Childhood vaccines: Schedule, hesitancy, and exemptions

[00:00:18]

SARA WHITLOCK: Hello, everyone, and welcome to SciLine’s media briefing on childhood vaccinations. In this briefing, we’ll give context about the vaccination schedule and how it’s developed, the scope of vaccine hesitancy among parents, and the impacts of vaccine exemption policies. My name is Sara Whitlock, and I’m SciLine’s scientific outreach manager. A little background about what we do at SciLine. We’re an editorially independent nonprofit based at the American Association for the Advancement of Science. We’re fully funded by philanthropy, so everything we do is free, and our team aims to make it as simple as possible for journalists to use scientific evidence and expertise as your reporting. A little scientific research can deepen your stories with evidence and context, whether you’re covering a topic that clearly involves science, like heavy rainfall or one where that science angle is less obvious, like funding for education or national parks. More of our resources are available on sciline.org, including interview opportunities and trainings. And you can click the blue, “I Need an Expert” button if you need to interview a scientific expert for your story. We’ll look for a source with the right background to answer your questions before your deadline. And a couple of notes before we begin. I’m joined here by three experts who have studied vaccination, vaccine hesitancy, and policies around vaccines in schools. I’ll let each of them introduce themselves and their topics of research. So Dr. Sawyer, would you go ahead?

[00:01:32]

MARK SAWYER: Welcome, everybody. My name is Mark Sawyer. I’m a pediatric infectious disease physician at the University of California, San Diego, and I’ve spent most of my career working in vaccine policy and the implementation of recommendations around vaccines, and I’m going to give you an overview of the schedule and why it is the way it is, and then be happy to take your questions.

[00:01:55]

SARA WHITLOCK: Thanks so much. And Dr. Williams, would you introduce yourself next?

[00:01:59]

JOSH WILLIAMS: Sure. Thanks so much for having me. My name’s Josh Williams. I’m a general pediatrician. I work in Denver Health, the safety net healthcare system, and I’m on faculty at the University of Colorado, and I study vaccine safety, vaccine hesitancy, and vaccination equity. So I’m looking forward to addressing concerns or questions around those issues.

[00:02:20]

SARA WHITLOCK: Thanks so much. And Dr. Buttenheim.

[00:02:22]

ALISON BUTTENHEIM: Hi, everyone. I’m Alison Buttenheim. I’m the other kind of doctor. I’m a behavioral scientist, a Ph.D. in public health, and I studied the human behavioral aspects of infectious disease prevention with a big focus on vaccination behavior and the impact of vaccine policy on that behavior.

[00:02:41]

SARA WHITLOCK: Perfect. Thank you. I’m going to ask each of our panelists some questions before we start taking audience questions. So journalists, you can submit your questions at any time during the briefing. Just click the “Q&A” icon at the bottom of your Zoom screen, and please let us know if you’d like your question directed to a specific panelist. We’ll be posting a recording of this briefing on our website later today, and a transcript will be added in the next few days. But with that, let’s go ahead and begin. So Dr. Sawyer, can you give an overview of what the infant and childhood vaccination schedule looks like?

[00:03:11]

MARK SAWYER: Absolutely. And I think there’s going to be a link in the chat if it’s not already there to the actual schedule if people want to refer to it. But the schedule for immunizations looks complex when you first take a look at it, but it’s actually pretty logical, and it’s based on the premise that we want to protect children as soon as we can from infectious diseases. The result of that is that the vaccines that we recommend stack up at certain ages. We give some at birth, as soon as a baby is born. We give a set at 2, 4, and 6 months of age. We give another set between 12 and 18 months of age. A set at 4 to 5 going into kindergarten. And finally, an adolescent focus around age 11 and 12. So if you actually look at the schedule, you see that it lines up with those age groups. Again, the rationale is we want to start protecting as soon as we can, or in the case of the adolescent vaccines, most kids are not at risk of exposure until they reach adolescence, so we can afford to delay those vaccines, and they’re more important during later adolescence or even early adult age groups. The same is true for the adult schedule. I think we’re not focusing on that today, but again, it’s based on the premise of when are people at risk and how soon can we protect them.

The process by which this schedule is developed is incredibly deep and well informed. And I’ll just summarize some of the highlights. It starts really with a vaccine company deciding they’re going to make a vaccine, often in collaboration with NIH or CDC, sometimes just based on the research that they do in their own laboratory or their own facilities. And then a vaccine is made, it’s put through clinical trials, the FDA then reviews the data about that vaccine and decides whether the vaccine should be licensed and approved in the United States. Then the CDC takes over with an advisory committee called the Advisory Committee on Immunization Practices or ACIP, which happens to be meeting right now today and tomorrow. You can tune in live if you want to see what the process is like. And that group gives input about what the recommendation for the use of the vaccine should be. You don’t necessarily give every vaccine to every person in the country, it depends on the risk and the benefit of the vaccine. But that process is incredibly well informed. There are liaisons from over 30 different organizations like the American Academy of Pediatrics, which is a group of pediatricians or the American Academy of Physicians, a group of internal medicine doctors, the Academy of Family Medicine and the obstetric and gynecology professional group. They all give input as do many other organizations. So by the time a recommendation comes out and it ends up in the schedule, people can be reassured that the safety, the effectiveness, the impact, the cost, all of the factors that one would like to consider around the use of a public health recommendation have been worked through. In fact, the CDC uses a very formal process to evaluate the evidence to recommendation, it’s called the evidence to recommendation framework. They go through a set of steps looking at what is the burden of this disease we’re trying to prevent? Who does it affect? Will people be willing to get the vaccine? Is it feasible to give the vaccine? Obviously, is the vaccine safe? And what are the risks and benefits of vaccine versus no vaccine? So it’s all very transparent and you can read about it online or again, as I mentioned, tune into the website and watch the ACIP process and the FDA process live and in action.

