Send Orders for Reprints to reprints@benthamscience.

ae

Current Drug Safety, 2015, 10, 9-15 9

Risk Communication of Vaccines: Challenges in the Post-Trust Environment

Frederic Bouder*

Department of Technology and Society Studies, Maastricht University, Maastricht, The Netherlands

Abstract: Highly publicised vaccine scares and recent debates about the risks suggest that public trust in immunisation
programmes is fragile. For instance, the recent outbreak of Measles in Wales was the direct result of almost fifteen years
of distrust for the MMR vaccine in the UK. This article shows how the latest science on risk communication will help
critical actors, especially policy-makers, to build trust when they communicate risks to citizens and patients. The article
offers policy advice on risk communication based on the results of three vaccines case studies. Five procedural principles
which were developed for the UK government – the so-called “five As” of public risk communication are used to
structure the discussion. Conclusions and recommendations suggest ways to move forward and build a two-way proactive
risk communication practice.
Keywords: Hepatitis B, HPV, MMR, policy, regulation, risk communication, trust.

INTRODUCTION immunisation programs will depend on the ability of these

agencies to communicate effectively.
In most countries, vaccination is fully or partially
compulsory and is driven by nationally and internationally Can more effective benefit/risk communication support
sponsored programmes. Funding and policy commitment public trust in vaccination? And what should be the features
have been critical factors in the success of essential global of such communications? The article starts with a short
health commitments, such as the near-eradication of polio review of key literature on risk communication and trust.
[1]. Yet, in the internet age and the 24/7 news society, highly Case studies developed by the author on MMR, Hepatitis B
publicised vaccines scares – from Measles Mumps and [5] and anti-HPV [14] vaccines are used to illustrate the
Rubella (MMR) [2, 3], to Hepatitis B [4, 5] and Human importance of taking risk communication science on board.
papillomavirus (HPV) vaccines [6-8]– suggest that public Concluding remarks highlight points that require urgent
trust in immunisation is fragile. Expert messages may no action.
longer fare well within significant segments of the
population. In Europe, this phenomenon can be traced back WHAT IS RISK COMMUNICATION AND HOW
to the health scandals of the 1990s – most prominently the DOES IT RELATE TO VACCINES?
BSE [9] and Human Immunodeficiency Virus (HIV)
contaminated blood disasters [10]. Controversies have The field of risk communication emerged from cognitive
challenged expert-based decision models and led to a research in risk perception that showed that ‘lay’ concerns
European “post-trust” environment [11]. Key features of the about hazards – from nuclear reactors [16-18] to chemical
emerging post-trust society include a loss of faith in plants [19], radon [20], space [21, 22], and genetic
government, the growth of scientific pluralism and the engineering [23-25]– do not correspond with experts
greater impact of the media and the internet on public quantifications [26]. A series of factors critically affect
perception. perceptions, e.g. degree of control, catastrophic potential,
and familiarity [27-29]. Rational decision-making is also
Government agencies often struggle to maintain clouded by ‘heuristics’ (mental shortcuts), bias and other
evidence-based and proportional policy responses when they emotions (e.g. “affect”) [30-32]. Research on risk
are confronted with vaccine controversies [5]. When this communication has focused on making use of these
occurs in developing countries the disastrous impact on cognitive insights to analyze and improve exchanges
public health becomes particularly worrisome [12, 13]. In between senders and receivers [33] of risk messages (e.g.
Europe, recent HPV controversies show that large sections scientists, manufacturers, government officials, the media).
of the public are more concerned about product safety and Theories have been formalized to explain critical
ethics than public health objectives [14]. The success of phenomena, such as the social amplification of risk by the
ongoing and future (e.g. anti-HIV vaccine [15]) media [34, 35], as well as the ups and downs of public trust
immunisation programmes demands that national and [11, 36, 37].
international agencies prepare themselves to address
society’s questions and concerns. The success of future Much has been written on risk from the perspectives of
health psychology and sociology [38, 39]. Yet, there has
been only limited discussion of pharmaceutical issues from
*Address correspondence to this author at the Maastricht University, the risk communication discipline [40]. A small number of
Department of Technology and Society Studies, Grote Gracht 76, 6211 SZ, studies, however, offer precious insights into vaccine
Maastricht, The Netherlands; Tel: +31 43 38 82 566; Fax: +31 43 38 84 917 perception and communication [41-46]. Research outcomes
E-mail: [email protected]
suggest that people are subject to relatively low overall

