Lessons in Better Vax Programs with Epidemiologist Sara Brown

As background for our interview for this month, let’s talk about creativity. After two decades of innovation work with dozens of organizations, here’s the most important bit of wisdom I gleaned:  Experiments never fail.

Of course, most things you try do not work out the way you hoped. BUT, the willingness and ability to try something different, to embrace the new despite long odds, that’s THE key skill of the innovator; thus, every experiment is a victory in the battle with complacency and mediocrity.

Speaking of trying something new…

You know who’s a tireless experimenter? Mother Nature. And that includes viruses. They’re relentlessly mutating and that’s why vaccination programs must, too.

WHAT GETS MEASURED GETS DONE… AND SOMETIMES UNDONE

Figuring out what really works

What got me thinking about experimentation in vax programs was talking with Sara Brown, the energetic epidemiologist at STChealth. (More on her and the life of an epidemiologist in a minute.)  Sara is involved in several ongoing research studies and I visited with her after reading read one of them, an analysis of the usefulness of reminder cards on vaccination rates.

The study was done in partnership with the immunization team at the Louisiana Department of Health and they monitored the results of sending out reminder cards. This project targeted one particularly vulnerable population, those 65-70 years of age, and it covered two time periods, with big samples — over 90K postcards mailed out. How did it go? Here are a couple of quotes from the published results of the study (JPHMP, May/June ’26):

“There were no greater odds of receiving the flu vaccine during the week after the reminder-recalls were mailed compared to the week prior.”

“Compared to prior seasons when no reminder-recall was conducted, no substantial difference in percent vaccinations was noted.”

You see why this got me thinking of “experiments never fail.” In this case: yes, the postcards failed, but the experiment did not.

CONCLUSION: YOU CAN’T BRING THE MOUNTAIN

How did Sara take the results of the reminder card study? She said, “The results are consistent with other studies, so maybe what we’ve done in the past is no longer applicable to where we are now right. The conversation around vaccines is different now. We need to meet the people where we’re at. You can’t bring the mountain. We have to find what is working, and this is showing that maybe postcards aren’t working. It’s a lot of money to do postcards — each postcard is about $0.50 to send out and we’re talking about tens of thousands of them. We can reinvest that money in another strategy that does work.”

So, are the results, in fact, good news? First, Sara put the finding in context. Figuring out what does and doesn’t work is one of her specialties. It turns out that her first job after getting a master’s in public health at USC was working in program evaluation at Cedars-Sinai in Los Angeles, and it was there she learned a big lesson …

“I started in program evaluation. One of the big issues for public health was the DARE program in elementary schools. Drug awareness/resistance education is this big thing and they spend so much money, and they’ve been spending it for all this time. But the research shows that it doesn’t really work in preventing teenagers from inevitably doing what teenagers do. When you take that data and take the feelings out, it doesn’t prevent drug use. You feel that it should work, right? You want it to work. People involved in these programs put their time and energy and money and then… wow, it didn’t work. But, what does work? Maybe we can be better so we can help more people.”  

(For anyone disappointed to hear the results of the drug program, Sara did add this: “However, we found that it does help with relationships with police officers.“)

So how should we look at disappointing research results? Take the time to acknowledge the feelings of “it should have worked” and then embrace the energy that comes with concluding this: “We just learned something important and we just freed up some resources – what can we try now?”

(START SIDEBAR)

“YOU’RE SUCH AN EPI”

We always like to get to know something about the people we interview, and in this case it was a chance to learn from Sara about how spending your days thinking about epidemics might affect you as a person. Here are some highlights from the conversation…

DALE: If I worked in epidemiology, I think I’d spend all my timeworrying. Are you a professional worrier?

SARA: I would say this: yes, you start off as a worrier. But then you have to be the calm one. You have to pull back and think, Is this a significant increase? Is this a pattern? Is this a blip? I would say epidemiologists are the warning bell: ‘Hey we’re noticing this and these are things we can do to prevent them.’ The news media really focuses on like the negatives and the sensationalism, but as an epidemiologist, you know how these diseases spread and you know when they go into the areas that have these high prevention effort and high vaccination rates, they stop. And that’s when we can see the benefit of all our efforts.

