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A lack of disease and heightened media attention to real and alleged side effects of vaccines lead some people to believe that the risks of childhood immunizations outweigh the benefits. By 1998, more than 10 states had introduced measures to expand exemptions to state vaccination mandates.
Beginning in 1999, the National Network for Immunization Information (NNii), an affiliate of the Infectious Diseases Society of America, developed an education campaign providing scientifically sound information about immunization to help parents, health care professionals and policy-makers make informed decisions about childhood immunizations and to help the media represent the topic accurately. Porter Novelli, a Washington-based public relations and social marketing firm, under a subcontract, conducted research to help develop the campaign and assisted NNii staff as needed.
At the end of the grant period in August 2003:
The Robert Wood Johnson Foundation (RWJF) partially funded this unsolicited project from February 1999 through August 2003 with a total of $4,799,584 in four grants to the Infectious Diseases Society of America for NNii to develop and run the education campaign.
Childhood immunization is one of the last century's greatest public health achievements, preventing the suffering and death of thousands of children from diseases such as polio, measles, diphtheria and smallpox. Yet, in the late 1990s, two developments have led some people to believe that vaccines may no longer be necessary or that the risks outweigh the benefits:
Those opposed to universal immunization of children focused their efforts within certain states to repeal legislation that mandates immunization for entry into school or daycare. State legislatures and the U.S. Congress held an unexpected number of hearings on this issue in 1998, the Infectious Diseases Society of America reports. More than 10 states introduced measures to expand exemptions to vaccine mandates. At that time, the medical community was not organized to provide legislators with the knowledge to make informed decisions about immunization.
RWJF had been involved with the issue of ensuring that all children receive their immunizations, through a national program, All Kids Count: Establishing Immunization Monitoring and Follow-Up Systems. The program, which ran from 1991 to 2001, supported the development and implementation of monitoring and follow-up systems to improve and sustain access to immunizations for preschool children. See the Grant Results on the program.
To ensure that children continue to be immunized, three professional organizations, the Infectious Diseases Society of America (Alexandria, Va.), the Pediatric Infectious Diseases Society (Alexandria, Va.) and the American Academy of Pediatrics (Elk Grove, Ill.), began a cooperative project in 1998 called the Vaccine Initiative, now renamed the National Network for Immunization Information (NNii).
The director, Bruce Gellin, M.D., M.P.H., of the Vanderbilt University School of Medicine (Nashville, Tenn.), proposed a communications campaign to establish NNii as a clearinghouse for reliable information on immunization, a source for expert advice on immunization for public policy and an independent watchdog for media accuracy on immunization.
RWJF provided four grants running from February 1999 through August 2003 (ID#s 035252, 036607, 038351 and 044378). NNii contracted with Porter Novelli, a public relations and social marketing firm in Washington to conduct research to develop the campaign and assist with campaign design and implementation. Louis Sullivan, M.D., (former secretary of the U.S. Department of Health and Human Services) and Samuel Katz, M.D., (pediatrics chairman emeritus, Duke University School of Medicine, Durham, N.C.) co-chaired the NNii steering committee (see Appendix 1 for a committee roster).
NNii sought to accomplish four goals by developing and spreading reliable information about vaccines and immunization through an education campaign:
Under the first two grants (ID#s 035252 and 036607), NNii and Porter Novelli staffs conducted audience research, completed the campaign design, developed informational materials and began outreach activities.
To discover how people think and act regarding immunization, Porter Novelli conducted separate focus groups of parents and physicians, a survey of legislative staff and a national survey of parents. (For more on this research, see Appendix 2. Findings from the parent survey appear in Findings.)
Project staff used research results to formulate campaign tactics and messages. For example, parents named health care providers as their most trusted source for immunization information, and physicians said they needed help to communicate effectively with their patients about immunization.
Since research identified health professionals as the best channel to reach parents, NNii staff designed an informational resource kit to support their efforts to educate patients during office visits.
To establish a wider reach among health professionals, build a network for dissemination and gather resources to achieve campaign goals, NNii approached some 60 professional societies and nonprofit organizations that Porter Novelli targeted as potential "partner organizations." It was able to establish partnerships with seven of them. (See Appendix 3 for a brief description of each partner organization.)
Although Gellin of NNii had earmarked the first grant for planning, he quickly recognized that the growing controversy over immunization in the media, state legislatures and Congress demanded a broader range of activities. RWJF approved his plan to reallocate funds for "strategic crisis communication" immediate response from NNii to key audience members (such as journalists or legislators) to correct misconceptions about immunization publicized by the media, or to give them access to immunization experts.