2212-3911/15 $58.00+.00 © 2015 Bentham Science Publishers

10 Current Drug Safety, 2015, Vol. 10, No. 1 Frederic Bouder

concerns for vaccines when compared to dreaded non- communication- developed by the author for the UK Risk
medical (e.g. nuclear) or medical (e.g. DNA manipulation) and Regulation Advisory Council [51]:
activities [47-49]. Yet, many people are reluctant to accept
1- Assembling the evidence
vaccines when the prevalence of a disease is low [42]; on the
other hand, safety concerns are heightened when vaccination 2- Acknowledgement of public perspectives
is mandatory [30]. Key factors also contribute to anti- 3- Analysis of options
vaccine decision heuristics [41-43] such as compression
(overestimating the frequency of rare risks and 4- Authority in charge
underestimating the frequency of common risks), availability 5- Interacting with the audience
(over-reporting of negative information by the media),
omission bias (actions are perceived as more harmful than The five principles are backed by 40+ years or so of
omission), risk ambiguity and freeloading (people rely on research on risk communication combined with direct
high vaccination rates and herd immunity to protect their contributions from leading researchers in the field and senior
unvaccinated child). These negative heuristics are sometimes practitioners. They may be described as a “survivor’s guide”
counterbalanced by positive feelings, especially altruism. designed to help and guide the actors themselves. The
Altruistic feelings have led most parents to widely approve following section will illustrate how the communication of
of vaccines being given to their children. vaccine-related risk situations could greatly benefit from this
input.
TRUST-BUILDING RISK COMMUNICATION
Assembling the Evidence
Over time, scientists and government experts have used
three distinct communication strategies [49]: The first step for institutional communicators is to
“assemble the evidence” about the risk. Concretely, this
(i) in its infancy risk communication has focused on means that risk communicators need to demonstrate that they
conveying probabilistic thinking to the general public understand the risk and therefore have a credible basis for
(...); their decisions. During a vaccine safety alert there is not
(ii) experts have then focused on persuasion and public always enough time to collect and interpret the evidence, or
relations to convince people that they should change to use risk jargon – it often takes time to establish the
their behavior (...); existence of a hazard, as well as estimate the magnitude and
likelihood of harm. On 6 February 2009, two girls from the
(iii) in the third and last phase, the focus has been on Spanish province of Valencia who had been vaccinated with
developing a two-way communication process in the same batch of anti- Human Papillomavirus (HPV)
which scientists, risk managers, and various vaccine Gardasil were admitted to a hospital. Immediate
laypersons engage in a social learning process”. non-publicized discussions took place between the Spanish
For most health and environmental risks, top-down pharmaceutical regulator (AEMPS) and the manufacturer
persuasion has been shown to achieve compliance when (Sanofi Pasteur). On 10 February, Sanofi Pasteur stopped the
public trust is high [11]. When regulators and industry do not entire batch as a pre-emptive precautionary measure. The
enjoy high levels of public trust they may build confidence Spanish Ministry of Health immediately confirmed this
and credibility through “multiple messages about the nature precautionary measure [14]. Such prompt action illustrates
of risk and other messages, not strictly about risk, that the tendency that regulators have to err on the side of caution
express concerns, opinions or reactions to risk messages or when they are confronted with an emergency situation.
to legal or institutional arrangements” [21,50]. Yet, this Yet, swift action should not be an excuse for
approach is unlikely to change behavior without the help of complacency. Regulators have often failed to re-appraise the
targeted policy measures. For example, asking parents to precautionary measure after the crisis, even when reassuring
consent to all teen vaccines increases consent for HPV evidence has been available. In the mid-1990s, the French
vaccine above asking about just that vaccine [46]. Health Minister Mr. Douste-Blazy launched an ambitious
Whether it is top-down or two-way, risk communication vaccination campaign against Hepatitis B. In October 1998
is more efficient when it is “proactive”. Proactive when controversies started to develop about a possible link
communication is significantly different from mere slogans. between the Hepatitis B vaccine and multiple sclerosis and
It takes place when institutions maintain multiple channels lupus, on the basis of a number of studies [52-57], Mr.
with influential stakeholders and avoid information vacuums Bernard Kouchner, Mr. Douste-Balzy’s successor,
[11]. A significant example is the Swedish Medical Product suspended the school-based hepatitis B vaccination
Agency’s handling of the H1N1 swine flu vaccine, where the programs. The Government’s position was that the claim
Agency succeeded in combating rumors regarding the side was at least credible. As a consequence, the large-scale
effects of the vaccine, thus ensuring the highest take up rates French hepatitis B vaccination campaign was put on hold. At
of the vaccine worldwide. the time, the state of the science was in the regulator’s view,
‘unsettled’. They demanded that more studies should be
LEARNING FROM VACCINE COMMUNICATION conducted. However, French regulators did not revise their
CASES judgments when reassuring evidence was published and
never resumed their large-scale immunisation efforts [5].
For expository purposes, we concentrate on five Assembling the evidence, however, is not only about paying
procedural principles – the so-called “five As” of public risk attention to the quality of the evidence that is being
Risk Communication of Vaccines: Challenges in the Post-Trust Environment Current Drug Safety, 2015, Vol. 10, No. 1 11