DALE: So, big picture, not a professional worrier, but the warning bell. What does that look like in everyday life/work?

SARA: [laughing] You’re thenagger of the group. Most people sit there and worry about viruses and think, there’s nothing we can do. But, with public health, there is a lot we can do. I know I can be really annoying with some of my nagging — like before my parents go on a plane, I tell them to wear a mask. When I go in concentrated areas, I will have amask with me and I’m one of like 30 people in the airport wearing a mask. And I always have hand sanitizer with me. When we have like a team meeting, I bring out hand sanitizer and offer it. One of my colleagues always says, ‘You’re such an EPI.’

DALE: Speaking of nagging, is there one thing that most people believe about disease that you wish they wouldn’t?

SARA: When you get your master’s in public health, you learn about perceived threat versus perceived benefit – how risky is this to me versus what I have to suffer. So, when it comes to a virus, people don’t think it’ll affect them. They think, I’ve been fine before, or, This has never happened to me and it won’t ever happen to me.  Everyone has a level of survivorship bias. You see it all the time:  ‘Well, I’ve never gotten the flu shot and I’ve been fine.’ One thinks it will never affect them until it does, and then it’s too late. My grandparents talk about how they had the measles and they made it through just fine. But we don’t talk about all the kids that have died from measles in the past because they don’t make it to adulthood to talk about it.

DALE: That’s dark. But you’ve reminded me of what I experience every year when I’m going to get a flu shot and invite my wife who invariably says, ‘I never get the flu.’

SARA:  I think we all suffer from it at different levels of survivor bias. The biggest misconception about disease spread is thinking it’s not going to happen to you — unless you’re an epidemiologist and then you do think that everything could happen to you.

* * * *

STATS OF THE MONTH

To Be (Immunized) or Not To Be (Immunization)…That Is The Question

By Bill Davenhall, Geomedicine Analyst

That title recalls the famous Shakespeare quote from Hamlet. Why do I ask it, and why ask now?

Well, perhaps it’s about perspectives on using data to solve non-mathematical problems along with the desire to see things clearly without limits and filters. It was looking at non-medical immunization exemptions rates in the US since 2014 that caused me to pause.

The graph below reveals what startled me – the speed of the change since 2014 in the observed rate of parents seeking exceptions for non-medical reasons for their children entering elementary school. The graph below, courtesy of USAFacts, suggests either a blip or a trend — what do you think? To me it’s a dramatic increase in a statistic that otherwise has been a rather steady state for over a decade – but this graph infused with more recent data (2025 school year) suggests that that this rate of growth will likely continue to rise if we also experience the continued polarization of immunizations/vaccine “theory”. Perhaps this suggests a focus on the outliers or extremes in the data instead of the value of seeking an average? Maybe the perspective about the usefulness of the average really matters versus the need to tightly focus on the extremes. Which perspective do you value the most?

Serious public health analysis is suggesting the change is the result of the passage of state legislation making non-medical exemptions easier to request and immunization easier to decline. Public health analysis now estimates that about 185,000 children received  an immunization exemption in 2025 (which in the estimated universe of 3.4 births for the same year). That number does not seem that concerning… or does it? That depends a great deal on whether if you think you are seeing a data blip or a longer lasting trend.  Climbing exemption may be suggesting that what we are experiencing is simply a symptom of a confused public — due to aggressive political advocacy and not due to the faulty practices of the scientific method.

So, a change in one’s perspective often helps analyze any data; or, better yet, helps in trying to explain the data to the public. The perspective of flying to the moon seems useful this month, offering us an example of how changing your view gives you a chance and the opportunity to dramatically alter your perspective on things, including immunization of children.

Christina Koch, Astronaut and Mission Specialist on Artimus II gave some good hints about changing perspectives this week when she spoke extensively about the overview effect (a cognitive/emotional shift many astronauts experience). So instead of Shakespeare, try this explanation of Christina’s ideas about perspective about her new view: “The overview effect is when you’re looking through the cupola and you see Earth as it exists with the whole universe in the background. You see the thin blue line of the atmosphere…What you realize is every single person that you know is sustained and inside of that blue line.”

As always, I appreciate your 2^nd opinions,