The bottom line is once a vaccine hits the schedule, it’s been very thoroughly evaluated for safety and effectiveness. It’s targeting children at the earliest age at which we can protect them, and the risk of getting vaccinated is far less than the risk of getting exposed to and getting the disease. There are some parents who elect not to follow the schedule based on some concerns about too many vaccines or too many vaccines too young in life. And the problem with that approach is that it leaves their children at risk. So a good analogy is putting on seat belts or putting a baby in a car seat. You could probably not do that for the first six months or a year of life and get away with it most of the time, but you might not. And that’s the same issue with vaccines. The earlier we can protect kids, the better off they are and preserve their health. I think I’ll stop there and look forward to your questions.

[00:08:03]

SARA WHITLOCK: Great. Thank you so much. I think we hit all of the points we were interested in covering there. So let’s move on to you, Dr. Williams. To start off, can you provide some context on the scope of vaccine hesitancy among parents and some of the common contributors to that vaccine hesitancy?

[00:08:18]

JOSH WILLIAMS: Yeah. That’s a great question, and I think we all recognize that vaccine hesitancy has been increasing for some time. I think we don’t really realize, though, that prior to COVID, it was actually listed as one of the top ten public threats worldwide in a report that was put out by the World Health Organization. So pre-COVID, there was already this acknowledgment that vaccine hesitancy was a growing problem, not just in the US, but around the world. And I think post COVID, we’ve seen that accelerate a little bit. I think the reasons for it differ depending on the context that you’re in, the vaccine that you’re talking about, the individuals that you’re talking to. One of the main points that I would have people take away from this is that vaccine hesitancy is a highly specific contextual thing, and that hesitancy about the HPV vaccine and adolescent might look very different than hesitancy about a shingles vaccine in someone who’s recently retired. So I think we always need to be attending to what the specific questions, what the specific context is for our patients, for the children that we care for as we think about addressing parents’ concerns or addressing adults or other patients’ concerns.

[00:09:31]

SARA WHITLOCK: That’s great to know. So what are the most effective strategies for communicating with parents or caregivers who you mentioned might be hesitant or unsure about these childhood vaccinations?

[00:09:41]

JOSH WILLIAMS: Yeah. The field of vaccine communication research is a growing field over the last 20 years, especially. And while a lot of things have been tried, there have really been two things that have stood out as being highly evidence based during that time. And one is the way that we even introduce the topic of vaccines in our visits. So as primary care pediatricians or family medicine physicians talk about vaccines and visits, what we found is that the more we presuppose that our families are going to vaccinate, the more likely families are to vaccinate their children. And I think it just goes along with the idea of vaccination as a norm within our practice, something that we’re recommending for all of our patients. And it’s true, we recommend it for all of our patients because we know vaccines are safe and effective, and the alternatives lead to suffering and at times even death for our children. So one of the things that’s been shown in communication research is that just starting our vaccination conversations with a presumptive approach, is what it’s called, has been really effective for increasing vaccination uptake. Then the second thing that’s been shown more recently is that as we engage families who have concerns about vaccines, really trying to do some light motivational interviewing around what the concerns those parents have does ultimately lead to increased vaccination uptake as well. Motivational interviewing is a really complex field that’s applied to all sorts of different disciplines. But in vaccination, I think really what it comes to is aligning the benefits of vaccination with the parent or the patient’s own goals or hopes or motivations for themselves or for their child. So really trying to pin down what the concern is, being a partner in the discussion around empathizing with parents who are worried about their children or empathizing with patients who are worried about a vaccine. And then trying to look for what are those good reasons that you actually might want to vaccinate knowing what it is that I know about you or your child, the things that you’ve told me that are important, your summer plans, where you help to go on vacation without measles, for example, and trying to really help align the dots so that people can make the connections around the benefits of vaccination for themselves or their children.

[00:11:58]

SARA WHITLOCK: That makes a lot of sense. And kind of related to our next question, which is, how can health professionals, but probably specifically public health campaigns and the journalists who are online, how can they combat misinformation without alienating concerned parents, maybe ways that they could tie into this aligning of goals?

[00:12:15]

JOSH WILLIAMS: Yeah. I think that it really comes down to trust, and that’s why I think that really large scale campaigns to address misinformation probably won’t be as successful as very small scale, hyper local contextual public health campaigns that are done in specific neighborhoods with trusted messengers or with specific health systems that have built up trust with their patients and their families over a period of time. So as I think about the role of local journalists or even national ones in trying to combat misinformation, I think a lot of it is connecting people who trust the messenger with reputable information, with trustworthy sources, to help them in the process of evaluating what’s true and what’s not, and also connecting them to those people as well who can really help them in the decision-making processes. So one of the things that I always talk to families about myself is my goal is not to pin your child down and vaccinate them today, right? My goal is for you to trust me. And I’d like for this to be one conversation that we have of many, including ones about stuffy noses, and broken arms, and a bruise on the leg that just won’t get away. And over time, I think we all play a role in building trust with one another, connecting people to appropriate resources. And that’s where I think the journalists on this call can really do good work in their communities where they’re trusted to help that process along.

[00:13:47]

SARA WHITLOCK: That makes a lot of sense, and what a lovely approach to sharing vaccine information. So we’re going to turn now to Dr. Buttenheim. So our first question for you is, how do vaccine exemption policies differ from state to state? And what kinds of exemptions are typically allowed?

[00:14:02]

ALISON BUTTENHEIM: Great, great question. And I’ll actually take it in reverse order. So let me just define the kinds of exemptions and just remind everyone that this all happens at the state level, and it’s often buried in the education code, not the health code of a state. So you sometimes have to go hunting in the regulatory literature where you don’t think these laws are going to be found. So all states have laws and then regulations about which vaccines kids have to get either to enter daycare or preschool or school, kindergarten. And they also have laws defining what kinds of exemptions parents can get from those mandates. So basically, if they want to get out of those requirements. Those tend to be medical, and actually all states offer some kind of medical exemption, and then religious, and some states do and some states don’t offer religious exemptions. And then a third category that is sometimes called philosophical or sometimes called personal belief. Then just to make it a little more confusing, religious and philosophical/personal belief are often lumped together into what’s called non-medical exemptions. And those policies differ. We have 50-plus policy laboratories, everything from five states that have said, we only have medical exemptions, we have no non-medical, religious, philosophical, or personal belief, to states that have quite lenient or open or easy exemption policies where you can pretty much exempt what you want, and it can be as easy as signing a form. So big variation, which makes for a lot of interesting policy and epidemiological analysis.