presented at a certain point in time. It should be about crucial data on risk perception. Too often, the tendency
engaging in an incremental process to generate, review and among experts has been to blame people’s irrationalities or
act on new evidence. the unpredictable nature of the crisis [65].
Typically, regulators tend to overestimate their capacity
to convince people to take a specific course of action. And
Assembling the evidence they underestimate the impact of contextual factors. For
Efficient risk communication requires demonstrating that your decisions instance, how one is perceived is of critical importance.
are based on evidence
Acknowledging public perspectives should include an
• What is the risk? ongoing commitment to ‘test for trust’, i.e. understanding
• Have you used the best available information to define the problem where people put their trust and why they consider some
at stake?
actors to be more trustworthy than others. The Gardasil scare
• Are you aware of the chance that the hazard may occur? was fuelled by negative views about the pharmaceutical
• Are you aware of the size of the hazard? industry. Opponents questioned the fairness of the
• Who will benefit and who will suffer if the hazard occurs? Will vaccination process. They thought that the Industry had
everyone be equally affected? resorted to unethical and aggressive marketing campaigns to
• Have you considered complexity, ambiguity and uncertainty? sell more vaccines. In addition, the immunisation
programme was seen as expensive and a waste of public
money – i.e. inefficient. Consumer groups and even some
The institutional reaction to the now ‘textbook’
regulators highlighted that they considered Gardasil to be
controversy about Measles Mumps and Rubella (MMR) [5]
overpriced and therefore a strain on public finances [14].
illustrates another problem: it takes very little to distort
evidence in the eyes of the public. In 1998, a study led by The Gardasil controversy therefore illustrates particularly
anti-vaccine campaigner Dr. Andrew Wakefield was well that decision-makers would gain from paying more
published in one of the leading scientific journals The attention to the well-established determinants of public trust:
Lancet. The paper indirectly suggested that the MMR efficiency, competence, and fairness are the three paramount
vaccination might be responsible for cases of autism [58]. variables of trust [11]. Those perceived as unfair and
The media picked up the issue. Instead of stressing that the inefficient are less likely to be seen as trustworthy. Acting on
study challenged the scientific consensus, journalists – these variables helps to formulate an effective risk
including the highly respected BBC- opted for a ‘balanced’ communication that proactively addresses people’s concerns
coverage where proponents and opponents would be given and (re)builds trust.
equal voice. They were slow to take on-board overwhelmin-
gly reassuring evidence [59-64]. Regulators did not give
credit to the Wakefield’s article. However, the nature of the Acknowledgement of public perspectives
reporting had the critical effect of undermining the science Efficient risk communication requires listening to individual and
and scaring many parents. society’s views of the risk
• Do you understand how members of the public perceive the risk?
Acknowledgement of Public Perspectives • Do you understand how influential risk actors view the risk?
• Have you identified the risk entrepreneurs that are likely to fear the
Studying people’s views and concerns is central to an risk the most?
evidence-based approach to communication. For instance, • Have you identified those groups that are likely to want to amplify
knowing more about distinct patterns of vaccine perception or diminish the risk, or others’ perceptions of the risk, for their own
would have helped scientists and decision makers devise benefit?
communications to address unscientific claims about the • Have you considered those groups that are negatively affected by
MMR, hepatitis B and other vaccines. In the French the risk, especially where those groups are seen as particularly
Hepatitis B case, the controversy started with a series of vulnerable?
articles that could be best described as evolving towards
some sort of ‘conspiracy theory’ [5]. Opponents often Analysis of Options
expressed their views on the Internet. They consistently
mixed the scientific issue with political considerations about Vaccination campaigns are often launched on a grand
the influence of the pharmaceutical industry on the scale, targeting millions of individuals. When worries
government’s decision to promote large-scale vaccination. emerge, precautionary measures may promptly replace
This was, arguably, one of the factors that contributed to a vaccination commitments. In the French Hepatitis B and
dramatic (negative) change in perception. The Health Spanish Gardasil cases policy makers concentrated on
Ministry did not anticipate these developments, which led to demonstrating that the government was tough and that they
a tougher reaction– i.e. a moratorium on the vaccination would enforce the ‘better safe than sorry’ precautionary
programme. principle. They failed to acknowledge alternative measures
and did not communicate the downside of precaution [66].
The understanding of public perceptions may have been The communications of the European Medicines Agency
used to judge the nature and seriousness of the negative were ambiguous, stressing at the same time the absence of
perceptions among the public. Risk communicators need to any causal relationship between the vaccine and the cases,
get a better understanding of the views and concerns of those the need for precautionary measures as well as further
affected by the risk, whether as a sufferer or as a producer. investigation to establish the links between the case and the
When a controversy develops, it is often too late to generate vaccine. The EMA even required that product labels be
12 Current Drug Safety, 2015, Vol. 10, No. 1 Frederic Bouder

