Increasing vaccine compliance: Coercion and persuasion, shock and shame only work so much

James Colgrove, Ph.D., M.P.H., of the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, writes in this commentary, in recent years, vaccine refusal and associated declines in herd immunity have contributed to numerous outbreaks of infectious diseases, consumed public health resources, and provoked increasingly polarized debates between supporters and opponents of vaccines.

vaccinationAlthough the prominence of the Internet as a forum for information and misinformation has given these conflicts a distinctly 21st-century character, they have deep historical roots. Many of the scientific, ethical, and political challenges that physicians and public health officials face today in dealing with vaccine refusal would be recognizable to their counterparts of previous eras. The heart of their task entails balancing the use of coercive and persuasive approaches.

Coercion is the older tradition in public health. During the 19th century, many states and localities passed compulsory-smallpox-vaccination laws covering both children and adults. These laws were of a piece with an expansive network of public health regulations that arose in that era concerning practices such as quarantine, sanitation, and tenement construction. Vaccination laws imposed various penalties, including exclusion from school for unvaccinated children and fines or quarantine for adults who refused vaccination. The effectiveness of the laws was soon demonstrated — jurisdictions with them consistently had fewer disease outbreaks than those without — and their constitutionality was upheld in numerous court challenges that culminated in the 1905 Supreme Court case of Jacobson v. Massachusetts.

The use of coercion has always raised concerns about state intrusions on individual liberty and the scope of parental control over child-rearing. Compulsory vaccination laws in the 19th century typically contained no explicit opt-out provisions. Today, all states offer medical exemptions, and almost all offer religious or philosophical exemptions. Nevertheless, even a law with an opt-out provision may exert a coercive effect, to the extent that the availability of the exemption may be limited and conditional and the consequence of the law is to make the choice to withhold vaccination more difficult (if only marginally so) for the parent. These laws continue to be the target of antivaccination activism.

Persuasion became an important part of the public health tool kit in the 1920s, with the rise of modern forms of mass media. Health professionals began to draw on techniques from the emerging fields of advertising and public relations to sell people on the importance of childhood immunization against diphtheria and pertussis. Such appeals began to acquire a more scientific basis in the 1950s, after the development of the polio vaccine, when sociologists, psychologists, and other social scientists began to identify the attitudes, beliefs, and social contexts that predicted vaccine-related behaviors. Their efforts brought increasing theoretical and empirical rigor to the study of why people accepted or declined vaccination for themselves and their children, and health professionals used these insights to develop approaches to increase uptake of vaccines, such as enlisting community opinion leaders as allies.1 Persuasive approaches, because they are less restrictive, are ethically preferable and more politically acceptable, but they are also time consuming and labor-intensive, and evidence indicates that by themselves they are ineffective.

Vaccine refusal revisited — The limits of public health persuasion and coercion

October 12, 2016, New Engl J Med; 375:1316-1317, DOI: 10.1056/NEJMp1608967

Yes: Can Hepatitis A be eliminated?

The U.S. Centers for Disease Control and Prevention reports that Hepatitis A virus (HAV) disease disproportionately affects adolescents and young adults, American Indian/Alaska Native and Hispanic racial/ethnic groups, and disadvantaged populations.

A packet of frozen Nanna's brand Mixed Berry is pictured in Brisbane, Monday, Feb. 16, 2015. The Patties Foods product has been linked to several cases of hepatitis A in Australia. (AAP Image/Dan Peled) NO ARCHIVING

A packet of frozen Nanna’s brand Mixed Berry is pictured in Brisbane, Monday, Feb. 16, 2015. The Patties Foods product has been linked to several cases of hepatitis A in Australia. (AAP Image/Dan Peled) NO ARCHIVING

During 1996–2006, the Advisory Committee on Immunization Practices (ACIP) made incremental changes in hepatitis A (HepA) vaccination recommendations to increase coverage for children and persons at high risk for HAV infection. This report examines the temporal association of ACIP-recommended HepA vaccination and disparities (on the absolute scale) in cases of HAV disease and on seroprevalence of HAV-related protection (measured as antibody to HAV [anti-HAV]).

ACIP-recommended childhood HepA vaccination in the United States has eliminated most absolute disparities in HAV disease by age, race/ethnicity, and geographic area with relatively modest ≥1-dose and ≥2-dose vaccine coverage. However, the increasing proportion of cases of HAV disease among adults with identified and unidentified sources of exposure underscores the importance of considering new strategies for preventing HAV infection among U.S. adults. For continued progress to be made toward elimination of HAV disease in the United States, additional strategies are needed to prevent HAV infection among an emerging population of susceptible adults. Notably, HAV infection remains endemic in much of the world, contributing to U.S. cases through international travel and the global food economy.