[00:15:46]

SARA WHITLOCK: I’m sure it does, wow. So speaking of those analyses, what has research shown about the impacts of vaccine exemptions for children in daycare or grade school on their greater communities, and particularly in regard to clustered outbreaks of vaccine presentable diseases?

[00:16:01]

ALISON BUTTENHEIM: Yeah. You used the magic word there, clustered. So vaccination behavior and vaccine exemption behavior is a very socially and spatially clustered behavior. We tend to see it in clumps. And that means that within county, or within state, or within school district variation, can be much greater than the cross state, which is how we tend to look at it. But people have been analyzing this for 20-plus years since vaccine hesitancy and vaccine exemptions have been on the rise, and there’s three really well-established relationships. So when it’s easier to get exemptions, there are more exempted kids. Very well established. When there are more exempted kids, there are more unvaccinated or under vaccinated kids. And pretty obviously, when there are under or unvaccinated kids, there are more outbreaks. So we know pretty rigorously that exemptions can both spark an outbreak and definitely fuel an outbreak of something like measles or pertussis. In fact, those diseases, whooping cough is pertussis, those are the two where we tend to analyze this because we have outbreaks and we look at what is driving this outbreak. We also have great, what we’ll call anecdotal, because we don’t have a lot of the peer-reviewed literature out yet, but the recent Texas measles case is a great example. The county in Texas, Gaines County, where the outbreak started, had the highest exemption rate in the state, well above the average, about five times the state average for exemptions. So not surprising that we would see that outbreak take hold there and spread.

[00:17:45]

MARK SAWYER: If I could just follow up for a second on this because I’ve experienced the same thing in San Diego. We can map coverage rate community by community, up and down the coast and inland in San Diego County. And in public health, there’s a term called herd immunity, which is, if we get enough people immunized, even unimmunized people are protected because they’re not exposed. So I like to say herd immunity depends on what herd you’re in. So if you’re in a community with low rates, that’s where the outbreaks are going to happen.

[00:18:19]

SARA WHITLOCK: That all makes a lot of sense. So I’m curious if there are demographic or geographic trends that are describing where these exemptions are commonly used.

[00:18:27]

ALISON BUTTENHEIM: Yeah. And I bet both Dr. Williams and Dr. Sawyer can comment on as well. So there’s some consistent predictors, there are a lot of inconsistent predictors, too. But we tend to see it in higher income communities, more white communities than communities of color, and either parents who are choosing to send their kids to private school or home school or religious school or just communities where a lot of the kids are in that type of schooling. And that tends to produce some archetypes or stereotypes of a parent pursuing an exemption, right? We think of the Whole Foods mom or the parent who prefers a natural lifestyle for their kid. There are certainly parents who feel that for religious reasons, they don’t want to vaccinate their kids, and that might also be associated with homeschooling or religious schooling. And then there’s a third category, and these can overlap, these categories, who really feel that parental freedom, parental choice, medical freedom, liberty is a really important value for them and they see a state imposition of a vaccine mandate as in conflict with those values. But again, those are all very tightly-clustered groups in space and socially, and they’re very influenced by what their social networks and their social peers are doing. So I think that’s a really important predictor, too, how tightly webbed into a network you are.

[00:19:57]

SARA WHITLOCK: That makes sense. Thank you. And I want to thank all of you for sharing your expertise with these questions. We’re now going to open it up for questions from the audience. So I’ll remind you again, if you have a question, please submit it through the Q&A box found at the bottom of your Zoom screen. But to kick off this part of our discussion, first, I want to ask all of you about the news coverage you’re seeing on childhood vaccination, both what advice do you have for reporters and what isn’t being covered that you think should be. So, Dr. Sawyer, I’ll turn to you first.

[00:20:25]

MARK SAWYER: Well, certainly, vaccines and the process by which they’re recommended has gotten a lot of attention in the last few months with the change in the federal administration and the changes at CDC and FDA. And it is an uncertain time, for sure. I can’t exactly predict what’s going to happen over the next six to 12 months. I’m very interested in this ACIP meeting, which is going on right now. So I think people should continue to focus on that because throughout this conversation so far, we’ve had the concept of trust and confidence and seeking information from certain places. And it’s key that people get good information so they can make an informed decision about vaccination either for themselves or their children. And I personally have some concern that the CDC may not be as reliable a source of information as it has been because of these changes. I haven’t formulated that opinion completely yet, I’m still waiting to see what happens, but I think media needs to keep their eye on this question and look at what other sources are available in their community to get information about vaccines.

[00:21:37]

SARA WHITLOCK: Thank you. And Dr. Williams, we’ll hear from you next.

[00:21:40]