modified to cover the risk of syncope, which was interpreted After the release of the conclusions of the investigation
by some observers as evidence that the public should worry committee, the media controversy ceased overnight, while
[14]. the Internet controversy faded away soon after [14].
Hastily devised precautions can undermine public
confidence in the risk assessment process and, ultimately,
challenges immunisation. Indefectible commitments to keep Authority in charge
immunisation programs on course may prove equally Effective risk communication requires thoroughly defining the nature of
your involvement
problematic when the pros and cons of business as usual vs.
contingency measures remain obscure. The UK government • What are the reasons for your organization to step in?
has always offered strong support for MMR vaccination; yet • Have you identified conflicting views within your organization?
it has sometimes used scare tactics and persuasion, a strategy • Have you made sufficient efforts to ensure that your organization
that is likely to fail [67, 68]. Engaging with lay audiences speaks with one voice?
and trusted parties in a reasoned discussion about the pros • Do you periodically check how well-trusted you are?
and cons of triple jabs vaccines versus single jab vaccines • Should any other public body be speaking out on this issue?
would have worked better. • Have you identified independent third parties that are more trusted
than you and may facilitate the public debate?
In a nutshell, the quality of risk communications will
benefit from openly discussing the broad range of options
and the associated trade-offs that drive immunisation Interacting with the Audience
policies. Crucially, this implies for institutional actors to
Even though they may otherwise blame the public’s
devise a clear communication of the expected impacts, costs
‘irrationalities’, ill-advised policy makers too often focus
and benefits of action as well as inaction. Too often, their communications on emotions. For instance, the
however, the cost/benefit assessment that underpins vital
response to the MMR vaccine scares has largely evolved
decisions remains a matter for experts with little outside
towards emotion-based communication. Policy makers have
input.
suggested that parents who refuse immunisation are putting
their children at risk [5]. Yet, in the initial phase of the
public debate, many parents were not opposed to the
Analysis of options vaccination, but were just unsure about the safety of the
Efficient risk communication requires balancing options and to be open MMR triple jab. Playing the emotional card did not help
about it
them understand why they could not have access to three
• Can you demonstrate that you have weighed the costs and benefits separate jabs against Measles, Mumps and Rubella. It only
of the risk and the options for managing it?
suggested that the government intended to push for
• Do you have good arguments for assigning the necessary trade-offs
between conflicting objectives and goals?
vaccination at any cost. If anything, the institutional
approach showed that attitudes that are perceived as
• Are you clear about the impact of doing too much, too little or
nothing? patronising only make compliance worse.
• When time permits, do you look for a range of options and select Traditional media outlets (such as newspapers and
the one that promises the best balance of ‘upsides’ and ‘downsides’? television) have been, and are still central communication
• When you have the opportunity, do you reduce those risks that are vehicles [34, 35]. Yet the Internet has become an
easy and inexpensive to reduce? increasingly important factor, including as a risk amplifier
[14] and propagator of unscientific rumors [12, 13]. The
Authority in Charge impact of the Internet in the reinforcement and propagation
of negative perceptions of vaccines – insofar as it has the
Risk communicators need to define the nature of their ability to act as an unreliable source of information, to
involvement with the risk. Who should speak? Who is spread quack science and rumors and to amplify risks – is
listened to? For example do governments and industries generating perplexity among those concerned with designing
always need to lead the communication process? For vaccine and implementing effective health programs. In the case of
manufacturers (so-called “risk producers”) and regulators the Hepatitis B scandal in France, reassuring news reports
silence is not an option [11]. In many cases, however, those did not prevent the propagation of internet-based conspiracy
who have a direct stake in the issue will benefit from theories [5].
stepping back and allowing neutral trusted parties to lead. In
2009 Spanish authorities successfully launched an ad hoc Nevertheless, such pessimistic portraits of the deleterious
expert committee to investigate and report on possible side effects of the Internet are only one side of the story. For
effects of Gardasil. The committee members were renowned public-health authorities and agencies, the Internet is also a
medical experts from a range of medical disciplines formidable, yet underused, instrument for the
(immunology etc.). The committee visited the hospital where communicating benefits and risks. For example, all
the two girls were diagnosed with status epilepticus. They regulatory agencies maintain websites. How effective is their
conducted a thorough inquiry that found no trace of a use of this technology? Do agencies do a good job of using
biological link between the vaccine and those cases. On 9 the web to prevent the amplification of negative perceptions?
April 2009, these results were communicated to the Ministry Is it likely that the current approach, which often focuses on
of Health. A reassuring summary report explaining the disclosure and the release of raw data [69-71], will be
Public Health aspects of the issue was published, made insufficient to ensure an effective communication of benefits
available on the internet and communicated to journalists. and risks. Our analysis of FDA [70] and European [71]
Risk Communication of Vaccines: Challenges in the Post-Trust Environment Current Drug Safety, 2015, Vol. 10, No. 1 13

