Abstract In response to the accompanying article by Yih et al. (Am J Epidemiol. 2018;187(6):1269–1276), we highlight the importance of moving beyond epidemiologic research on human papillomavirus (HPV) vaccine safety to focus on translation of this strong evidence base into successful vaccine safety communication strategies to bolster vaccine uptake. The potential of the HPV vaccine to reduce cancer incidence is substantial, yet actual HPV vaccination rates in the United States are disappointingly low in comparison with other routine childhood vaccines with similar safety profiles. This is no doubt due, in part, to persistent parental safety concerns. In 2016, safety remained the second most common reason for lack of vaccination intent by parents of unvaccinated adolescents. While the strong study by Yih et al. makes use of a novel statistical method and a large medical claims database to confirm the low occurrence of adverse events following HPV vaccination observed globally, their study also highlights a key challenge for epidemiologists: translating our research findings to other public health domains, so that evidence-informed communication strategies can be used to disseminate the information in a way that is understandable and useful to the public. Moving forward, multidisciplinary research teams will be essential to ensure that our epidemiologic findings have a broad public health impact. adverse events, health communication, HPV vaccination, human papillomavirus, translational epidemiology, vaccine safety The study by Yih et al. (1) in this issue of the Journal applies a novel statistical method to identify adverse events potentially related to quadrivalent human papillomavirus (HPV) vaccination in an extremely large medical claims database of vaccine initiators. This study contributes to an already extensive body of literature on the low incidence of adverse events associated with the HPV vaccine, further supporting its safety. As epidemiologists, we take great comfort in using different methods and data sources to reach the same conclusions. This type of research moves the field of study forward, providing a reliable evidence base from which to make public health inferences and recommendations. However, in the case of HPV vaccination, there is a noticeable gap between the science supporting vaccine safety and the perception of millions of parents of adolescents in need of cancer protection. A limitation of the article by Yih et al. is the very restricted discussion of the existing literature on vaccine safety and of how their results, namely the frequency and type of adverse events identified, compare with both prior research and prior concerns that have been communicated outside of scientific journals—concerns which their paper can provide direct evidence to contradict. As the first vaccine designed to prevent cancer, the public health potential of the HPV vaccine is substantial. Despite this promise, actual HPV vaccination rates in the United States are disappointingly low in comparison with other routine childhood vaccines, and they fall well below public health targets (2, 3). According to the National Immunization Survey–Teen, only 50% of males and 63% of females had initiated the HPV vaccine series in 2015 (4). Low HPV vaccination among adolescents results from a complex array of factors, including cost, access to health care, and a range of parental concerns and misperceptions about the vaccine (5). In particular, vaccine safety continues to be a primary concern among parents who choose not to get the HPV vaccine for their children, despite the robust body of scientific evidence in support of vaccine safety (6). The study by Yih et al. is a strong example of this evidence. Unlike investigators in prior studies, they used an unbiased approach that scanned for any diagnoses, not just a list of prespecified or suspect diagnoses, which could potentially be temporally related to recent HPV vaccination. Their study focused on emergency department and inpatient records completed within 42 days of vaccination, so it was inherently designed to identify acute yet more severe events. This new methodology identified only 2 significant clusters of adverse events, both of which had been previously identified: “cellulitis and abscess of the arm” and “other complications of surgical and medical procedures” (1). Because of the analytical complexity of the study, related to multiple risk windows, the exact rate of potential adverse events for direct comparison with other US-based and international results is not clear. However, of the 1.9 million vaccine patients, only 31 (“cellulitis and abscess of the arm”) and 58 (“other complications of surgical and medical procedures”) cases were identified in the 2 statistically significant clusters (1). The authors were able to review these patients’ medical records, and they found that the majority of the patients experiencing “other complications” had had at least 1 other vaccine administered on the same day as the HPV vaccine, lessening the causal link to the HPV vaccine specifically. These results are consistent with the broader literature suggesting that serious adverse events following HPV vaccination are very uncommon and are comparable to rates for other routine vaccinations with much higher acceptance rates. For example, the World Health Organization estimated the occurrence of anaphylaxis related to HPV vaccine at 1.7–2.6 cases per million, similar to that of annual influenza vaccines (7, 8). From an epidemiologic perspective, these events appear quite rare and indicate the overall safety of the vaccine. However, from the public’s perspective, even rare and isolated adverse events can be cause for concern, particularly when events are amplified or misrepresented by media coverage (9). The circulation of misinformation about vaccine safety can have a dramatic impact on public health. In Japan, HPV vaccination rates fell from 70% in 2013 to 1% in 2017 following the spread of misinformation, including circulation of videos of girls reportedly having HPV-vaccine-related seizures, and media coverage of a study purporting to show a link between the vaccine and brain damage (10). This example, which is just one of many worldwide, demonstrates how anecdotal evidence of rare or even unsubstantiated adverse events can prove challenging to overcome with even the most robust scientific data. While the results from the Yih et al. study are important, the complex title of their article (1) alone highlights one of the key challenges for epidemiologists and the broader public health community: translation and communication of study findings to the targets of the research, in this case parents of unvaccinated adolescents. Although scientific evidence is critical, additional psychological, social, and political considerations also factor into the public’s perception of vaccine acceptability (11). While the safety evidence has been growing since the introduction of the HPV vaccine and should continue to be monitored, safety concerns among parents have been growing right alongside those data (12). A recent systematic review found that although safety concerns were not prominent among health-care providers, these concerns loomed large among parents of adolescents eligible for vaccination (5). Despite the continuous safety data from the HPV vaccine trials, World Health Organization reviews, and the Centers for Disease Control and Prevention’s Vaccine