JOSH WILLIAMS: Yeah. I think one of the things that we hear a lot about in the media are concerns about the safety of vaccines. And what we don’t see a lot of are stories about people who’ve been impacted by vaccine-preventable diseases. A lot of my research over the last few years has been around community engagement, specifically with people who have made the decision to vaccinate themselves and their children against influenza and people from various diverse communities as well, and the reasons for and one of the things that I think all journalists on this call would agree with is that stories are powerful and they create a resonance with readers around more than just the content of the story, but there’s shared lived experience oftentimes in the reader and in the writer. And so one of the things that I think happened with COVID very early on, for example, was a ton of coverage around the impact of cases and people being hospitalized and people dying, and specifically the impacts of that on our communities and not just the personal impacts, but also the inter-generational fabric of our communities, the way in which wisdom figures in communities were being taken from us, the way in which children were being kept at home, right, leading to further disparities in schooling outcomes. So one of the things that I think I’d like to see a little bit more of are coverage around these cases when they do arise because they are devastating oftentimes. And I think every winter, there’s a great opportunity to even talk about something as simple as the burden of influenza, which routinely kills one to 200 children a year and thousands of adults, and has billions of dollars of economic impacts on our country. So I think we need to do good vaccine safety research and reassure the American people and communicate those findings well, that vaccines are safe and effective. And we also need to remind, I think, the American public, who’s lost a collective memory around what it’s like to have all these diseases readily circulating. I think part of that is reaching out to people like my grandma, who I just saw this weekend. She’s 94 going on 95, and we talked about this, and she was telling me stories about summertime and how she wasn’t allowed to go out some weeks during the summer when there was polio circulating in the community, so she’d have to sit at home and play with her dolls all day. And they even had a public health worker come and put a notice on her door at one point in time because she was a contact of someone who had come down with polio, and so she couldn’t leave her house at all for a two-week period of time, many years ago. So again, thinking through some of the ramifications of these diseases and what it used to look like very practically to live in communities where these are readily circulating.

[00:24:38]

SARA WHITLOCK: What an interesting story and how chillingly reminiscent to what some of us experienced during COVID. So I’m sure people can resonate a lot with that. I’ll turn next to you, Dr. Buttenheim.

[00:24:47]

ALISON BUTTENHEIM: Sure. And building on great answers from Dr. Sawyer and Dr. Williams. I think I have two quick things I’d love to plant in the ear of the reporters covering this story. One is, I know it’s always tempting to go where people disagree, but I think it’s really important to cover the extent to which the American public agrees on this. Just today, there’s a great new survey out from the Chan, the Harvard Chan School of Public Health along with the Robert Wood Johnson Foundation that says something like, here, I got the stats. 79 percent of Americans support childhood vaccine requirements. Like, what other issue do 79 percent of Americans agree on? And 91 percent believe routine child vaccines are safe. So I think- I know it’s not sexy to have an opening, a headline or a lead about agreement, but that is pretty remarkable these days. And the second thing I’ll say on the policy wonk side is there is so much activity on this front in state legislatures, especially around exemptions. So get to know the committee chairs or the legislators for whom this is a really important issue. And you will see many, many, many, many bills being proposed, not all of them are even voted on or enacted, but to make exemptions harder, to make exemptions easier, to take vaccines on and off the mandated schedule for that state. It’s really fascinating, and I feel like it’s important for the public to know how legislators are thinking about this issue and how they’re influenced by different kinds of advocates and different kinds of evidence. So really interesting, kind of wonky area of reporting.

[00:26:26]

SARA WHITLOCK: Thank you so much.

[00:26:27]

MARK SAWYER: I’d just like to follow up on something Dr. Williams said, this idea of highlighting what these diseases are like, because most of these vaccine-preventable diseases are now rare until they’re not. The Texas outbreak is the latest great example. But every few years, we have outbreaks of infectious disease, swine flu or Ebola, we’ve lived through it all, especially COVID. And the challenge is once the genie is out of the bottle, it’s very hard to get it back in. So once an outbreak gets started, it’s really thousands of people can be impacted that weren’t even aware that the disease was still around.

[00:27:07]

ALISON BUTTENHEIM: And I’ll follow up on that with just one comment that I tend to see be quite persuasive to people, which is to think about our herd immunity that Dr. Sawyer introduced as a national asset. We have invested a lot in building a vaccination program and financing for it and these amazing vaccines scientifically to build this herd immunity, and it is at risk. It’s expensive when it’s decreased, and it’s very costly, as Dr. Williams pointed out, in terms of life and healthy living and free and easy and fun living. So think about that as an asset just like whatever, our national parks or our weapon stores, whatever, that we don’t want to put at risk through under vaccination.

[00:27:56]

SARA WHITLOCK: Thank you so much. And I think this ties into one of the reporter questions that we’ve had come in. This is from Rebecca Raghunath, who’s from the investigative news organization 100Reporters. And they’re asking, “Is there a direct link between unvaccinated children and an increased risk of exposure or illness in adults? So how are these kids impacting us as adults?”

[00:28:16]

MARK SAWYER: Well, I’ll start with that. The answer is yes. I mean, the reason we give some vaccines is to prevent transmission from one person in the family to another. I’ll use hepatitis A as an example. Hepatitis A is generally a mild infection in young children, and if everybody got it and got it over with, that would be one thing. But what happens when a child gets hepatitis A is they bring it home, and with adults and especially senior adults, they don’t do nearly as well. It can be a very severe disease. Similarly, the respiratory viruses like influenza and COVID. Obviously, schools are one place where those things spread relatively easily, and the kids bring them home to their grandparents who are at high risk. So, absolutely, vaccination not only benefits the person getting the vaccine, but their whole family.

[00:29:04]

SARA WHITLOCK: That makes sense. Anything you want to add, Dr. Williams?

[00:29:08]

JOSH WILLIAMS: I think that was well said.

[00:29:10]

SARA WHITLOCK: Perfect. So I want to circle back around to something that you were talking about a little bit, Dr. Buttenheim, about agreement among so many different types of people around the vaccine schedule. So freelance reporter Carol Morton says that in her rural area, the far left and far right find common ground on suspicion of vaccines and distrust of the media. They aren’t really agreeing with the premise of vaccination as early as possible, so that traditional schedule. So one of her questions is, “Are there alternative schedules that are specific to a child’s highest risk for certain diseases at certain ages?”

[00:29:43]

ALISON BUTTENHEIM: I’ll defer to Dr. Sawyer on the actual schedule, but let me quote my colleague here at the University of Pennsylvania, Dr. Paul Offit, who talks a lot about vaccines and vaccine safety and vaccine schedules. He was on the ACIP for a long time, actually on VRBPAC. And was a pediatrician, vaccine pediatrician, an infectious disease doc. And he said, when I hear a parent ask me about the safest way to space or skip or time vaccines, and then he always puts alternative in scare quotes, alternative schedule. He said, that’s like a parent saying to me, I don’t feel like using a car seat. Can you show me the safest way to just hold my child in the back seat of the car? He’s just like, the premise is wrong. There isn’t- and I’m not going to choose my favorite vaccine or help micro diagnose your kids specific risk environment. The schedule has been worked out painstakingly to maximize effectiveness, to maximize efficiency and coverage. And he just wants to take that alternative schedule question off the table. I think that’s a helpful metaphor or analogy.