practices finds that transparency initiatives are often crucial role of interpersonal relationships – with
confusing for patients and that proactive communication is patients and with those who object to becoming
much needed. patients – should not be underestimated.
3- In recent years, European regulators, including the
EMA, have made their websites more user-friendly.
Audience to interact with However, the conduct of effective risk
Effective risk communication requires interacting with the right communication on the web requires engaging in more
audience using the right methods
interactive uses of Internet technology. Seek solutions
• Have you clarified who the audience of your message is likely to that foster exchanges of information, feedback, and
be?
reasoned discussion of the science. The websites of
• Have you clarified how you will interact with other groups (through
information, consultation, and deliberation)?
conventional media, such as that of the BBC science
pages for example, have already engaged in this kind
• Are you clear whether messages are intended to inform your
organization, organized groups or the general public? of process.
• Have you used communication methods that have worked in similar More science is clearly needed. External risk
circumstances? communication advisory boards, composed of experts from
• Do you select and train effective communicators and learn from the risk communication and medical fields would help
examples of similar situations where messages have proven integrate risk communication research into everyday
successful?
practice.

CONCLUSION CONFLICT OF INTEREST

Careful analyses of institutional communications The author confirms that this article content has no
highlight practices that need to be tackled urgently: conflict of interest.
- Communications are often one-way rather than two-
way. Regulatory agencies use web portals as their ACKNOWLEDGEMENTS
primary instrument to reach outside audiences. Too
The author would like to thank the UK Government
often this leads to data dumping (so-called ‘fishbowl
Office for Science and the Economic and Social Research
transparency’) or one-size-fits-all communications
(‘press releases’) that confuse patients and are not Council which funded the “Practical Guide to Public Risk
Communication”. The author is also grateful for the support
sufficient to build trust [69-71].
received from the European Medicines Agencies who funded
- Against the advice of risk theorists, persuasion an evaluation of the Gardasil case. The author would also
remains the agencies’ main goal. Communications like to thank leading scholars, especially Prof. Ragnar
often seek to educate the public about the agency’s Löfstedt, Prof. Baruch Fischhoff and Prof. Ortwin Renn for
view, rather than to engage in a two-way their ongoing support and advice.
communication process.
- In contrast to the recommendations of risk theories, REFERENCES
the current risk-communication approach does not [1] Rath B, Mohammad A, Elemuwa C, et al. Prioritizing polio. Expert
typically balance benefits and risks. In the event of a Rev Vaccines 2012; 11(12): 1389-92.
vaccine (or drug) alert, the regulator’s discourse [2] Horton R. MMR Science and Fiction: Exploring the vaccine crisis.
focuses on the risks. As a consequence, the content of 2004; London: Granta.
[3] Fitzpatrick M. MMR and Autism: What Patients Need to Know.
the communications tends to be excessively risk- 2004; London: Routledge.
averse. [4] Levy-Bruhl D. Impact of Hepatitis B vaccine safety issues on
vaccination strategies and their implementation in France,
One important lesson is that agencies have been able to presentation, Meeting on Prevention and Control of viral hepatitis
build trust through direct or delegated interactions (e.g. an in France: Lessons Learnt and the way forward, November 2004;
expert committee to investigate the issue). The FDA’s and 18-9. Accessed at
EMA’s commitment towards more transparency is likely to http://www.vhpb.org/files/html/Meetings_and_publications/Present
increase rather than diminish the role of the Internet as the ations/VDL63Levybruhl.pdf on 20 January 2005.
[5] Bouder F. A Contribution to Transnational risk analysis:
instrument of choice for the release of information about comparative analysis of risk perception related to human health
benefits and risks. Yet merely providing information without issues. In Richter IK, Sabine Berking S., Müller-Schmid R. Eds.
paying attention to perceptions does not constitute successful Risk Society and the Culture of Precaution. 2006; Basingstoke:
communication. Trust in immunisation programs requires Palgrave Macmillan.
[6] Gibbs N. Defusing the War over the “Promiscuity” Vaccine. Time
effective risk-communication methods. In conclusion, risk- 2006.
communication studies recommend a number of simple steps [7] Nau J-Y, Corine L. Gardasil Un vaccin dans la tourmente. Le
towards achieving critical improvements that agencies may Monde. 27 May 2007.
consider: [8] Gerhardus A. Wissenschaftler/innen fordern Neubewertung der
HPV-Impfung und ein Ende der irreführenden Informationen. 25
1- Always test for trust before selecting a November 2008. Accessed at http://www.uni-
communication approach. bielefeld.de/gesundhw/ag3/downloads/Stellungnahme_Wirksamkei
t_HPV-Impfung.pdf on 22 July 2010. English translation, 23
2- Think of new technologies – especially the Internet December 2008. Accessed at http://www.uni-
and the new media - as tools among many. The bielefeld.de/gesundhw/ag3/downloads/Statement_HPV-vaccine.pdf
on 22 June 2010.
14 Current Drug Safety, 2015, Vol. 10, No. 1 Frederic Bouder