State-Level Activities. Gellin also proposed to set up "state immunization information teams" to assess local conditions and intervene with local legislators and media. RWJF awarded a supplementary grant (ID# 036607) that allowed project staff to finish and test the resource kit for health professionals; launch and publicize the project, its Web site and its resource kit; and organize information teams in targeted states.
In 2000, NNii staff and consultants conducted three workshops to train state immunization information teams, with representatives from 12 states with active or anticipated challenges to their immunization mandates. Because NNii has no state-level infrastructure, its partner organizations with local chapters helped to put together networks of health care professionals in individual states.
Two issues compelled project staff to abandon this approach in the states in April 2001. The day-to-day demands on health care providers prevented them from becoming a self-starting team of advocates. Training alone is not sufficient; they need a clear plan, regular management and consistent support. Without dedicated funding to provide this support, state teams remained inactive. Instead, the NNii steering committee decided to shift the focus to work with partner organizations to identify needs, expectations and opportunities to share NNii's messages and resources with their members across the country. This approach did bear some fruit. See the Results section Building and maintaining a network for immunization information.
Accelerating the Campaign. With the third and fourth grants from 2000 to 2003 (ID#s 038351 and 044378), NNii implemented, adjusted and accelerated the campaign while trying to find sustainable funding. NNii staff continued to monitor and counteract vaccine misinformation when the media reported it.
They set up an "early warning system" to alert health professionals and others to vaccine-related developments in the media, and to make accurate information about the topic under discussion readily available. Project staff distributed the resource kit to health professionals, developed new materials and added more resources to the project Web site.
In 2001, NNii hired Burness Communications to promote www.immunizationinfo.org to search engines, other Web sites, listservs and "site of the day" forums and train NNii staff to market the Web site. Porter Novelli conducted a usability study of the Web site to improve its function.
The campaign also ramped up outreach activities to establish NNii as a credible, science-based resource for reporters and legislators. Project staff held editorial briefings in major news centers across the country and set up a speakers bureau to give ready access to immunization experts. Gellin and Katz submitted statements for Congressional committees debating immunization or specific vaccines. Gellin talked about NNii and its resources in many types of forums, from meetings of government health agencies to local Rotary clubs. (See the Communications section for more on presentations.
In 2002, NNii staff obtained limited funding from the Children's Vaccine Program at PATH (the Program for Appropriate Technology in Health, an international nonprofit organization), but could not secure ongoing funding. Several foundations expressed regret that, given the economic conditions in 2002, they could not promise resources to NNii. RWJF's fourth and final grant (ID# 044378) supported NNii's core operations and some consulting activities.
In 2002, NNii contracted DCA®, a Boston-based management consulting firm, to identify new and appropriate sources of funding. Gellin left NNii that September to become director of the National Vaccine Program Office at the Department of Health and Human Services. A steering committee member, Louis Z. Cooper, M.D., served as interim director. NNii did not obtain long-term funding, and without it could not hire a new director. The Infectious Diseases Society covered the budgetary shortfall in 2003. That September, NNii moved to a new organizational home in Galveston. (For details, see After the Grant.)
Six organizations provided additional funding, including the Children's Vaccine Program at PATH ($100,000) and the Infectious Diseases Society of America ($85,000). (See Appendix 4 for a list of all funders.) To build and preserve its credibility as an independent source of reliable information, NNii did not accept funding from industry or government after the first award from RWJF.
NNii staff described results from a national survey of parents in "Do Parents Understand Immunizations? A National Telephone Survey," published in the November 2000 issue of Pediatrics (see the Bibliography for details). Based on telephone interviews with a nationally representative sample of 1,600 parents with a child younger than six or expectant parents conducted in April and May of 1999, the authors report that:
Investigators offered the following conclusion in the Pediatrics article:
The key results for each of NNii's goals are:
Resources for Health Care Professionals
Partner organizations and project staff formally launched the National Network for Immunization Information (NNii) at the annual meeting of the American Academy of Pediatrics in Chicago on October 30, 2000. Gellin presented findings from "Do Parents Understand Immunizations? A National Survey" at the meeting, which Pediatrics published in November (available online).
NNii simultaneously introduced its Web site and unveiled a new resource for health professionals, Communicating With Patients About Immunization: A Resource Kit from The National Network for Immunization Information. To publicize this launch, representatives from NNii held two press briefings and issued both print and video news releases.
Project staff report that national and local coverage reached an estimated audience of 50 million. Print outlets included the Associated Press and USA Today. Some 40 television stations used NNii's video news release 82 times. (See Bibliography for details about publications and media coverage described in this section.)