[00:30:51]

SARA WHITLOCK: Yeah. Very vivid mental image-

[00:30:54]

ALISON BUTTENHEIM: Yeah.

[00:30:54]

SARA WHITLOCK: -of what might be happening with these alternative schedules. Anything, either you, Dr. Sawyer, or Dr. Williams want to add around the science behind the schedule?

[00:31:04]

MARK SAWYER: Well, I’ve already made the point about how the schedule ends up the way it is, but this issue emphasizes Dr. Williams point that we need trusted messengers so that these people who are suspicious can find a source of information that they are comfortable with and hopefully is giving out accurate information. So one would hope that’s their own physician or their child’s physician, believe me, the pediatricians of the country are not conspiring to give dangerous vaccines to children. So hopefully we can help guide them to good sources of information.

[00:31:41]

SARA WHITLOCK: That makes a lot of sense. So, Dr. Williams, we have a question from Caroline Long from Utah Public Radio, and that question is, has vaccine hesitancy increased since the COVID-19 pandemic? And would you say to people or what kind of things would you say to people who may be distrustful of either pharmaceutical companies or the U.S. healthcare system?

[00:32:01]

JOSH WILLIAMS: Yeah, that’s a really good question, and, you know, the answer to the question about whether or not hesitancy has increased post COVID has actually been looked at. There was a study that was recently done by one of my colleague, Sean O’Leary, who’s an infectious disease doctor and a member, not a voting member, but a liaison member to the ACIP or what is still currently on. And they were looking, they were doing a study while COVID happened, looking at parental hesitancy around routine infant immunizations. And what they found was that the overall rate of hesitancy didn’t necessarily change for the caregivers who were enrolled in the study pre and post the COVID pandemic and lockdown orders. But what they did see was, they did see a spreading toward the extremes of caregivers’ perceptions of infant vaccines. And so the idea that the people who thought previously they were maybe a little bit sure or a little bit unsure that vaccines were safe, post COVID, people either really thought vaccines were safe or they really didn’t think the vaccines were safe, right. So I think what we’ve seen with COVID is that there’s been an increased polarity or polarization to caregivers’ attitudes around vaccines since COVID has come around. But I think it’s really important to mention what Dr. Buttenheim brought up earlier on, that the vast majority of Americans still vaccinate their kids on time with the routine recommended schedule that Dr. Sawyer pointed out, and that this is a point of agreement for the vast majority of the American people. And so I think COVID has played a role in polarizing attitudes toward vaccines, but the reality is that this is still something in which there’s a lot of consensus, a lot of people going with the recommended schedule for themselves and for their children.

[00:33:55]

SARA WHITLOCK: It is so comforting to hear that many people are still on board with the vaccination schedule. Thank you for sharing that. And moving along on the theme of things that might change people’s attitudes towards vaccination, Emily Brindley at the Dallas Morning News asks, what impact does the current administration, particularly Secretary Kennedy, have on the anti vax or medical freedom movement? And have any of you seen significant shifts in that movement or its goals in the past six months or so, and anyone can chime in, but maybe Dr. Williams will start with you.

[00:34:25]

JOSH WILLIAMS: Yeah, maybe I defer to my colleague Dr. Buttenheim from the policy angle and some of the work that she’s done around exemptions. From a practicing pediatric standpoint, I don’t have as much to add here.

[00:34:37]

SARA WHITLOCK: Sounds good.

[00:34:40]

ALISON BUTTENHEIM: I’ll keep it, again, in the state legislative space. I think there is a feeling that this is a window of opportunity, for groups that may want to loosen up exemption policy or even think about tweaking school entry mandates. So again, this is determined at the state level, but I think that feeling that that would be supported at the federal level, that the kinds of conversations now that are being had at the CDC and even in this ACIP meeting today, create a window of opportunity to just make it easier and more common to not vaccinate your kids before school.

[00:35:29]

MARK SAWYER: What I’ve seen is that we’re already adding to the erosion of confidence in vaccines. So one of the reasons people were skeptical about COVID vaccine is the message changed so frequently, and that was partly due to the virus changing so frequently, and we were learning as we go. But for example, the announcement by Secretary Kennedy that we’re not going to immunize pregnant women with COVID vaccine. At today’s ACIP meeting, they presented data that shows women would benefit and their babies would benefit. So I’d be very surprised if ACIP says we shouldn’t vaccinate, they’re going to say we should. So now we have two different messages coming from the federal government on the same question, and that just erodes confidence. And that’s going to inevitably lead to some decreases in coverage.

[00:36:20]

SARA WHITLOCK: Thank you for that. And so a follow up question from Emily at Dallas Morning News is that, is there a particular state or group of states in the U.S. that you see as trend setters in the anti vax movement? If so, which States are you concerned about from a vaccine hesitancy perspective? So maybe Dr. Buttenheim you can kick us off there.

[00:36:38]

ALISON BUTTENHEIM: Yeah, I don’t know if it’s at the vanguard, but one interesting State we’ve always watched is West Virginia. And for decades, West Virginia and Mississippi were the only two States that only allowed medical exemptions. They had no non-medical exemptions. Maybe it’s interesting both those States have interesting histories of how they got to that point, but it was these sort of vanguards of holding the line on exemptions. And because of that, those two States always had the highest kindergarten coverage and the lowest medical exemption rate. There’s been a lot of movement, and I think again, there’s a window of opportunity to introduce now a religious exemption and some very effective and creative strategies judicially, legislatively, for trying to open that window again. And what door do you use, is this a religious freedom issue, is this a medical freedom issue? Are there lessons from what States did around COVID mandates that can be imported or exported over to the school exemption field? So I think that’s one to watch. Connecticut, California, Washington, Idaho, there’s just no end of interesting stories. I think it’s the organizations where we see the- I think there are organizations to watch that are maybe trying things on multiple fronts in multiple States. And again, these creativity around what kind of legal argument can be introduced that will hold up in appellate court and maybe even the Supreme Court to loosen up exemptions.

