Trend worries public officials

by Helen Gao | inewsource
Search a map for personal belief exemption rates by school.

Getting inoculated for diseases such as whooping cough and measles used to be a childhood rite of passage that few questioned. Now with shifting parental attitudes about vaccine safety, a growing number of California children are entering kindergarten without shots.

The trend worries public health officials because of the link between immunization rates and infectious outbreaks. As they grapple with the worst whooping cough epidemic in half a century, they are fighting back with outreach campaigns to promote vaccinations.

inewsource, a nonprofit investigative journalism center based at San Diego State University, found that waivers signed by parents who choose to exempt their children from immunizations for kindergarten enrollment have nearly quadrupled since 1990. California allows parents to opt out of some or all shots on the basis of personal beliefs, be it religious objections or distrust of the medical establishment.

inewsource’s analysis also revealed that San Diego County’s exemption rate has been consistently higher than the state average over the past two decades.

“Un-immunized people in general contribute to any disease rates. As the rates of un-immunized kids go up, we are inevitably going to see more and more outbreaks of diseases,” said Mark Sawyer, a pediatric infectious disease specialist at Rady Children’s Hospital in San Diego.

inewsource examined 20 years of county-by-county records and two years of school-by-school data from the California Department of Public Health to find:

  • Personal belief exemptions granted to entering kindergartners reached a record high of 10,280 in public and private schools statewide last fall, up from 2,719 in 1990.
  • San Diego County’s exemption rate is 2.64 percent, compared to 2.03 percent statewide. While those percentages seem small, public health officials are concerned that unvaccinated children tend to cluster in certain areas, creating pockets of vulnerability.
  • Schools with the highest exemption rates tend to be private schools, public charter schools, and traditional public schools in affluent areas. Among schools with 25 or more kindergartners last year, 14 campuses had immunization waivers for more than 15 percent of their kindergarten class. Waldorf School of San Diego was at the top, at 51 percent.

Source: California Department of Public Health

Exemptions have drawn renewed scrutiny with each new report of measles or whooping cough, which is also known as pertussis. More than 3,000 cases of whooping cough have been confirmed statewide this year, and San Diego County reached an all-time high of 384 cases last week. This year, California has had 19 cases of measles as of Aug. 17, compared to nine for all of 2009.

Some medical experts believe that parental refusal of vaccines plays a contributing role in the whooping cough epidemic, and they want to see the exemption procedure changed. But even those who are fully vaccinated can catch it because their immunity wears off over time. A bill is pending in the state Legislature to require booster shots for students in 7-12 grades starting Jan. 1. Opt-outs are allowed under this legislation.

inewsource’s analysis found five of the ten counties with the highest incidence of pertussis as of Aug. 17 had above average exemption rates in 2009, while the other five were below average. Marin County, where 7.13 percent of the kindergartners had waivers last fall, tops the chart in the number of cases in relation to its population. Fresno, which had a 0.98 percent exemption rate last fall, also has a very high concentration of cases.

Multiple scientific studies have established correlations between geographical clusters of vaccine refusers and whooping cough and measles outbreaks throughout the country.

For each one percent increase in exemptions at a school, the risk of having a pertussis outbreak went up by 12 percent, a 2000 study in the Journal of the American Medical Association found. The study also found that at least 11 percent of the vaccinated children in measles outbreaks were infected through contact with somebody who was exempt.

Parents like Lara Hayes of Cardiff aren’t convinced vaccines are necessary. The mother of two children, ages 5 and 2, with another baby on the way believes breastfeeding her children and raising them with proper nutrition and plenty of exercise are the better ways to protect them.

Aug. 20, 2010, San Diego, Ca. — Lara Hayes (center) takes her two children, Zalia, 5, (left) and Finnely, 2, for an outing at the San Diego Zoo. Lara, a former registered nurse from Australia, doesn’t agree with immunizing her children. Photo by Earnie Grafton/The San Diego Union-Tribune.

“If you are going to take responsibility for your children, you’ve got a right to say I don’t want to vaccinate” said Hayes, a former registered nurse who homeschools.

Sawyer said parents who choose not to vaccinate are not just making an individual decision, they are making a community decision.

