Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Healthy People 2010: Failing to Obtain Targets for Infectious Disease- Due to a Flawed Plan of Action- Elena Quattrone

The Development of the Healthy People 2010 Campaign
Over the past thirty years there has been an increasing interest from United States public health officials to promote wellness among the population. Since 1979, initiatives to combat specific health issues with obtainable goals were pursued to promote health and prevent disease. Similarly, at the turn of the century the newest public health initiative to promote health and to prevent illness, disability, and premature death launched as the Healthy People 2010 campaign sponsored by the U.S. Department of Health and Humans Services. The Healthy People Consortium developed a campaign which consisted of an alliance of over 350 national organizations and 250 state public health agencies. The campaign addressed 226 health objectives in 28 categories to achieve over 10 years, with the key mission of increasing quality and years of healthy life, and eliminating health disparities (1-2). The issues targeted range from access to health care, to environmental health issues, to physical fitness activity, substance abuse and others. To date, the Healthy People 2010 campaign has seen much success. However, it is under the Immunization and Infectious Disease Category objective 14.8 that targets Lyme disease where the Healthy People 2010 campaign failed in developing and executing a plan of action to effectively lower rates of Lyme disease throughout the country.
The Healthy People 2010 consortium’s only strategy to combat Lyme disease was based on the availability of the LYMErix vaccine. The vaccine was developed by SmithKline Beecham Pharmaceuticals and was the only Food and Drug Administration (FDA) approved Lyme disease vaccination at the launch of the campaign. However, the vaccine was taken off the market by the manufacturer in 2002 due to poor sales and reported unspecified adverse effects (4). Since 2002, as incidence of Lyme disease has increased steadily there has been no additional public health intervention to combat incidence (5). Such negligence poses an unwavering obstacle for the Healthy People 2010 target to be reached. Therefore, the Healthy People 2010 initiative to combat the incidence of Lyme disease is a failed intervention due to its reliance on a vaccination as the primary means of control absent from necessary media involvement and educational support.
Lyme Disease: An Emerging Epidemic
Lyme disease is the most commonly diagnosed vector-borne disease in the U.S. The disease is prevalent in 48 states, especially in endemic areas such as the Northeast, Wisconsin, Minnesota, and Northern California (2). Contraction is caused by exposure to areas infected by Borrella burgdorferi-infected ticks and is categorized by a variable incubation period. Lyme disease is a multi-system disease described as having early and late stages. Persons of every age, race, and demographic are at risk for contracting the disease, with elevated rates occurring in children 2 to 15 years old, and adults 30 to 55 (3). Because the disease targets such a wide scope of the population, Lyme disease is a high-risk public health concern. However, despite the persistence of the disease, Lyme disease is controllable by individually targeted mechanisms.
The Healthy People Consortium confirmed that their plan of action to control incidence of Lyme disease was encouraging at-risk populations to receive the LYMErix vaccination. At the launch of the campaign there were a reported 17.4 new cases per 100,000 population. The Healthy People 2010 goal was to reduce this rate to 9.7 new cases per 100,000 population; a 44% decline (4). Since setting the target, cases of reported Lyme disease have more than tripled. To date, 32.5 new cases per 100,000 population in endemic regions have been reported annually (5).
Raising Public Awareness
The first step in targeting a public health problem is raising awareness that a problem exists. An effective way to increase awareness about any growing issue or epidemic is involving the media. The Agenda-Setting Theory, introduced by Maxwell McCombs and Donald Shaw in 1973, states that the mass media has the ability to convey to the public, information about issues of concern, thus influencing the public’s agenda (6-7). Involving the media in Lyme disease prevention at the launch of the Healthy People 2010 initiative would have been most beneficial in increasing awareness about the precautions at-risk populations may take to prevent contraction of disease.
As previously noted, the LYMErix vaccination was taken off the market in 2002 largely in part to poor sales (4). If the Healthy People 2010 Committee on Immunization and Infectious Disease had engaged the media to follow an agenda which promoted protection from Lyme disease, at-risk populations would have been more aware of Lyme disease as an impending epidemic. This increased awareness would have developed a desire for the public to obtain protection from contraction, resulting in an increased demand for the vaccination. Such an increase in demand would have boosted sales and prevented the vaccine from going off the market.
The existence of a vaccine to control the prevalence of Lyme disease is simply not enough to combat the epidemic. The Healthy People Campaign could have taken a much more productive approach by involving the media, also advertising the necessity of the vaccine. Similarly, the media could have educated the public on simple behaviors that at-risk populations could take, such as avoiding grassy areas, or knowing how to recognize ticks (7). Even though raised public concern would have not guarantee the at-risks populations becoming vaccinated, if the issue were brought to the public’s attention the media would have at least instigated public thought about the issue (6-7). Press intervention in the case of the Lyme disease epidemic could have controlled the increasing rates of incidence by bringing the issue of Lyme disease to the public’s attention.
Framing an Issue for Successful Intervention
Increased attention from the media regarding the dangers of Lyme disease and fear of contraction would have only been effective if the issues were framed correctly. Supplemental to agenda-setting theory which focuses on which issues are portrayed to the public, framing focuses on how issues are portrayed by the media to the public (6-8). Agenda-Setting Theory and Framing Theory work hand in hand, and incorporating both is crucial when attempting to influence a population’s behavior.