US: Progress toward eliminating Hepatitis A disease in the United States

Centers for Disease Control and Prevention

Trudy V. Murphy, MD; Maxine M. Denniston, MSPH; Holly A. Hill, MD, PhD; Marian McDonald, DrPH; Monina R. Klevens, DDS; Laurie D. Elam-Evans, PhD; Noele P. Nelson, MD, PhD; John Iskander, MD; John D. Ward, MD

New Jersey restaurant at center of hepatitis A outbreak closes

The Hamilton restaurant where four people contracted Hepatitis A at the end of 2014 has permanently closed its doors.

hep.aRosa’s Restaurant, the South Broad Street mainstay, quietly announced that it was closing its doors with small signs hanging on the front and rear doors thanking its customers.

Rosa Spera-Gilmore, the restaurant’s owner and namesake, said in an interview Wednesday Rosa’s last hurrah was a New Year’s Eve party that attracted 300.

“Coming to America from Italy at the age of 11, I never imagined I’d one day own and run my own business,” Spera-Gilmore said. “I was glad that being a business owner let me put others to work and to give back to the community by supporting a lot of civic events and groups. These are the things I’ll think about when I think about the old restaurant.”

A confirmed case of Hepatitis A has been traced to a food worker employed at Rosa’s Restaurant and Catering in Hamilton, officials said late Monday

Spera-Gilmore said the catering portion of the business will continue, despite the demise of the restaurant, but she declined to cite the hepatitis A outbreak as a contributing factor in the closure.

Four people linked to the restaurant were diagnosed with hepatitis A beginning in Dec. 2014.

In response, the township sponsored a vaccination clinic for township residents and urged others to consult their physicians for a vaccine.

The disease originated with an employee of the restaurant, with the remaining cases reported in customers, including a hairstylist and fitness instructor who had regular interaction with the general public.

“There’s some question regarding their hand washing procedures,” Jeff Plunkett, township health officer, said at the time. “The cases certainly have a possibility of being linked, but it’s hard to say whether the gentleman infected himself or contracted it somewhere else and brought it to the facility.”

The restaurant had a history of health violations before and after the outbreak. 

Inspectors found multiple violations related to hand washing, food storage and preparation between October 2014 and January 2015.

On Dec. 1, 2014, inspectors visited the site after the original employee was diagnosed with hepatitis A, ordering food destroyed, surfaces sanitized and denaturing of certain products, such as soups that couldn’t be placed in the trash, by pouring bleach on them.

Inspectors intervened after employees briefly began preparing meals for new customers using food they were ordered to throw away, improperly washed their hands and handled food with bare hands.

The Township Committee considered local legislation that would have imposed stiffer fines on restaurants with health code violations, but in March opted to postpone a vote on an ordinance that would have tripled inspection fees on restaurants that fail two or more health inspections.

“I’m grateful for the years of patronage and so many customers who became family,” Spera-Gilmore said. “I look forward in the year ahead to starting a new business that will focus exclusively on catering.”

Market impacts of E. coli vaccination in US feedlot cattle

Immunization through vaccination has been a commercially available pre-harvest intervention to reduce E. coli shedding in cattle for about five years.

Despite demonstrated substantial improvement in human health that vaccine adoption offers, it has not been widely adopted. This highlights the need for understanding the economic situation underlying limited adoption.

Using an equilibrium displacement model, this study identifies the economic impact to U.S. feedlots implementing this vaccination across a series of alternative scenarios.

Producers face $1 billion to $1.8 billion in welfare losses over 10 years if they adopt this technology without any associated increases in demand for fed cattle. Retail beef demand increases of 1.7% to 3.0% or export demand increases of 18.1% to 32.6% would each individually make producers economically neutral to adoption. Retail or packer cost decreases of 1.2% to 3.9% would likewise be sufficient to make producers neutral to adoption.

Agricultural and Food Economics 2015, 3:7

Glynn T Tonsor and Ted C Schroeder

Hepatitis A vaccines work: Michigan, 2013

Hepatitis A virus (HAV) infections among persons with developmental disabilities living in institutions were common in the past, but with improvements in care and fewer persons institutionalized, the number of HAV infections has declined in these institutions. However, residents in institutions are still vulnerable if they have not been vaccinated.

hepatitis.AOn April 24, 2013, a resident of a group home (GH) for adults with disabilities in southeast Michigan (GH-A) was diagnosed with hepatitis A and died 2 days later of fulminant liver failure. Four weeks later, a second GH-A resident was diagnosed with hepatitis A. None of the GH-A residents or staff had been vaccinated against hepatitis A. Over the next 3 months, six more cases of hepatitis A were diagnosed in residents in four other Michigan GHs. Three local health departments were involved in case investigation and management, including administration of postexposure prophylaxis (PEP). Serum specimens from seven cases were found to have an identical strain of HAV genotype 1A.