[00:38:22]

SARA WHITLOCK: Thanks so much. And we’ve mentioned it a couple of times, but we have a question from Megan at Scientific American. For folks who have tuned into the ACIP meeting today, what has struck you and what are your concerns moving forward? So, those of you who have watched some or all of it, what do you want reporters to know. Dr. Sawyer, do you have any other things to add?

[00:38:42]

MARK SAWYER: Well, I’m going to- we haven’t gotten to the most controversial topics. Those are coming up later today and tomorrow morning, so I haven’t reached a full conclusion. I was reassured that the presentations by the CDC staff seemed to be similar to past. And based on what I know about the literature and the evidence, they stuck to the evidence. There were some questions from the new panelist members that struck me as a little bit odd in the light of what we already know about vaccines. But until they make a recommendation or vote, I’m going to reserve my conclusions about that particular recommending body. But either way, I think it’s important that people learn where to get trusted information. If it turns out that ACIP and CDC aren’t really that trustworthy, then we need to turn to other sources, and those sources are stepping up to provide good information.

[00:39:42]

ALISON BUTTENHEIM: I’ll build on that and just say, I was also very impressed by the folks from the CDC presenting. They clearly anticipated the kinds of questions they would get, for example, about the adverse event reporting system, the VAERS system that’s often used to try to introduce uncertainty or worry about adverse events, side effects, et cetera, and they were prepared for that question. There were questions out from left field about spike proteins and virus and vaccine ending up in organs. And they also just did a great job of just not engaging on those questions that didn’t have the scientific foundation that usually is the heart of these ACIP meetings. So in that sense, it felt reassuring, but I think the interesting stuff is to come later this afternoon and tomorrow.

[00:40:38]

SARA WHITLOCK: Good to know so people can stay tuned in with that. And we have a little bit of a more specific question about the things that are happening at the ACIP meeting. So if any of you have contexts to share on this, feel free to jump in. So Paul Monies at Oklahoma Watch asks about the ACIP slides on COVID vaccinations, which he says, show very few long term problems with the myocardia events among male teens, that seemed to drive a lot of hesitancy. So have any of you seen that, and do you have a comment there?

[00:41:05]

MARK SAWYER: I think, for me, the COVID vaccine rollout is a great example of how robust our vaccine safety system now is. We didn’t have the system 20 years ago, and that’s where people started to get more hesitant when there was a lack of data. Now there’s plenty of data, we know more about COVID vaccine than we know about any other vaccine we’ve ever used because we have given literally billions of doses around the world. And so if there were some weird side effect, we would know about it. And what was presented today at the ACIP, meaning is the only serious side effect that is really there is this myocarditis occurrence after usually first vaccination in adolescents and young adult males predominantly, it doesn’t affect females nearly as frequently. And that overall rate is still low, making the benefit of the vaccine still outweighing the risk, but it is a real risk, and it’s appropriate for the ACIP to highlight that risk and make everyone aware of it. But that’s the only serious risk that’s been found, and none of the other things that we have read about in the media have turned out to be true side effects.

[00:42:19]

SARA WHITLOCK: And Dr. Williams, I’m curious if you’ve had any experiences dealing with parents who might feel hesitant around the COVID vaccine due to those adverse events with younger men.

[00:42:29]

JOSH WILLIAMS: Yeah, I had many counseling conversations about that very specific adverse event. And one of the things that I raised very often in those conversations was that COVID infection itself naturally causes myocarditis in a small group of children. And so what we know about COVID infection induced myocarditis is that it’s usually much more severe than COVID vaccine related myocarditis, which is usually very brief, perhaps involving a one day hospital stay just for some cardiac monitoring, followed by a quick discharge. Whereas COVID induced myocarditis from the actual virus itself can cause someone to be in a cardiac ICU and cause them to require getting medications to support cardiac function or blood pressure can really cause some long lasting cardiac complications, as we saw with MISC, which was a condition that was affecting many children early in the COVID pandemic as well. And so one of the things that I talked frequently about was this is a known adverse event for adolescent males in that age group. But we know that the alternative is perhaps much worse, and so for me, when it came down to the vaccination decision, I often talked too about what I did for my own family and for my daughter who is not quite an adolescent at that point in time, but talking to people just about this is why I’m making this vaccination decision for my own children because I have seen what the possibility is, and I prefer that to the alternative.

[00:44:10]

MARK SAWYER: To put it in very stark terms, the COVID vaccine causing myocarditis has not killed anybody or less than five people in the world, as far as I know, and yet COVID the disease has caused hundreds of deaths in the recent the early stages of the outbreak in children, I’m talking about in children, and even to this day, causes between 50-100 deaths a year. So if you add up the pros and cons on either side, you’re still going to end up with vaccination.

[00:44:44]

ALISON BUTTENHEIM: In myocarditis example, myocarditis issue is a great example of something we look at as behavioral scientists in terms of people’s decision making rules or the mental models that they consult. And there’s something called omission bias, which means as a tendency, as humans, we would rather not do something and have a bad consequence come from that, than do something and have a bad consequence from that. We feel like the inaction is a get out of jail free card. And one thing you can do to counter that is to either point out that there are also costs to inaction or actually make that inaction feel like an action. So not choosing to vaccinate isn’t doing nothing, it’s actually a choice and a route that can also have negative consequences. So I think myocarditis is just a great illustration of that.

[00:45:42]

SARA WHITLOCK: It does sound like it, yeah. And then we have another follow up question from Emily Brindley at Dallas Morning News. Dr. Buttenheim you mentioned some organizations to watch when it comes to advancing anti vax or medical liberty goals. And she was curious if you could give some specific examples of those organizations you’re watching.

