Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

84th Canadian Paediatric Society Conference

Montreal, Quebec / June 25-30, 2007

HPV and Rotavirus Prevention

Human papillomavirus (HPV) infection is the most common sexually-transmitted infection. According to Dr. Marina Salvadori, Assistant Professor of Medicine, Infectious Disease, Department of Paediatrics, University of Western Ontario, London, the majority of sexually-active adults contract an HPV infection at some time in their lives. Most infections clear spontaneously, but persistent high-risk HPV infections are linked to the appearance, 10 to 15 years later, of cervical cancer. All patients who contracted cervical cancer previously had a persistent high-risk HPV infection.

Dr. Salvadori affirmed that vaccination is a very important preventive strategy. A new quadrivalent HPV vaccine, which is administered in three intramuscular (i.m.) doses within six months, has been shown in recent studies to be effective against two types of the high-risk virus responsible for about 70% of all cervical cancers and two types of the low-risk virus responsible for about 90% of genital warts. In studies of premalignant Pap smear results from women aged 16 to 23 years who were vaccinated before their sexual debut, its efficacy was 93% to 100%.

The vaccine will still prevent HPV in patients who are sexually active, and a follow-up of patients who were already HPV-positive found 0% incidence of lesions from the remaining HPV types after two years. Since the antibody titre after vaccination is above or equal to the natural levels seen in HPV-positive patients, it is believed to provide lifetime immunity. To protect them before they become sexually active, the National Advisory Committee on Immunization recommends universal usage for girls nine to 13 years of age.

Almost 100% of children will contract at least one rotavirus infection by the age of 24 months. Both in developed and in developing countries, rotavirus is the major cause of severe acute gastroenteritis among children under the age of five years; in the US alone, it leads to 70,000 hospitalizations.

A recent study demonstrated that a new pentavalent human-bovine rotavirus vaccine achieved 98% efficacy in preventing severe rotavirus gastroenteritis and 74% efficacy against any gastroenteritis. The study also determined that this vaccine was not associated with intussusception and was well tolerated.

The vaccine was approved in the US as part of their routine schedule of immunizations. The precautions given for prescribing this vaccine are for children with moderate-to-severe illness, altered immunocompetence, pre-existing chronic gastrointestinal disease or previous intussusception. Dr. Salvadori also indicated that this vaccine can be given to breast-fed infants and may be co-administered with other vaccines. She suggested administering the first in the series of three oral doses in the twelfth week to avoid any confounding results due to naturally occurring intussusception.

The Science of Behaviour Change

As discussed by Stephen Hotz, PhD, Adjunct Professor of Psychology, Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, patients need to make informed decisions. However, he sees several barriers which interfere with sound decision-making by the patient. Dr. Hotz has developed programs and techniques targeting motivation and behaviour change.

A barrier is a statement (i.e. excuses, justification, rationalizations) that indicates that something is happening in the communication process that is getting in the way of the patient’s ability to make a sound decision. Often, the speaker inadvertently does something to stimulate non-change behaviour in the person he or she is trying to convince. When presented with a treatment option, the patient is confronted with having to make a decision under conditions which place the patient under stress. On the physician side, there are barriers, too. They feel a time pressure and typically respond by transmitting a lot of words and expressing a sense of hurry. They are sometimes ahead of the patient and push for action before the patient is ready to act.

The most important barrier is the weak or equivocal recommendation that a physician may offer. Dr. Hotz suggested that by giving a strong recommendation, the doctor actually stimulates the patient’s thinking and questions, while still leaving the patient in control. It gets the patient’s attention and initiates the decision-making process.

Dr. Hotz described a four-stage decision-making continuum which happens in a patient’s mind once a treatment has been recommended and before action is taken. The challenge for the physician is to facilitate progression along this continuum in three minutes or less during a patient visit. The progression is the important thing: it is not necessary to get them from stage 1 to stage 4 in a single visit.

A common error that people make is talking about the issues at stage 4 when the receiver is thinking about the issues of stage 1 or 2. In this situation, persuasion will not work and the receiver is prone to respond by pushing back with defensive arguments. The physician’s communication goals must therefore be tailored according to the stage the patient is at, getting the patient to the point where he or she subjectively values action more than inaction.

Dr. Hotz described each of the stages and appropriate goals for communication with a patient at that stage. In stage 1, the patient is disengaged from the treatment recommended and focused on the disadvantages. It is highly unlikely that a patient will make an informed, objective decision at this stage. He suggested that physicians reply by legitimizing the downside and then shift their focus to the positive side in order to facilitate a balanced view of the issue. The patient at stage 2 is ambivalent. Dr. Hotz recommended asking about desired health outcomes and their value and answer questions to help the patient arrive at an informed decision. When the stage 3 patient is committed to change, he stated that physicians should answer their questions, asking about implementation barriers to help them develop an action plan. At stage 4, when the patient is ready to make a change, he suggested physicians reinforce the decision and implement the protocol.

Key Principles for Efficient Communication

A sender encodes a message and sends it along a medium to a receiver: this is transmission of information. Communication, however, is having messages going both ways. Communication has not taken place until the receiver acknowledges that they have understood the message.

Accredited master communicator Eric Bergman, in private practice in Toronto, Ontario, is focused on helping his clients communicate more effectively. He stressed that effective communication in the face-to-face medium must be conducted at the pace of the receiver, and cautioned physicians not to confuse transmitting their knowledge for communicating.

“What you say means nothing, but what they get and understand is everything,” Bergman told the audience. He recommended following a certain pattern of communication: pause; answer the question; and stop talking. He suggested just answering the question that the patient asks and letting the patient direct the line of questioning.

People do not remember what you said, but they remember what they thought about what you said, noted Bergman. To facilitate the receiver remembering what was actually said more accurately, he instructs people that they should be prepared to answer the question in 10 words or less; six, if it is a subject out of the receiver’s element. This allows the patient to ask more of the questions which are relevant to his/her decision-making process in the time available. They generally require less of the physician’s scientific knowledge than one may expect to be able to relate this issue to their life. This is especially important if they have to go and discuss it with family and return with a decision. Patients tend to like, trust and respect the recommendation more when this communication method is used, and also retain more of the information, Bergman remarked.

He concluded the session by stating that physicians need to understand this continuum. He stressed that physicians must recognize that asking and answering questions is key at every stage to managing their patient’s expectations and understanding and to give them the knowledge they need to help themselves, which is the essence of informed consent.