. 2. CONVENIENCE: Determined by degree to which services can be provided in culturally safe contexts that are convenient and comfortable. Includes affordability, geographic accessibility, language, and health literacy. 3. CONFIDENCE: Based on trust in: - Safety and efficacy of vaccines - Health care system that delivers vaccines (including HCPs) - Policymakers/governments who decide which vaccines are used

3.3 Outcomes of Vaccine Hesitancy¶

Outcomes are uniform regardless of genesis: - Decrease in vaccine demand and uptake - Decrease in coverage by childhood and adult vaccines - Increase in vaccine-preventable diseases - Outbreaks and epidemics of disease

Recent social and cultural trends, combined with new communication formats and amplified by the COVID-19 pandemic, have created a crisis of confidence.

4.1 Individualized Health Care¶

Over the past 30 years, medicine has shifted to patient-oriented, individualized care with emphasis on treatment and prevention options tailored to individual patients. In vaccination programs, this manifests as requests for individualized vaccine recommendations and customized immunization schedules. This has forced public health away from community focus and created tension between individual rights and community health.

4.2 Parenting Trends¶

Cultural shifts have reframed the 'good parent' image to refer to 'a critical consumer of health services and products, accounting for their own individual situation as they see it with little regard for the implications of their decision on other children.' Good parents are now expected to seek individual medical advice tailored for their specific child, which can conflict directly with public health vaccine recommendations organized to maximize community health.

4.3 Traditional Media¶

Traditional media have been criticized for offering equal coverage to scientific evidence and unproven claims of vaccine harms, leading to false equivalencies. Celebrity advocates further amplified antivaccine messages. During COVID-19, traditional media approaches diversified based on political orientation of news sources, affecting patient risk perceptions and vaccine acceptance.

Approximately 92% of Americans and 95% of Canadians use the Internet; 90% of Americans and 86% of Canadians have active social network profiles. Problematic aspects: - 'Echo chamber' effect - users select information sources harboring similar beliefs, reinforcing existing views - New platform for vaccine misinformation (inaccuracies due to error) and disinformation (deliberate lies) - Forum for vaccine-resistant individuals to organize and raise funds - Personal stories and anecdotes disproportionately influence decision-making over fact-based sources In 2019, social media companies began deemphasizing antivaccination information, but misleading content remained widely available. Antivaccination users switched to alternate platforms without restrictions.

4.5 COVID-19 Infodemic¶

The pandemic accelerated spread of misinformation to the point of being termed an 'infodemic.' Response tools include: - WHO Early AI-Supported Response with Social Listening Platform (WHO EARS) - used in 30 countries - WHO/CDC infodemic management training - Centralized monitoring of vaccine misinformation with summaries and rebuttals provided to HCPs

5. VACCINE ACCEPTANCE CONTINUUM¶

Vaccine acceptance is framed as a continuum pyramid, with active demand for all vaccines representing the largest group at the bottom and outright refusal at the top. In the middle lies vaccine hesitancy with varying degrees of vaccine demand and acceptance.

5.1 Active Demand - No Doubts or Concerns (Base of Pyramid)¶

Characteristics: - Considers vaccines important and safe - Trusts HCP/vaccines/health system - Social norm is vaccinating Communication: Very short conversation with HCP about vaccination; address any questions to maintain active-demand status. Use Presumptive Communication Approach.

5.2 Hesitant - Minor Doubts and Concerns¶

Characteristics: - Focused toward vaccine risk - Complacency: low perceived benefits of vaccination - Can move up or down continuum based on various influences (HCP recommendation, vaccine scare, outbreak) - Trusts HCPs and health system - Convenience: need few barriers to vaccination Communication: Longer conversation but vaccination likely at same visit; potential to move to active demand. Use Presumptive Communication Approach.

5.3 Hesitant - Many Doubts and Concerns¶

Characteristics: - Focused on vaccine risks - Conversation with trusted HCP strongly influential - Actively seeking information and wants to verify it - Wants advice specific for their child - Confused by conflicting information - Social norm is vaccinating but individual feels conflicted Communication: Requires longer conversation and may require multiple visits. Use Participatory Communication Approach.