Adverse Event Reporting System (7, 13–15), safety concerns continue to be a primary driver of nonvaccination. In 2016, 16% of parents who did not intend to vaccinate their teenagers in the next 12 months indicated safety as a main reason for this decision (16). This concern is second only to believing the vaccine is not necessary (22%) (16). And while provider recommendation has been shown to be one of the most important promoters of HPV vaccine uptake, safety concerns remain prominent among nonvaccinating parents who have received a provider recommendation (17). Thus, the solution to the challenge of increasing vaccine uptake must move beyond simply building more evidence to building more effective communication based on that evidence. In a recent review of barriers faced by HPV vaccination programs, Bonanni et al. concluded that the public health benefits of vaccination may only be realized when there is “broad community confidence” in vaccine safety (18, first page). Because scientific evidence rarely reaches the public directly, it is crucial for epidemiologists to identify pathways for translating and disseminating vaccine safety evidence to nonscientific audiences. The field of health communication can serve as a bridge across the chasm between epidemiologic evidence and population uptake of HPV vaccination. Health communication entails “the study and use of communication strategies to inform and influence individual and community decisions that enhance health” (19, p. 2). Health communication strategies can turn epidemiologic data into persuasive and digestible information for the general public through the application of behavioral theories to messaging (20). Health communication facilitates the translational process in several ways, including 1) identifying target audiences who have information needs and concerns, 2) designing effective messages grounded in behavioral science principles to address and mitigate those concerns, and 3) developing dissemination plans to reach target audiences with those messages. Communication researchers have investigated approaches to effectively convey the evidence supporting HPV vaccination to the public and promote vaccine uptake. Recent studies have provided support for a variety of communication-based strategies, including strengthening the quality of provider recommendations (21), disseminating multimedia education materials to target populations (22), and using persuasive narrative messages in public health campaigns (18, 23, 24). In particular, research has shown that narratives, despite representing specific events rather than cumulative evidence, are useful tools for conveying scientific information to nonexpert audiences (25) and offer substantial potential to impact behavior change (26). This is why, as Yih et al. note (1), several specific examples of adverse events (e.g., Japan) have been powerful enough to influence HPV vaccination on the population level, despite the mountain of evidence supporting general vaccine safety. In response to such media narratives about adverse events, public health communicators can draw from scientific evidence to prepare counter-narratives about vaccine safety. In fact, narratives and/or hybrid messages (i.e., narratives paired with statistical evidence) may be more persuasive than data-focused messages alone in the context of HPV vaccination (24). While findings from the early HPV vaccine communication efforts noted above are promising, this area of health communication research is still emerging (20). To date, the majority of this work has not focused specifically on adverse events and vaccine safety. Health communication researchers are well-positioned to team with epidemiologists to harness the power of narratives and other messaging strategies that reiterate what scientific evidence tells us about vaccine safety. Such messages can aid in illustrating epidemiologic data for the public and can help public health officials readily combat misinformation surrounding isolated reports of adverse events. Bonanni et al. noted that “a weak communication strategy” may be the downfall of vaccination programs (18, first page). Persistent parental concerns, coupled with the dramatic impact of misinformation, make it clear that development of evidence-supported communication strategies to convey vaccine safety information to the public will be crucial to future vaccination uptake. Epidemiologists must play a central role in addressing this translational problem and working toward a solution. To this end, we offer 3 starting points for consideration. First, we should acknowledge when and where there is a need to shift focus from generation of stand-alone evidence toward research on translation and communication of the data. For example, at minimum, epidemiologists should address when a consistent evidence base has accumulated and then discuss next steps in the translational research process in the Discussion sections of their published articles, or produce a lay summary of the research findings to share across public health disciplines to facilitate understanding and dissemination. Second, we can ensure the creation of strong multidisciplinary partnerships in future research that bring epidemiologists together with health communication and media specialists. These partnerships can build on and extend the epidemiologic evidence of vaccine safety by focusing new research on health communication and promotion strategies that work. Through team-based science, epidemiologists can aid health communication researchers in deeply understanding the nature of the methods and limitations of adverse event surveillance. In turn, health communication researchers can guide the translation of this evidence into effective public health messages. Third, we can recognize this translation and communication gap in many of our training programs and work to incorporate health communication theory and practice into coursework and other forms of academic training. Unfortunately, the gap between evidence and public perception discussed here is not unique to the case of HPV vaccination but indicative of a larger “communication failure” across science (27). Thus, solutions found at the intersection of health communication and epidemiologic research are likely to have farther-reaching applications for other areas where concerns and misinformation about safe and effective health technologies are barriers to enhancing public health impact (28). Within the current challenges of a complex communication environment—which may include misinformation, media narratives about adverse events, and resistance to scientific evidence—it is more important than ever that we, as a public health scientific community, find better ways to communicate directly to the public. ACKNOWLEDGMENTS Author affiliations: Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (Anne F. Rositch); and Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (Melinda Krakow). The views expressed in this commentary are those of the authors and do not necessarily reflect the views of the National Cancer Institute, the National Institutes of Health, or the US government. Conflict of interest: none declared. Abbreviations HPV human papillomavirus REFERENCES 1 Yih WK, Maro JC, Nguyen M, et al. . 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American Journal of Epidemiology – Oxford University Press
Published: Feb 23, 2018
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