Prior to the launch, the New Yorker magazine introduced readers to NNii's work in a 1999 "Talk of the Town" column. Major print news outlets such as the Associated Press, Reuters, United Press International, and HealthScout also carried stories about this project. A wide range of magazines (e.g., Consumer Reports, Science News, Better Homes and Gardens, Self and Newsweek) and national newspapers (e.g., Wall Street Journal, Los Angeles Times, Boston Globe and Washington Post) described NNii's resources or its perspectives in articles on vaccine misconceptions, the shortage of vaccines, vaccine risk/benefit analysis and other topics.
Journalists and producers increasingly asked members of the network to comment on immunization-related issues. A 1999 "60 Minutes" segment about vaccines and autism featured NNii steering committee co-chair Katz. Former DHHS secretary and co-chair Sullivan, appeared on CNN's "Larry King Live" in March 2001.
In "Following ER," a spot that local news programs broadcast right after selected episodes of the popular television series "ER," Katz talked about the immunization concepts the episode introduced and explained the importance of vaccinations. This spot aired 38 times in 25 NBC markets on February 15, 2001.
On a National Public Radio broadcast of "Public Interest," Gellin was among the guests discussing vaccine shortages. From April 2002 through August 2003, the NNii received more than 70 inquiries from journalists covering immunization stories on subjects like pertussis outbreaks, the nasal influenza vaccine and vaccine safety.
Policy Meetings and Presentations
NNii representatives were called upon to participate in national immunization policy meetings and many conferences. Gellin and Katz provided statements to Congressional hearings on the hepatitis B vaccine and on balancing public health and personal choice in immunization policy.
At least one member of NNii's steering committee regularly participated in national immunization policy meetings of the CDC Advisory Committee on Immunization Practices, the CDC Vaccine Risk Communication Working Group, the U.S. Department of Health and Human Services National Vaccine Advisory Committee and the U.S. Food and Drug Administration Vaccine and Related Biological Products Advisory Committee.
Gellin and members of the steering committee gave more than 50 presentations at international, national, state and local immunization meetings, universities and professional conferences. Over the course of the grants they published eight articles in peer-reviewed journals and produced four resource kits or issue briefs. (See Bibliography for details on the articles and issue briefs.)
The NNii Web site and other information conduits continued to grow. From April 2002 to August 2003, the site received 224,735 visitors, averaging about 13,000 visitors per month viewing more than 39,000 pages.
Most major search engines list www.immunizationinfo.org first when users search for "immunization information". By August 2003, some 899 other Web sites linked to www.immunizationinfo.org, and the site had won notice from periodicals like the British Medical Journal, the Lancet and Popular Science. Articles that focused on NNii or referenced the network's informational resources appeared online at www.wnbc.com, www.cbshealthwatch.com, www.ama-assn.org (the American Medical Association) and more than 20 other sites.
Awards conferred on NNii's Web site include: "Hot Site of the Day" from USA Today, "Cool Site of the Day" from coolsiteoftheday.com, "Editor's Choice" from Popular Science and "Reference Site of the Day" from refdesk.com. The World Health Organization's Vaccine Safety Net Project lists NNii as one of 23 Web sites on vaccine safety that meets their criteria for "essential and important good information practices."
People most frequently visit pages of NNii's resource kit, Communicating with Patients about Immunization. The network sold it in binder form for $20, or it can be downloaded free from the Web site use to inform others about the kit. Network members distributed more than 28,000 copies copies through 2002. From 1999 to 2003, subscriptions to Immunization Newsbriefs grew from 200 to more than 4,100 subscribers in more than 80 countries.
Effective September 2003, Immunization for the Public Health (I4PH, a nonprofit organization in Galveston, Texas, affiliated with the University of Texas Medical Branch) took over the mission and operation of the National Network of Immunization Information. Internationally recognized leaders in immunization policy many from NNii's founding committee guide I4PH. Martin G. Myers, M.D., professor of pediatrics, preventive medicine and community health, University of Texas Medical Branch, directs NNii. The Infectious Diseases Society continues to provide media-related support. To sustain its credibility as a nonbiased source of information on immunization, I4PH maintains NNii policy to accept no commercial or government funding.
NNii continues to provide the same quality and range of information on a redesigned Web site, with regular updates. It now includes information in Spanish about specific diseases and their vaccines, and more than 35 new or revised articles in English. By April 2005, the NNii Web site featured more than 60 synopses of vaccine-related journal articles that explain in nontechnical language the purpose, findings and relevance of the studies. In 2005, project staff, based on an online article, developed a brochure that health professionals can give to parents entitled "Evaluating Information About Immunizations on the Internet." To access the article or to purchase booklets, go to the Web site. I4PH plans to launch an additional immunization information Web site in both English and Spanish.