5.4 Late and Selective¶

Characteristics: - Questions safety and necessity of vaccines - Actively seeks information from many sources - Has conflicting feelings on whom to trust - Social norm is not vaccinating - May have had negative or traumatic experience with health system Communication: Vaccination may not occur; requires strong trust relationship with HCP and many visits/conversations. Use Participatory Communication Approach.

5.5 Refuses/Rejects Vaccines (Top of Pyramid)¶

Characteristics: - Strong distrust of health system/pharmaceutical industry/government - Strong-willed and committed against vaccines - Negative or traumatic experiences with HCPs and health system - May use natural approach to health/alternative HCPs - May have strong religious/moral considerations for refusal - May cluster in communities (geographic and online) Communication: Vaccination is very unlikely; alternative strategies to protect individual and community must be discussed. Use Participatory Communication Approach.

6. APPROACH TO THE PATIENT¶

An ideal vaccine-hesitancy intervention results in full compliance with vaccination, patient satisfaction with the health care encounter, and sustained trust in HCP recommendations. On a programmatic level, interventions should be multicomponent, dialogue-based, and tailored to specific undervaccinated populations.

6.1 Provider Challenges¶

HCPs may feel that vaccine-hesitant patients cast doubt on their personal and professional integrity, authority as medical experts, and competence as communicators. Some HCPs are reluctant to initiate conversations due to concerns about compromising clinical rapport. Others believe they lack sufficient training to confidently recommend vaccines and answer questions.

6.2 The Opportunity¶

Discussing vaccines with hesitant patients provides an opportunity to honor principles of patient-centered care by: - Demonstrating interest in patients' opinions - Engaging in dialogue - Increasing patients' confidence in vaccine recommendations Studies demonstrate that an unambiguous, strong recommendation by trusted HCPs is most often the reason patients, including those who are vaccine hesitant, choose to vaccinate.

7. FACTORS IN EFFECTIVE VACCINE RECOMMENDATIONS¶

Vaccine recommendations should be made within an established, trusting patient-provider relationship where patients are comfortable asking questions and voicing concerns. All recommendations should be: (1) Strong, (2) Tailored, (3) Transparent and accurate, (4) Supported by trustworthy information resources, and (5) Revisited with reinforcement during follow-up encounters.

Table 3-2: Sample Vaccine Conversations¶

Category	Example Statements
Strong Vaccine Recommendation	"We are headed into the respiratory virus season. Getting flu, RSV, and COVID vaccines not only protects you, but it helps protect other people around you who can get very sick from flu, RSV, or COVID. I strongly recommend you get shots. Do you know where to get them?"
Strong Vaccine Recommendation	"You will be turning 50 next year. This means you will be eligible for a vaccine that prevents shingles, and I strongly recommend you receive it. Have you heard about this vaccine before? Can I answer your questions about it?"
Strong Vaccine Recommendation	"I know you are not comfortable getting vaccinated today. I do want to make it clear that I recommend vaccines because I am convinced they are the best way to protect you from some serious diseases. Is there something that would lead you to think about getting vaccinated in the future?"
Tailored Communication	"I recommend that children and adults stay up to date on recommended vaccines. I see from your vaccine record that you've had your childhood vaccines, but you haven't gotten any adult vaccines. I wanted to clarify whether this is because you decided not to get vaccines or something else prevented you from getting vaccinated."
Tailored Communication	"There is strong evidence that COVID-19 vaccines work well for all people, regardless of their ethnic or genetic background. What particular concerns did you have about the vaccine?"
Tailored Communication	"Thank you for telling me about your fear of needles. This is quite common in children and in adults. Would you like to talk about some potential strategies to help you with getting vaccinated?"
Transparency and Accuracy	"Serious side effects can develop after MMR vaccination but are very rare. On average, 3 out of 10,000 children who get MMR vaccine will have a febrile seizure/convulsion in the days after vaccination. Febrile seizures can be frightening, but nearly all children who have a febrile seizure recover very quickly and without any long-term consequences. On the other hand, 1 out of 1000 children who get measles will develop encephalitis that not only causes seizures but can also lead to permanent damage."
Transparency and Accuracy	"About 10 out of every 10,000 Americans who do not get vaccinated against flu die because of influenza every year, and many more are hospitalized. While flu vaccine does not prevent all cases of influenza, it is the most effective vaccine we have. By getting the vaccine, you also help protect people around you from getting sick."
Transparency and Accuracy	"You are correct, aluminum is used in some vaccines to help the body's immune system respond. However, aluminum is also present in food and drinking water. In fact, the amount of aluminum present in vaccines is similar to or less than what is present in breast milk or infant formulas."