[9] Powell D, Leiss W. Mad Cows and Mothers Milk. Montreal: [36] Pidgeon, Nicholas Frank, Poortinga, Wouter, Walls, J. Scepticism,
McGill-Queen’s University Press. 1997. reliance and risk management institutions: Toward a conceptual
[10] Beaud, O. Le sang contaminé: Essai critique sur la criminalisation model of critical trust. In: Siegrist M. Earle TC. Gutscher H. (Eds)
de la responsabilité des gouvernants. Paris : Presses Universitaires Trust in Cooperative Risk Management: Uncertainty and
de France. 1999. scepticism in the public mind. London: Earthscan. 2007.
[11] Löfstedt RE. Risk Management in Post-Trust Societies. [37] Slovic P. Perceived trust and democracy. Risk Anal 1993; 13(6):
Basingstoke: Palgrave. 2005. 675-82.
[12] Agosti JM, Goldie SJ. Introducing HPV vaccine in developing [38] Berry D. Risk, communication and health psychology.
countries—key challenges and issues. N Engl J Med 2007; Maidenhead: Open University Press. 2004.
356:1908-10. [39] Calman KC. Cancer: Science and society and the communication
[13] Larson H, Brocard P, Garnett G. The India HPV vaccine of risk. Br Med J 1996; 313: 799-802.
suspension. Lancet 2010; 376: 572-73. [40] Bennett P. Kenneth C, Sarah C. (Eds) Risk Communication and
[14] EMA. Benefit/risk communication by the European Medicines Public Health, Second edition. Oxford: Oxford University Press.
Agency: a study of influential stakeholders’ expectations and 1996.
attitudes. 15 March 2011. Accessed at [41] Bostrom A. Vaccine risk communication: Lessons from risk
http://www.ema.europa.eu/docs/en_GB/document_library/Report/2 perception, decision making and environmental risk
011/05/WC500106865.pdf. communication research, paper based on a presentation at the
[15] Virgin HW, Walker BD, Immunology and the elusive AIDS Vaccine Safety Forum, IOM, 1996. Accessed at:
vaccine. Nature 2010; 464: 224-31. http://www.fplc.edu/RISK/vol8/spring/bostrom.htm
[16] Farmer FR. Siting Criteria – a new approach. In Containment and [42] Ball LK, Evans G, Bostrom A. Risky Business: Challenges in
Siting Nuclear Power Plants. Vienna: International Atomic Energy Vaccine Risk Communication. Pediatrics 1998; 101: 453-58.
Agency 1967. [43] Bostrom A. 'Who calls the shots? Credible vaccine risk
[17] Farmer FR (Ed.) Nuclear Reactor Safety. New York: Academic communication' in Cvetkovich G. and Löfstedt R. (Eds.) Social
Press. 1977. trust manag risk; London: Earthscan. 1999.
[18] Fischhoff B, Slovic P, Lichtenstein, S. The ‘public’ vs the [44] Petts J, Niemeyer S. Health risk communication and amplification:
‘experts’: perceived vs actual disagreement about the risk of Learning from the MMR vaccination controversy. Health Risk
nuclear power, In: Covello VT, Flamm J, Rodericks J, Tardiff R Soc. 2004; 6(1):7-23.
Eds. Analysis of Actual Versus Perceived Risks. New York: [45] Downs JS, Bruine de BW, Fischhoff B. Parents' vaccination
Plenum. 1983. comprehension and decisions. Vaccine 2008; 26:1595-1607.
[19] Covello VT, Sandman P, Slovic P. Risk Communication, Risk [46] Fischhoff B, Brewer N, Downs JS (Eds.). Communicating risks and
statistics, and risk comparison: A manual for Plant Managers. benefits: An evidence-based user’s guide. 2011. Washington, DC:
Washington DC: Chemical Manufacturers Association. 1988. Food and Drug
[20] Bostrom A, Atman CJ, Fischhoff B, Morgan MG. Evaluating risk Administration.http://www.fda.gov/AboutFDA/ReportsManualsFor
communications: completing and correcting mental models of ms/Reports/ucm268078.htm
hazardous processes’, Part II. Risk Analysis 1994. 14: 789-98. [47] Slovic P, Fischhoff B, Lichtenstein S. Characterizing perceived
[21] Löfstedt RE. The precautionary principle: risk, regulation and risk’. In: Kates RW, Hohenemser C, Kasperson J, (Eds.). Perilous
politics. Trans IChemE 2003; 81(B): 36-4. progress: Managing the hazards of technology. Boulder, CO:
[22] Maharik M, Fischhoff B. The risks of using nuclear energy sources Westview. 1985, pp. 91-125.
in space: some lay activists’ perceptions. Risk Analysis 1992; 12: [48] Slovic P, Kraus N, Lappe H, Major M. Risk perception of