[00:45:58]

ALISON BUTTENHEIM: Sure. The big three are ICAN, so the Informed Consent Action Network, the misleadingly named Children’s Health Defense, which is actually Secretary Kennedy’s organization, used to be called the World Mercury Project. And then the National Vaccine Information Center, which also sounds very innocuous and harmless. Those three all have active advocacy, arms, alerts, work at the State level, do a lot of lobbying at the federal level.

[00:46:28]

SARA WHITLOCK: Thanks so much. I want to turn now to a more specific question that we have from Madison Czopek from Politifact. And that is, what do we know exactly about how many vaccines are available on the market today that contain thimerosal? I apologize for that pronunciation. Are there estimates about how many people receive vaccines containing this preservative each year, and is that something we should be concerned about? So I’ll turn to maybe Dr. Sawyer and then Dr. Williams.

[00:46:57]

MARK SAWYER: Well, that question has been out there for a decade or more, and first of all, there’s been no evidence to date that thimerosal, which is a preservative in vaccines, that it has a mercury base. When you hear about mercury in vaccines, we’re talking about thimerosal. There’s no evidence to date that it really causes any harm whatsoever. There are still some vaccines, but the routine pediatric schedule, you can get completely immunized without any thimerosal containing vaccines. As far as I know, the main vaccines that still contain thimerosal are large vials of influenza vaccine which are used in some clinics and health departments, but you don’t have to use those. You can buy alternative products. And I don’t have any hard numbers on the number of people exposed to them, but I am very confident that those exposures are not leading to any problems.

[00:47:52]

SARA WHITLOCK: And, Dr. Williams, anything you want to add there maybe about why the idea of vaccines containing mercury is a turn off or causes vaccine hesitancy?

[00:48:02]

JOSH WILLIAMS: No. I think Dr. Sawyer did a great job just around the numbers game. I think people are concerned about heavy metals, rightfully so, I think I personally don’t want to ingest any heavy metals that I do not need to, but Dr. Sawyer is really right to point out that this is not mercury. This is thimerosal which is different, and the ways in which this product has been studied extensively and shown to not be associated with things like autism spectrum disorder or other adverse events that people have worried about over the years are pretty remarkable. And so I think encouraging parents to know a little bit more about the research that has been done in those conversations that we have as partners is a really powerful way just to help them feel reassured, yeah, that’s a good question. It makes sense that you’d be worried about mercury in vaccines and good news. We’ve done a lot of research in that area.

[00:49:03]

SARA WHITLOCK: Great. Thank you. And a follow up from Caroline Long at Utah Public Radio. So if adults didn’t receive their childhood vaccinations, should they get them as adults, and is it going to be equally effective for those adults getting those vaccinations?

[00:49:16]

MARK SAWYER: Yeah, there’s a whole schedule for adults that addresses what should happen if they didn’t get any vaccines prior to becoming adults. The schedule is different than pediatrics, you wouldn’t repeat everything. Some diseases are unique to pediatric age groups, for example. So diseases you need many fewer doses of vaccine to get protected when you’re an adult. So the answer is yes, they should get caught up on their vaccines. But as to the details of that, you can look at the adult schedule, and individuals should just consult with their physician who should be up to date on how to do that.

[00:49:52]

JOSH WILLIAMS: And I think a lot of people right now are specifically interested in measles because it has been circulated and wanting to know, am I protected against measles? And so one number that I’ve just had in the back of my mind for the last few months has been 1957. If you were born before 1957, you probably had measles and you’re protected against measles. But otherwise, it’s going to be important to know whether or not you’re protected and whether or not you had one dose of measles vaccine or two doses because about 20 years ago or so, a second dose was recommended after seeing that the effectiveness was a little bit lower with just one dose of protection, but still pretty good at around 93 percent with one dose, and then with two doses, 97 or so percent protection against measles.

[00:50:39]

MARK SAWYER: And measles is particularly important when you travel because there are many countries where measles is still happening more often than it is here, and that’s a good chance to get exposed. Most of the cases in the United States originate from people who travel somewhere else and bring measles back here. And then if they’re in a community that Dr. Buttenheim mentioned that’s at low immunization rate, then it’s going to take off in that community.

[00:51:05]

SARA WHITLOCK: That makes sense. And you mentioned the importance of knowing the difference between having had one or two doses of that measles vaccine. But what about people who may not know, maybe they lost their record, maybe their parents can’t remember. What should those people do?

[00:51:19]

MARK SAWYER: Well, the good news is it doesn’t hurt if you get an extra dose. So when in doubt, when we don’t have an immunization record or we can’t verify it, we immunize people as if they have not received any, and that is safe to do.

[00:51:34]

SARA WHITLOCK: That’s great. And I’m sure very comforting for folks who can’t remember. And one last reporter question from freelance reporter Carol Morton. She’s wondering how she can successfully get doctors to speak with her on the record. So oftentimes she’s finding that they don’t want to go on the record and risk losing trust they need to successfully recommend certain key vaccines, maybe measles or pertussis vaccines. So any of you have advice about finding doctors who might be willing to speak with you on the record?

[00:52:05]

MARK SAWYER: Well, I’ll start with going to your local American Academy of Pediatrics chapter for pediatric vaccines. Every community has a group of pediatricians who are pretty well organized around this topic of vaccine and vaccine communication. And I would be amazed if you couldn’t find people who would talk on the record about how they approach vaccines and all of these challenges.

[00:52:30]

JOSH WILLIAMS: And I think it really is important and to Dr. Sawyer’s point about going to your local chapter because those are people that you may be rubbing shoulders with in the community, and oftentimes those are well respected community leaders and figures in local private practices or under safety net institutions. Who are known to be passionate advocates about vaccines and are often already doing work in various communities where there may not be as much trust, whether it’s in vaccines or in health systems or in physicians. And so I think the local nature of that outreach is going to be really important.