Category	Example Statements
Support from Information Sources	"Your child and other boys and girls his age will be eligible for the human papillomavirus vaccine this coming school year. Have you heard about this vaccine before? What questions do you have about it? Here's a list of websites for parents and teenagers that explain what it is about."
Support from Information Sources	"There's a lot of information about vaccines on the Internet, and a lot of that information is not based on facts. Here is a list of websites that have been reviewed by health care professionals and accurately describe benefits and risks of each vaccine, including information resources written by the LGBTQ community that many of my patients have found useful."
Revisiting and Reinforcement	"During our last visit, we talked about why COVID vaccine is recommended for your son and some of the concerns you had about potential side effects, especially myocarditis. It is important to weigh the risks of side effects against the risks of infection. Have you had a chance to look at the take-home information I gave you? Was there anything else you or your partner would like to ask about?"
Revisiting and Reinforcement	"It's possible that the symptoms you experienced after receiving the vaccine were an adverse reaction to the vaccine. I will report this to the health authority. Let's discuss what we can do next time to prevent symptoms from occurring again."

7.1 Strength of the Recommendation¶

HCPs should make it explicit (in the absence of medical contraindications) that vaccination based on the recommended schedule is the best option. While HCPs should elicit patients' questions and address concerns, the recommendation should be made in clear and unambiguous terms.

7.2 Tailored Communication¶

It is helpful for HCPs to understand their patients' attitudes toward vaccination at the start of the appointment. Sample questions to assess hesitancy: 1. Did you have a chance to review the vaccine leaflet/online resource we provided? Did you have any questions about it? 2. Have you ever been reluctant or hesitant about getting a vaccination for yourself or your child? If so, what were the reasons? 3. Are there other pressures in your life that prevent you from getting yourself or your child immunized on time? 4. Whom/what resources do you trust the most for information about vaccines? Whom/what resources do you trust the least?

7.3 Communication Style Selection¶

PRESUMPTIVE/DIRECTIVE APPROACH: - Example: 'Your child is due for MMR vaccination.' - Results in higher rates of vaccine uptake - Best for: Active demand and minor hesitancy categories PARTICIPATORY/GUIDING APPROACH: - Example: 'What are your thoughts about the MMR vaccine?' - May feel less pressuring to highly hesitant patients - Allows for ongoing clinical rapport and dialogue - Best for: Hesitant with many doubts, late/selective, and refusers Regardless of approach, a strong vaccine recommendation should be made at each encounter.

7.4 Transparency and Accuracy¶

Vaccine recommendations should: - Be transparent with accurate information about benefits AND risks - Emphasize why benefits outweigh risks - Acknowledge that serious side effects can occur but are often very rare and quickly resolve U.S. Federal law (National Childhood Vaccine Injury Act) requires HCPs to provide a copy of the current CDC Vaccine Information Statement describing benefits and risks before vaccination. These statements should not replace discussion with the HCP. Methods to communicate risk may include: - Words and numbers - Graphics - Personal anecdotes (e.g., why the provider vaccinates their own children) - these are powerful and influential

7.5 Addressing Misconceptions¶

Discussion of benefits and risks provides opportunity to address specific misconceptions, such as: - Autism following MMR vaccination (not supported by evidence) - Myocardial infarction following influenza vaccination in elderly (not supported by evidence) Providers should emphasize the vaccine safety monitoring system: - Prelicensure clinical trials - Review and approval by regulatory authorities (FDA, Health Canada) - Strict manufacturing regulations - Ongoing postmarketing safety surveillance

7.6 Support from Accessible Information Sources¶

All vaccine recommendations should be supported by additional information sources patients can access after the encounter. HCPs play an important role as information intermediaries, navigating information and misinformation and directing patients toward reliable, appropriate resources. Consider what resources will be suitable for a patient or population - available in different media formats using combinations of images and text for various audiences.