Public Education Campaign on Childhood Vaccinations
Infectious Diseases Society of America (Alexandria, VA)
Director of Communications, Infectious Diseases Society of America: Diana Olson
National Network for Immunization Information Steering Committee, 2003
Samuel L. Katz, M.D. (Co-Chair)
Professor and Chairman Emeritus of Pediatrics
Louis W. Sullivan, M.D. (Co-Chair)
U.S. Department of Health and Human Services
Morehouse School of Medicine
Louis Z. Cooper, M.D.
Professor of Pediatrics
New York, N.Y.
Bruce B. Dan, M.D.
President, MedNet Communications
Adjunct Assistant Professor of Preventive Medicine
Vanderbilt University School of Medicine
Stanley A. Gall, M.D.
Donald E. Baxter Professor
Department of Obstetrics and Gynecology
University of Louisville School of Medicine
Advisory Committee for Immunization Practices at the CDC
American College of Obstetricians and Gynecologists
Alan E. Kohrt, M.D.
Clinical Associate Professor of Pediatrics
Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine
Board of Directors
American Academy of Pediatrics
Elk Grove Village, Ill.
Martin C. Mahoney, M.D., Ph.D., F.A.A.F.P.
Chair, AAFP Commission on Clinical Policies and Research (former)
Guideline Panel of the AAFP and American Academy of Pediatrics
American Academy of Family Physicians
Edgar K. Marcuse, M.D., M.P.H.
Professor of Pediatrics
University of Washington
Children's Hospital and Regional Medical Center
Dennis L. Murray, M.D.
Professor of Pediatrics
Chief, Section of Infectious Disease
Medical College of Georgia Children's Medical Center
Fellow, Pediatric Infectious Diseases Society
Georges Peter, M.D.
Professor of Pediatrics
Brown University School of Medicine
Gregory A. Poland, M.D.
Director, Mayo Vaccine Research Group
Professor of Medicine
Mayo Clinic and Foundation
William Schaffner, M.D.
Professor of Infectious Diseases
Chairman, Department of Preventive Medicine
Department of Preventive Medicine and Infectious Diseases
Vanderbilt University School of Medicine
Thomas E. Stenvig, R.N., M.S., M.P.H., C.N.A.A.
Associate Professor, College of Nursing
South Dakota State University
Board of Directors
American Nurses Association
Patricia Stinchfield, R.N., M.S., C.P.N.P.
Program Director, Children's Immunization Project
Adjunct Clinical Faculty
University of Minnesota School of Nursing
National Association of Pediatric Nurse Practitioners
Cherry Hill, N.J.
Patricia Whitley-Williams, M.D.
Associate Professor of Pediatrics
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
New Brunswick, N.J.
Formative Research by Porter Novelli
Porter Novelli examined the parent, physician and public policy audience segments separately.
Organizations Affiliated with the National Network for Immunization Information (during the grant period)
American Academy of Family Physicians (AAFP) aims to improve the health of patients, their families and the American people, to advance and represent the specialty of family practice and to serve the unique needs of members with professionalism and creativity.
American Academy of Pediatrics (AAP) is an organization of 57,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well being of infants, children, adolescents and young adults.
American College of Obstetricians and Gynecologists (ACOG) is a private, voluntary, nonprofit membership organization of professionals providing health care for women with a current membership of 40,000 physicians.
American Nurses Association (ANA) is a professional organization representing the nation's registered nurse population.
Infectious Diseases Society of America (IDSA) is an organization of more than 7,500 physicians and scientists. It promotes and recognizes excellence in patient care, education, research, public health and prevention in the field of infectious diseases.
National Association of Pediatric Nurse Practitioners (NAP) is committed to improving the health care of children (infants through young adults) and provides leadership for the over 6,000 Pediatric Nurse Practitioners who deliver primary health care in a variety of settings.
Pediatric Infectious Diseases Society (PIDS) promotes excellence in diagnosis, management and the prevention of infectious diseases of infants, children and adolescents through clinical care, education, research and advocacy.
Funders of the National Network for Immunization Information
The total includes:
*The Infectious Diseases Society of America also has pledged to contribute an additional $25,000 to NNii for 2006.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Gellin BG. "Vaccination." In Grolier's 2003 Multimedia Encyclopedia, CD-ROM, New York: Grolier, 2002.
Gellin BG. "Pediatricians Have Important Role in Correcting Parents' Misunderstandings about Vaccines." California Pediatrician, Spring: 1922, 2001.