[00:53:11]

MARK SAWYER: That reminds me to put in a little plug for local immunization coalitions, which exist in many communities. These are not just physicians, but various people from the community who are passionate about vaccines and communicating about vaccines. And in those groups, you can find some of these trusted messengers who are not physicians who are equally important in bringing the message to their community.

[00:53:38]

SARA WHITLOCK: Those are all super helpful resources to keep in mind. Thank you so much. And then a question for Dr. Buttenheim, are there any successful examples of community led or culturally tailored approaches to improving vaccine uptake?

[00:53:51]

ALISON BUTTENHEIM: So many great examples came out of COVID. Again, we heard a lot about the communities where nothing was working, but the Indian Health Service and urban Native American and Indian communities knocked it out of the park. They just went in early, they got a lot of community buy in, building on what Dr. Williams said yesterday. They prioritized the CDC had its prioritization schedule, and they said, we’re starting with our native speakers because if we lose them, we lose our language. And that’s our priority, and that was important, so they’re just wonderful, and they’ve been written up in the Lay literature and then in the scientific literature for us to learn from. There were also a lot of great innovations around advertising and promotion. So one that leaps to mind, I think I was quoted in the New York Times story about this was a community campaign coming out of New Orleans, and it was called Sleeves Up, NOLA was their campaign. And it was really built around the Mardi Gras parades. And what we could gain from reaching a point where we were all protected and safe and could go out again and party. And they had very well known celebrities from the Mardi Gras parade scene, from different troops. And everyone, it was a very short ad, but everyone said in the ad, why they were getting vaccinated, to dance with my troop, to march with my brother, to take my mom out for gumbo, to live another day. And I just teared up every time I watch it. So I think those partnerships between a public health entity and a marketing firm or a social marketing firm that heard from the community what was going to land were really, really successful.

[00:55:42]

SARA WHITLOCK: That sounds like a great campaign, for sure. And kind of a related question for Dr. Williams. What does your research or experience tell us about working with faith based communities to address concerns around childhood vaccines, and are there examples of effective engagement or partnerships in this space?

[00:55:58]

JOSH WILLIAMS: Yeah, yeah. In a past, in what seems like a past life, I did a lot of research with faith based communities around vaccination. And what I found was that very few individuals in very different faith communities had religious questions about vaccines. It just happened to be that many people who were people of faith happened to have more secular nuts and bolts questions about the schedule or vaccine safety or why do I need to get a flu shot every year? And that they felt like hearing from a trusted messenger within a faith community was a very comfortable place in which they could trust the information they were receiving. And so there have been some great examples of faith based partnerships that have been done over the years, especially efforts led by Emory. They had a coalition of faith based partnerships around the U.S. for influenza immunization campaigns, and those were shown to not only be highly effective but shown to reach marginalized groups of individuals who historically have had low rates of vaccination uptake. My own work here in Denver has shown very similar findings, although on a smaller scale. I will say, though, that one of the reasons that I think we need to temper our expectations for faith based campaigns currently is that fewer and fewer individuals in American society today are attendees of brick and mortar faith based communities. I think we’re seeing a rise of what are called the religious nones. So people who don’t identify with any specific faith community or people who kind of identify more with a sense of spirituality than a specific religious belief or a system of belief that has specific tenets around things like vaccination, right. And even for people who might say they’re Catholic, where there’s a robust theology of vaccination, they may not necessarily agree with that theology themselves individually, right. And there’s also a lot of changing dynamics, so for example, here in faith communities that are predominantly black faith communities, a lot of the older individuals in those congregations are starting to age out, and there hasn’t been as many younger individuals in the same communities that I’ve been working with, and there are a lot of reasons for that. Whereas in our Latino Spanish speaking only faith communities, there’s a robust number of younger individuals with large families comprising those faith comes. So every community is going to be a little bit different, and the questions in each community will be a little bit different leading to different approaches for public health campaigns. So I still think it’s a really important thing for us to consider, I think faith based communities are they’re anchor institutions in our communities. Their leaders, are trusted messengers who are often open to public health partnerships, and historically, that’s been a really successful model, but I do think that contextually, things are changing a little bit, and we need to rethink what it looks like to do effective partnerships with faith based communities in the 21st century post COVID.

[00:59:15]

SARA WHITLOCK: Thank you. That’s really helpful context to have. Now we have one more question for our experts, which will give them a chance to quickly cover the most crucial insights that we’ve shared here. But first, I want to flag for journalists that you’ll receive a short e-mail survey when you sign off from this briefing. So if you could take even 30 seconds to give us any feedback that you have, it’ll help us design our services to give you what you need for your reporting. So, for our final question, in about 30 seconds, what is one take home message for reporters covering childhood vaccination? And Dr. Sawyer, I’ll start with you.

[00:59:44]

MARK SAWYER: I think I’ll go back to my point that once a vaccine has made it all the way through the process of coming to a recommendation, it has been thoroughly studied and all of the pros and cons and angles have been looked at. And if it’s recommended, it means that your risk from getting the vaccine is lower than your risk from the disease, and you’re better off choosing vaccine.

[01:00:08]

SARA WHITLOCK: Thank you so much, Dr. Williams.

[01:00:11]

JOSH WILLIAMS: Yeah, I think it’s just a reminder that the vast majority of the American public do vaccinate on time and according to the recommended schedule, and that we need to do a better job continuing to lift up the stories of people in the community who are making these decisions every day to protect themselves, their children, and their communities.

[01:00:32]

SARA WHITLOCK: And Dr. Buttenheim.

[01:00:34]

ALISON BUTTENHEIM: I think I’ll double down on my message that our collective herd immunity against these diseases is a national asset that’s worthy of our attention and worthy of our protection.

[01:00:46]

SARA WHITLOCK: Great. Well, huge thanks to the panelists here for sharing so much information and wisdom, especially as the landscape of vaccination in the U.S. continues to change. And from all of us here at SciLine, we want to thank the journalists who’ve logged in to gain insight and contexts that will enrich your coverage. And I hope we’ll see you at our next briefing. Thank you.