7.7 Revisiting and Reinforcement¶

All health care encounters offer opportunity to revisit and reinforce vaccine recommendations. For hesitant individuals who do not accept vaccines but are willing to review information: - Offer follow-up appointment - Reinforce previously made recommendations - Address further questions For hesitant patients who accept vaccines: - Follow-up appointment to confirm and document vaccine receipt (if not given at point of care) - Ascertain whether vaccine was well tolerated - Reinforce message about vaccine safety and effectiveness For active-demand patients: - Usually do not require much follow-up other than confirming documentation - Address additional questions arising after vaccination - Often can be covered without an office visit

8. OTHER CLINICAL CONSIDERATIONS¶

Several important factors beyond direct counseling affect vaccine uptake and must be addressed by healthcare providers.

8.1 Missed Opportunities¶

WHO Definition: 'Any contact with health services by an individual who is eligible for vaccination (unvaccinated or partially vaccinated and free of contraindications) which does not result in the person receiving one or more of the vaccine doses for which he or she is eligible.' Impact: - Up to 45% of undervaccinated children could be up to date if all opportunities to vaccinate were taken - Up to 90% of female adolescents could be up to date with HPV vaccination Recommendations: - Incorporate vaccine counseling and vaccination into clinical care for all ages - Remind patients about seasonal vaccines (influenza, COVID-19) and new vaccines (RSV for older individuals) - Take advantage of every health care encounter (emergency department visits, diabetes clinic follow-ups, elective surgery planning) to recommend and provide vaccines - Make preemptive vaccine recommendations (discuss infant vaccines during pregnancy, inform parents about HPV before eligibility) - Ensure vaccine recommendation is followed by vaccination - inform patients where they can be vaccinated if not done at point of care - Follow up at subsequent appointments to confirm vaccination

8.2 Discussing New Vaccines¶

HCPs should be prepared to: - Understand and explain newer vaccine platforms (mRNA, DNA, viral vector vaccines) - Provide examples of older vaccines developed by similar techniques - Explain how vaccines are evaluated before approval - Explain how vaccine safety is monitored after use in the population - Be honest about known rare side effects (e.g., myocarditis in young males following COVID-19 vaccine) and positive outcomes - Place potential vaccine risks in context of known disease risks - Explain why specific high-risk groups may be prioritized

8.3 Adverse Events Following Vaccination¶

Although rare, adverse events may influence vaccine acceptance. Important considerations: - Frequent acute adverse effects are captured in clinical trial data - Worries about rare and long-term side effects can only be addressed by direct evidence after program initiation - Provide patients with incidence of common health events in unvaccinated populations (background rates) over 4-week period to distinguish normal from concerning - Ensure more specific background-rate information is available for individual groups (pregnant individuals, children, immunocompromised people) - HCPs, public health programs, and manufacturers should anticipate questions and develop answers Reporting Requirements: - Identify and follow up with ALL patients who experience adverse events regardless of prior vaccine attitudes - Report to relevant monitoring systems: - U.S.: Vaccine Adverse Event Reporting System (VAERS) - Canada: Canadian Adverse Event Following Immunization Surveillance System (CAEFISS)

8.4 Addressing Inequities in Vaccine Access¶

Discrepancies in access to health care services create inequitable access to vaccines, disproportionately affecting Black people, Indigenous populations, and people of color. Key points: - Socially disadvantaged individuals are at greater risk of vaccine-preventable diseases (crowded living conditions, limited sanitation access, poor nutrition, substance abuse) - They are also at greater risk of being undervaccinated due to limited access and pervasive discrimination within the health care system - Some recommended vaccines may not be covered through public funding or private insurance Recommendations: - Be aware of alternative funding models such as the Vaccines for Children Program (free vaccines for U.S. children <19 years with financial barriers) - When vaccines are not funded/covered and patients cannot afford them, do NOT withhold a vaccine recommendation - Still communicate risks and benefits with strong recommendation - Provide patient opportunity to decide whether they can afford the vaccine