Gellin BG, Maibach EW and Marcuse EK. "Do Parents Understand Immunizations? A National Telephone Survey." Pediatrics, 106(5): 10971102, 2000. Also available online.
Gellin BG and Schaffner W. "The Risk of Vaccination The Importance of 'Negative' Studies." New England Journal of Medicine, 344(5): 372373, 2001.
Havinga W. "Too Many Vaccinations?" Pediatrics, 110(3): 648649, 2002. Also available online.
Kastner JL and Gellin BG. "Measles-Mumps-Rubella Vaccine and Autism: The Rise (and Fall?) of a Hypothesis." Pediatric Annals, 30(7): 408415, 2001.
Katz SL and Shine KI. "Guaranteeing Vaccines for All Americans." January 4, 2002. National Academies Office of News & Public Information, National Academies Op-Ed Service Archive.
Marshall GS and Gellin BG. "Challenges to Vaccine Safety." Primary Care Clinics in Office Practice, 28(4): 853868, 2001. Abstract available online.
National Network for Immunization Information. "Nurses' Perceptions and Intentions Regarding Smallpox Vaccine: A National Survey." Alabama Nurse 30(1): 11, 2003. Available online.
Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, Gellin BG and Landry S. "Addressing Parents' Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant's Immune System?" Pediatrics, 109(1): 124129, 2002. Also available online.
Offit PA, Quarles J, Gerber MA and Marcuse EK. "Immunization's Undaunted Record." Seattle Post Intelligencer, February 17, 2002.
Grantmakers In Health. Issue Brief No. 4: Victims Of Our Own Success: Will Immunization Remain the Paradigm of Effective Prevention? Washington: Grantmakers In Health, June 2000. Also available online.
National Network for Immunization Information. Communicating With Patients About Immunization: A Resource Kit from The National Network for Immunization Information. Alexandria, Va.: National Network for Immunization Information, 2000. Revised January 2003. Also appears online.
National Network for Immunization Information. Know the Facts about Immunization. Alexandria, Va.: National Network for Immunization Information, 2000. Also appears online.
National Network for Immunization Information. National Network for Immunization Information Brochure. Alexandria, Va.: National Network for Immunization Information, October 1999, revised March 2002.
National Network for Immunization Information. Nurses' Perceptions and Intentions with Regard to the Smallpox Vaccine: A National Survey Report. Alexandria, Va.: November 2002.
Porter Novelli. Survey Research Conducted among Parents and Expectant Parents: Final Report. Washington: Porter Novelli, 1999.
Public Health Seattle & King County (with input from the National Network for Immunization Information). Plain Talk About Childhood Immunizations. Seattle: Public Health Seattle & King County, 2000. Also appears online.
Usability Studies, Inc., Usability Study: NNii Web Site Usability Testing and Evaluation Report. Superior, Colo.: Usability Studies, Inc., November 28, 2001.
National Network for Immunization Information, a video news release giving a digest of an NNii presentation at the 2000 Annual Meeting of the American Academy of Pediatrics, including findings from a national telephone survey findings published in Pediatrics, Chicago: National Network for Immunization Information, October 30, 2000.
"Name Test #3." Porter Novelli, fielded August 2731, 1999.
"National Network for Immunization Information 1999 National Survey Instrument." Porter Novelli, fielded AprilMay 1999.
"Nurses' Perceptions and Intentions with Regard to the Smallpox Vaccine." National Network for Immunization Information, fielded November 2002.
www.immunizationinfo.org provides comprehensive information on immunization and vaccines; information about vaccine-preventable diseases; a database of state-by-state vaccine requirements; a downloadable resource kit for health care professionals, Communicating with Patients About Immunization: A Resource Kit from the National Network for Immunization Information; and Immunization Newsbriefs, abstracts of recent news about immunization with an archive of past issues of the listserv. Alexandria, Va.: National Network for Immunization Information, October 2000.
www.vaccine.org. The Allied Vaccine Group is a Web portal composed of Web sites that present valid scientific information on the subject of vaccines. Users can search multiple sites simultaneously to find information. Cape Coral, Fla.: UniScience News Net, Inc., April 1998.
Bruce Gellin, written statement for the House Committee on Government Reform, Hearing on Autism, "Autism: Present Challenges, Future Needs Why the Increased Rates?" Washington, April 6, 2000.
Samuel Katz, statement before the House Committee on Government Reform Hearing, "Vaccines Finding the Balance Between Public Safety and Personal Choice," Washington, August 3, 1999. Available online.
Report prepared by: Antonia Sunderland
Report prepared by: Jan Hempel
Report prepared by: Linda Bernstein Jasper
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Paul Tarini
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