383-92. prescription drugs: report on. A survey in Canada. Canad J Public
[23] Frewer L, Howard C, Shepherd, R. Public concerns in the United Health 1991; 82: S15-S20.
Kingdom about general and specific applications of genetic [49] Leiss W. Three phases in the evolution of risk communication
engineering: Risk, benefit and ethics. Sci Technol Human Values practice. Kunreuther H, Slovic P, (Eds.): Challenges in risk
1997; 22:98-124. Assessment and risk management, special isssue of the annaly of
[24] Shepherd R, Barker G, French S, Hart A, Maule J, Cassidy A. the American academy of political and social science 1996; Vol
Managing food chain risks: integrating technical and stakeholder 545 (May), pp. 84-95.
perspectives on uncertainty. J Agricul Econ 2006; 57(2): 313-27. [50] National Research Council. Improving risk communication.
[25] Shepherd R, Barnett J, Cooper H, Coyle A, Moran-Ellis J, Senior Washington DC: National Academy Press. 1989.
V, Walton C. Towards an understanding of British public attitudes [51] Bouder F. A Practical Guide to Public Risk Communication, the
concerning human cloning. Social Sci Med 2007; 65: 377-392. five essentials of good practice. Pamphlet for the Risk and
[26] Boholm A. Comparative Studies of Risk Perception: A Review of Regulation Advisory Council, Department for Business, Innovation
Twenty Years of Research. J of Risk Res 1998; 1(2): 135-163. and Skills. London: BIS. 2009.
[27] Starr C. Social benefit versus technological risk: What is our [52] Shaw FE Jr, Graham DJ, Guess HA, et al. Postmarketing
society willing to pay for safety? Science 1969; 165:1232-38. surveillance for neurologic adverse events reported after hepatitis
[28] Fischhoff B, Slovic P, Lichtenstein S. How safe is safe enough? A vaccination: experience of the first three years. Amer J Epidemiol
psychometric study of attitudes towards technological risks and 1988;127: 337-52.
benefits’. Policy Sci; 1978; 9:127-52. [53] Herroelen L, de Keyser J, Ebinger G. Central nervous system
[29] Slovic P. Perception of Risk. Science 1987; 236:280-85. demyelination after immunization with recombinant hepatitis B
[30] Finucane ML, Alhakami A, Slovic P, Johnson JM. The affect vaccine. Lancet 1991;338: 1174-75.
heuristic in judgments of risks and benefits. J Behav Decis Mak [54] Mahassin F, Algayres JP, Valmary J, Bili H, Coutant G, Bequet D,
2000; 13: 1–16. et al., Myélite aiguë après vaccination contre l’hépatite B. Presse
[31] Lerner JS, Keltner D. Beyond valence: Toward a model of Médicale 1993; 22: 1997.
emotion-specific influences on judgment and choice. Cogn Emot [55] Trevisani F, Gattinara GC, Caraceni P, et al. Transverse myelitis
2000; 14:473-93. following hepatitis B vaccination. J Hepatol 1993; 19: 317-8.
[32] Slovic P, Finucane ML, Peters E, MacGregor DG. Risk as analysis [56] Nadler JP. Multiple sclerosis and hepatitis B vaccination. Clin
and risk as feelings: Some thoughts about affect, reason, risk, and Infect Dis 1993; 17: 929-38.
rationality. Risk Anal 2004; 24(2):pp.311–22. [57] Tartaglino LM, Heiman-Patternson T, Friedman DP, Flanders AE.
[33] Laswell HD. The structure and function of communication in MR Imaging in a case of postvaccination myelitis. Am Soc
society. In: Bryson L, (Ed.). The Communication of Ideas: A Series Neuroradiol 1995; 16: 581-82.
of Addresses. New York: Cooper Square Publishers 1948; 32-5. [58] Wakefield AJ, Murch SH, Anthony A, et al. Ileallymphoid-nodular
[34] Kasperson RE, Renn O, Slovic P, Brown HS, Emel J, Goble R et hyperplasia, non-specific colitis, and pervasive developmental
al.. The social amplification of risk: A conceptual framework. Risk disorder in children. Lancet 1998;351: 637-42.
Anal 1988; 8(2):177-187. [59] Peltolta H, Heinonen O. Frequency of true adverse reactions to
[35] Pidgeon N. Kasperson R, Slovic P. The social amplification of measles-mumps-rubella vaccine, a double-blind placebo-controlled
Risk. Eds. New York: Cambridge University Press 2003. trial in twins. Lancet 1986;1: 939-942.
Risk Communication of Vaccines: Challenges in the Post-Trust Environment Current Drug Safety, 2015, Vol. 10, No. 1 15