8.5 Providing Culturally Safe Care¶

Cultural safety is defined as an outcome based on respectful engagement between patient and HCP that recognizes and strives to address power imbalances inherent in the health care system. It results in an environment free of racism and discrimination where people feel safe receiving health care. Key considerations: - Be aware of the legacy of discrimination, racism, and medical experimentation (e.g., Tuskegee Syphilis Study) and the resulting distrust in vaccines - Approach clinical practice with cultural humility and self-reflection - SARS-CoV-2 has highlighted fractures in the health care system for minority and marginalized communities - Addressing these issues goes beyond vaccine hesitancy and is needed for all types of medical care in these communities

8.6 Communication With Patients Who Refuse Vaccines¶

The proportion of people who completely refuse all vaccines and are unwilling to talk to their HCP is small. However, when attempts to address vaccine refusal are futile: - Focus on common goals of care - Preserve the therapeutic relationship - Document vaccine refusal well in patient's chart - Continue with tailored communication - Be open to future discussions Important: Vaccine demand and vaccine refusal are rarely static over time.

9. SPECIAL CONSIDERATIONS¶

Certain populations and situations require specific attention in vaccine counseling.

9.1 Adolescents¶

Depending on jurisdiction, adolescents may or may not have legal ability to consent to or decline vaccines
Adolescents' views, questions, and concerns may differ from their caregivers'
These should be explored as part of adolescent health care
Initiate discussions about HPV vaccine before child becomes eligible

9.2 Pregnancy¶

Initiate discussions about infant vaccines during pregnancy
Discuss pertussis booster during pregnancy
Ensure specific background-rate information is available for adverse events in pregnant individuals

9.3 Immunocompromised Patients¶

Rely on herd immunity for protection
At increased risk when active transmission occurs
Individual-level characteristics may affect response to vaccine and level of protection
Ensure specific background-rate information is available for adverse events in immunocompromised people

9.4 Religious Communities¶

Many outbreaks are contained within nonvaccinating religious communities
Some spread to other undervaccinated communities geographically contiguous with the outbreak community
Require tailored communication strategies that respect beliefs while providing accurate information

9.5 Needle-Phobic Patients¶

Fear of needles is common in both children and adults
Discuss potential strategies to help with getting vaccinated
Sample statement: 'Thank you for telling me about your fear of needles. This is quite common in children and in adults. Would you like to talk about some potential strategies to help you with getting vaccinated?'

10. KEY POINTS & CLINICAL PEARLS¶

Essential takeaways for clinical practice in addressing vaccine hesitancy.

10.1 Core Principles¶

Vaccine hesitancy is complex and context specific - it varies with time, place, patient, and vaccine
HCPs are well positioned to address vaccine hesitancy and should develop skills, knowledge, and confidence to make strong vaccine recommendations
A strong, unambiguous recommendation from a trusted HCP is the most effective intervention
Addressing vaccine hesitancy requires intervention at multiple levels: individual, health system, and state

10.2 Clinical Pearls¶

Always make a strong vaccine recommendation at every encounter - even to hesitant patients who decline
Match your communication style to the patient's position on the hesitancy continuum - presumptive for most, participatory for the highly hesitant
Distinguish between true vaccine hesitancy and access barriers - solutions differ
Use personal anecdotes about why you vaccinate your own family - these are powerful and influential
Frame risk discussions with comparisons: 3/10,000 children have febrile seizures after MMR vs 1/1,000 children with measles develop encephalitis
Never miss an opportunity to discuss vaccines at any clinical encounter
Always follow up - hesitancy and refusal are rarely static over time
Document all vaccine discussions and refusals in the medical record
Report all adverse events to VAERS/CAEFISS regardless of patient's prior vaccine attitudes
Address cultural safety and recognize the legacy of medical discrimination that affects vaccine trust in certain communities

10.3 Resources for Patients and Providers¶

CDC Vaccine Information Statements (required by law before vaccination)
Australian National Centre for Immunisation Research and Surveillance (www.skai.org.au/healthcare-professionals)
Immunization Action Coalition/CDC partnership (vaccineinformation.org)
WHO Early AI-Supported Response with Social Listening Platform (WHO EARS)
WHO/CDC infodemic management training materials
Local health authority resources