This report describes the outbreak investigation, the challenges of timely delivery of PEP for hepatitis A, and the need for preexposure vaccination against hepatitis A for adults living or working in GHs for the disabled.

CDC MMWR 64(06);148-152

Susan R. Bohm, Keira Wickliffe Berger, Pamela B. Hackert, Richard Renas, Suzanne Brunette, Nicole Parker, Carolyn Padro, Anne Hocking, Mary Hedemark, Renai Edwards, Russell L. Bush, Yury Khudyakov, Noele P. Nelson, Eyasu H. Teshale

Vaccination works: Hepatitis A rates fall in US children, rise in adults

As all children attending two schools in Portsmouth, UK will be vaccinated against Hepatitis A in light of a potential outbreak, researchers at the U.S. Centers for Disease Control report that adults are particularly at risk for Hep A infections.

hepatitis.ABackground. In recent years, few US adults have had exposure and resultant immunity to hepatitis A virus (HAV). Further, persons with liver disease have an increased risk of adverse consequences if they are infected with HAV.

Methods. This study used 1999–2011 National Notifiable Diseases Surveillance System and Multiple Cause of Death data to assess trends in the incidence of HAV infection, HAV-related hospitalization, and HAV-related mortality.

Results. During 1999–2011, the incidence of HAV infection declined from 6.0 cases/100 000 to 0.4 cases/100 000. Similar declines were seen by sex and age, but persons aged ≥80 years had the highest incidence of HAV infection in 2011 (0.22 cases/100 000). HAV-related hospitalizations increased from 7.3% in 1999 to 24.5% in 2011. The mean age of hospitalized cases increased from 36.0 years in 1999 to 45.1 years in 2011. While HAV-related mortality declined, the mean age at death among decedents with HAV infection increased from 48.0 years in 1999 to 76.2 years in 2011. The median age range of decedents who had HAV infection and a liver-related condition was 51.0 to 68.0 years.

Conclusions. Although vaccine-preventable, HAV-related hospitalizations increased greatly, mostly among adults, and liver-related conditions were frequently reported among HAV-infected individuals who died. Public health efforts should focus on the need to assess protection from hepatitis A among adults, including those with liver disease.

Trends in disease and complications of hepatitis A virus infection in the United States, 1999–2011: a new concern for adults

Journal of Infectious Diseases [ahead of print]

Kathleen N. Ly and R. Monina Klevens

Make Hep A vaccinations mandatory for everyone, especially those who serve food

Guelph, the town and the university, is like every other cow-town, eager to blow itself (it’s in Canada).

hepatitis.AThe Guelph Mercury says in an op-ed the Wellington-Dufferin-Guelph Public Health board received a review this week of the agency’s response to a public health scare arising from a local restaurant staffer being diagnosed with hepatitis A.

The board heard that the organization was quickly informed by the worker’s physician of the diagnosis and made prompt, effective and smart moves upon receipt of that information.

Among other correct and timely moves the board heard the agency made in this case was using a variety of media formats to spread the word of this situation and to communicate times and locations where concerned residents could obtain vaccinations at rapidly convened clinics.

(They contacted to get an estimation of reach; how the hell do I know, we just put stuff out there.)

The organization also adjusted quickly and resourcefully to meet higher than anticipated public demand for vaccines, the board heard.

By the account of the board, it was a case well-handled by health unit staff — and commendations were offered to that team following the briefing.

An earlier story declared the response to the Hepatitis A outbreak was public health’s finest hour.

When a family doctor alerted Wellington-Dufferin-Guelph Public Health that he had a patient with hepatitis A, the health protection and prevention agency leapt into action.

Dr. Nicola Mercer, the local medical officer of health, painted a picture of a responsive staff and an amicable public to the board of health Wednesday as she described the series of events that led to some 1,400 vaccinations being administered after a food handler at the popular Marj’s Kitchen in Alma was diagnosed with the hepatitis A virus.

Mercer said she received the call from the physician on Jan. 21.

“Normally you wouldn’t hear about a hepatitis A case,” Mercer said. “But in this case, the patient was a food handler who had worked the entire time of being infectious.”

After examining the lab work, staff determined the individual was infectious between Jan. 2 and Jan. 20 and that potentially 4,000 people had been exposed.

A number of things happened in tandem. Staff interviewed all staff at Marj’s Kitchen and administered vaccinations since these were the people most at risk of infection.

Lost in the platitudes is a simple message: make Hepatitis A vaccinations mandatory for everybody, especially food service workers.

Red Robin has second hepatitis A incident in two weeks, this time in Missouri

Two weeks ago I wrote that I were a food business owner I’d be worried about hepatitis A.