The Healthy People 2010 campaign never utilized the media effectively in targeting incidence of disease especially in how the issue was framed. Published articles reporting the possible failures of the LYMErix vaccine have run rampant in newspaper and magazines, “framing” the issue of vaccination as a dangerous means of prevention. Other articles reported the ineffectiveness of the vaccine (8). Reports also suggested that recipients of the vaccination were at risk for developing Lyme arthritis and other chronic arthritic disorders (8). Though such potential effects may be considered unwanted, the unspecified adverse effects of a vaccination seem miniscule compared to the definite effects of Lyme disease. Included in such effects are flu-like symptoms, fever, fatigue, muscular pain, secondary skin lesions, and facial paralysis occurring in the initial stages of the disease. Long-term untreated effects include distinctive arthritic, neurologic and cardiac problems (7).
However, if the media framed Lyme disease as a controllable epidemic that could be prevented with effective care and proper precautions, rates of incidence would not persist. Instead, the media raised awareness to the failure of the Healthy People 2010 campaign by publishing articles which did not support vaccination control (8). A national public health problem, such as Lyme disease, targets a wide scope in the political arena. Proper framing of the issue was necessary for any intervention to succeed. Unfortunately, Healthy People 2010 failed not only in engagement of the media, but in positively framing the LYMErix vaccination as a step towards prevention.
Failing to Provide Educational Support
In conjunction with the lack of Agenda-Setting and appropriate framing of Lyme disease, the Healthy People 2010 campaign to target incidence of Lyme disease also lacked a necessary education component. As reflected by the Rational-Empirical approach, education for at-risk populations about an issue is critical when influencing the adoption of a behavior (9). The goal behind the theory is to influence behavior without fear or persuasion. By providing persons with rational and logical information, at-risk persons will adopt a behavior if the behavior can be justified as beneficial (10-23). In 1999 before the launch of the campaign, the FDA, Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) all agreed that education was the most important step to prevent Lyme disease contraction (7). By just relying on a vaccine-based strategy to combat incidence, the Healthy People 2010 campaign failed to utilize the necessary educational component.
Educational support could have benefited the Healthy People 2010 initiatives on Lyme disease. As previously mentioned, in line with the Healthy People 2010 plan of action, using agenda-setting and appropriate framing to educate the public about the LYMErix vaccine would have been effective. Education regarding disease management and general information about disease etiology would have been beneficial for at-risk populations. If accurate information is supplied to an individual, then a person can decide for him or herself the course of action that best addresses his or her needs (9). Perhaps vaccination was not the best approach for everyone. However, vaccination was the best choice for some, and education about the vaccination would have resulted in additional protection for those at risk.
Is Future Progress a Possibility?
In 2007, seven years after the launch of the Healthy People 2010 campaign, the Immunization and Infectious Disease Committee faulted the removal of the LYMErix vaccine as their main obstacle in lowering the incidence of Lyme disease. They discussed new approaches to the issue, strategizing about educational approaches they may take to promote safety by targeting school-aged children. They also discussed environmental steps that can be taken to promote practices that will reduce tick habitats near homes, suburban and residential areas (5). Unfortunately, the Healthy People 2010 committee on Immunization and Infectious Disease is still ignoring the fundamental causes that contributed to the campaign’s failure in the first place, which is supporting an intervention absent from media engagement and education about the disease for at-risk populations.
The way in which the media presented the issue of Lyme disease to the public highly influenced perceptions and actions towards vaccination. The lack of integration between media influences and education for the population is the reason behind the failed public health intervention of advocating the use of a vaccine to prevent contraction. When analyzing the campaign, it is apparent that the initiative never fully advocated the use of the vaccine. A remedy for a problem is useless unless vulnerable populations are aware that an effective remedy exists. The Healthy People 2010 Consortium failed to achieve the proper engagement to make the necessity of the vaccination known. Unless public health officials are willing to incorporate different social behavior models into one intervention, hope is slim that incidence of Lyme disease will decrease in time to reach the Healthy People 2010 target.
1. U.S. Department of Health and Human Services. Healthy People 2010 Understanding and Improving Health. Washington, DC: U.S. Dept. HHS, 2000.
2. Brody J. Fighting Lyme Disease, With a Pinhead as the Enemy. The New York Times, 2003. .
3. LYMErix Lyme Disease Vaccination. SmithKline Beecham Biologicals. Philadelphia: SmithKline Beecham, 1998. .
4. Groch J. Lyme Disease Worsens in Endemic States. Medpage Today, 2007. .
5. U.S. Department of Health and Human Services. Healthy People 2010: Progress Review Immunization and Infectious Diseases. Washington, DC: Office of Disease Prevention and Health Promotion, 2007.
6. McCombs, M., Shaw, D., and Weaver, D. Communication and Democracy. Mahwah: Lawrence Erlbaum Associate, 1997.
7. Lewis C. New Vaccine Targets Lyme Disease. FDA Consumer Magazine 1999.
8. Kliger C. Is the Lyme Disease Vaccine a Lemon? WebMd Medical News. Washington, DC, 2001. .
9. Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.
10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.

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