[60] Peltola H, Patja A, Leinikki P, Valle M, Davidkin I, Paunio M. No [65] Alaszewski A, Horlick-Jones T. How can doctors communicate
evidence for measles, mumps, and rubella vaccine–associated information about risk more effectively? Br Med J 2003; 327: 728-
inflammatory bowel disease or autism in a 14-year prospective 31.
study. Lancet 1998; 351: 1327-28. [66] Suspensión temporal de la administración de un lote de una de las
[61] Taylor B, Miller E, Farrington CP, et al. Autism and measles, vacunas frente al virus del papiloma humano Suspensión temporal.
mumps, and rubella vaccine: no epidemiological evidence for a 2009.
causal association. Lancet 1999; 353: 2026-29. [67] Fischhoff B. Risk Perception and communication unplugged:
[62] Fombonne E, Chakrabarti S. No evidence for a new variant of twenty years of progress. Risk Anal 1995; 15:137-45.
measles-mumps-rubella-induced autism. Pediatrics 2001; [68] Fischhoff B. Non-Persuasive communication about matters of
108(e58):1-8. greatest urgency: climate change. Environ Sci Technol 2007;
[63] Kaye JA, Del Mar Melero-Montes M, Jick H. Mumps, measles, 41:7204-208.
and rubella vaccine and the incidence of autism recorded by [69] Löfstedt R, Bouder F. The Ditchley Transparency Manifesto. Drug
general practitioners: a time trend analysis. British Med J 2001; Inf J 2012; 46(7): 7.
322: 460-63. [70] Löfstedt R, Bouder F, Chakraborty S.Transparency and the food
[64] Taylor B, Miller E, Lingam R, Andrews N, Simmons A, Stowe J. and drug administration - A quantitative study. J Health Commun
Measles, mumps, and rubella vaccination and bowel problems or 2013; 18(4):391-6.
developmental regression in children with autism: population [71] Bouder F, Way D, Löfstedt R. Transparency in Europe- a
study. Br Med J 2002; 324: 393-96. quantitative study. Forthcoming.

Received: March 14, 2014 Revised: May 6, 2014 Accepted: May 28, 2014