Individuals can shed the virus without showing symptoms and even a Hep A positive handwashing superstar will result in lineups outside the business or at the health department while patrons get their post-exposure shots.RedRobinLogo1-300x214

Authors of a 2000 Journal of Food Protection paper on the cost effectiveness of vaccinating food handlers arrived at the conclusion that the public health benefit of vaccinating for hep A doesn’t outweigh the costs – but doesn’t factor in all the bad publicity, hassle and incident management costs. The stuff that a Stroudsburg, PA Red Robin restaurant is going through right now.

The corporate Red Robin folks must be working overtime, as an identical situation has popped up at a Missouri outlet of the chain. Same story, different location. According to USA Today, up to 5,000 may have been exposed to hepatitis A following after a food handler was diagnosed with the virus.

Health officials worry that as many as 5,000 people could have been exposed to hepatitis A at a Red Robin restaurant here after a worker was diagnosed with the virus.

Springfield-Greene County Health Department officials received a report Tuesday about the illness, which can affect the liver, and worked with state and federal officials to get enough vaccine shipped so people who went to the restaurant May 8 to 16 can be immunized.

The goal is to get as many customers vaccinated within 14 days of their possible exposure, officials said Wednesday. Otherwise, the shot won’t work, so they’ve set up clinics through the Memorial Day holiday weekend.

“Upon being informed of the incident, the Springfield Red Robin took all safety measures to ensure the well being of our guests and team members including arranging the inoculation of all Springfield team members with the immune globulin prophylaxis shot,” Red Robin Gourmet Burgers officials said in a statement.

Wonder how many incidents it takes for a company to tip the scales to benefit outweighing cost on providing or requiring food handlers to have a hep A vaccination.

Hepatitis A linked to Red Robin restaurant in Pennsylvania

If I were a food business owner I’d be worried about hepatitis A. Individuals can shed the virus without showing symptoms and even a Hep A positive handwashing superstar will result in lineups outside the business or at the health department while patrons get their post-exposure shots. RedRobinLogo1

Authors of a 2000 Journal of Food Protection paper on the cost effectiveness of vaccinating food handlers arrived at the conclusion that the public health benefit of vaccinating for hep A doesn’t outweigh the costs – but doesn’t factor in all the bad publicity, hassle and incident management costs. The stuff that a Stroudsburg, PA Red Robin restaurant is going through right now.

According to the Pocono Record, the Pennsylvania Department of Health is looking into a Red Robin food handler who was recently diagnosed with hepatitis A.

“The Disease Prevention and Control Law prohibits us from providing further details as the investigation is ongoing at this time,” said Aimee Tysarczyk, press secretary/director of communications for the state Health Department.

“As the investigation continues and if any public health risks evolve, the department will provide additional information to ensure the safety and well-being of the public, as needed,” Tysarczyk said.

In a statement to the Pocono Record, Red Robin said:

“On May 5, 2014, Lehigh Valley Restaurant Group was informed by the Pennsylvania Department of Health that an employee at the Red Robin restaurant in Stroudsburg, Pa., had contracted Hepatitis A.

“The employee has not been in the restaurant since April 27, 2014, and will not return to work until he has been granted medical clearance.

The welfare of our guests and team members is Red Robin’s top priority.

“We are working closely with the health department to go beyond what is required.

With the last restaurant exposure listed as April 27 there isn’t a huge window to administer IgG shots.

Hepatitis A at Newmarket, Ontario Tim Hortons

The Toronto Star reports that a health alert was issued today after it was discovered that two employees of a Newmarket Tim Hortons were found infected with Hepatitis A.

York Region Public Health was notified of a case of hepatitis A at the Tim Hortons at 16545 Yonge St., near Savage Rd., on April 21. Following the initial investigation, it was decided the risk to customers was very low based on the employee’s position.

"He was not involved in food handling," said York Region medical officer of health Dr. Karim Kurji. "Given that, we didn’t feel the need to notify the public."

Oops, because…

The next day investigators conducted routine tests and offered immunization to workers. These tests revealed a second case, which was discovered on April 24. It was decided the risk of contamination to the public in this case was higher.

"The overall assessment when investigating the risk with the second case was the employee was handling food," said Kurji. "It was prudent for us to reach out to public and take necessary precautions.

York Region Public Health is holding a vaccine clinic Monday from 4 p.m. to 8 p.m. in the auditorium of the Newmarket Health Centre. People who ate food from this Tim Hortons between April 13 and April 22 are eligible for the vaccine. However, anyone who ate there between April 2 and April 22 could be infected.

Hep A happens a lot, but the way this one has been handled raises a few questions for me:

I wonder why the folks who ate at the Hortons before April 13th are excluded from eligibility from the vaccine? Does someone need to prove (with a receipt?) that they ate there between April 13 and 22nd? Who bears the cost if someone wants to get an IGG shot and is excluded? What happens if that individual gets sick?

This week’s food safety infosheet was about Hep A in a produce handler in Colorado.