“You can choose to not put your child in a seat belt. All that’s going to happen is he might get injured,” he said. “But if you let your kid get measles, and it somehow spreads to another kid, and that kid dies, you have a direct role in putting that child at risk.”

Rebecca Estepp of Poway, a mother of two boys 12 and 10 years old, is familiar with that logic, but she cannot square it with her maternal instinct.

After her first son suffered adverse reactions from vaccines and developed autism, she decided to not to go through with the full schedule of immunization for her second son.

“I don’t know if there is an acceptable level of collateral damage in the war against infectious diseases,” said Estepp, who is also the government and media relations manager for SafeMinds, a nonprofit that investigates the link between vaccine ingredients and neurological disorders.

Like Estepp, Yvonne Haines of Serra Mesa perceives the risks of vaccinations to be far greater than the benefits. Her younger son, 15, and three of her grandchildren 5 to ten years old have either had no vaccinations or just a few of them. Based on her own research, she’s convinced that it’s better for children to develop immunity naturally from being exposed to diseases like chicken pox.

“We do find that the unvaccinated kids are extremely healthy because their bodies have been allowed to develop their own immune system, rather than relying on vaccinations, which are like substitutes,” she said.

Public health officials stress that extensive research has debunked the connection between autism and vaccinations. They also warn that some diseases, such as measles, can cause serious harm in unvaccinated children, including brain swelling and pneumonia.

This year, three children in San Diego County who were unvaccinated by choice have come down with measles, including one toddler from Solana Beach this month.

Source: California Department of Public Health

In 2008, an intentionally unvaccinated 7-year-old boy sparked the largest measles outbreak in the county in 17 years. The boy, who contracted the disease during a trip to Switzerland, attended San Diego Cooperative Charter School where 20 percent of kindergartners that year had immunization waivers. The exemption rate there remained high, at 12.5 percent last fall.

“The 2008 measles outbreak did not create a significant shift in immunization rates among our student population,” said principal Wendy Ranck-Buhr. “There are strong emotions on both sides.”

She noted that many parents who sign waivers still partially vaccinate their children.

Schools that top the list of 20 highest exemption rates in the county in 2009 are almost all either private or charter schools. The private Waldorf School of San Diego, where tuition ranges from $7,500 to $14,000 a year, has the highest exemption rate. Last fall, half of its kindergarten class had waivers.

“Our parents are really educated. They are trying to make their own decisions, not being influenced by pharmaceutical companies,” said Johannes Lasthaus, Waldorf’s administrator.

His school, he noted, has had no outbreaks and maintains a policy of keeping sick children at home.

“It’s all about people’s right to choose what is right for their child and their family and really respecting people’s choices, whether they choose to vaccinate or choose not to vaccinate,” said Julie Joinson, Waldorf’s director of admissions, speaking for herself. She noted that her daughter, 14, who has never been vaccinated, is “super healthy.”

“It’s not that I think that vaccinations are terrible,” Joinson said. “If I lived in a third-world country with open sewage running down the streets, I would probably vaccinate my child. At this point, I really have concerns about what goes into vaccinations.”

California is one of 48 states that allow non-medical exemptions. Parents simply sign a form stating that “some or all immunizations are contrary to my personal beliefs.” Other states, such as Wyoming and South Carolina, require notarized statements.

States with easy exemption procedures were associated with a 90 percent higher incidence of pertussis compared to states with difficult procedures, according to a 2006 study in the Journal of the American Medical Association.

Many public health officials believe California’s waiver process needs to be revamped so that parents understand the full implications of opting out.

Robert Benjamin of Alameda County, who chairs a committee on personal belief exemptions for the California Conference of Public Health Officers, wants to see the waiver language changed.

He would like the statement to read something like this: “By declining these immunizations, I understand that not only do I put my child’s health at risk but also the health of others.” That type of language, he believes, would foster “social consciousness.”

It’s up to the state Legislature and the state Department of Public Health to make the change to exemption procedures but neither has plans to do so.

Fred Schwartz, public health officer for Marin County, which has one of the highest exemption rates in California, said the whooping cough epidemic provides a prime opportunity for lawmakers to re-examine the exemption policy.

“I think many public health officers would like to see things like a requirement to have more education offered to the parent in order for them to be able to make the decision to do a personal belief exemption,” Schwartz said.

He believes exemptions are a contributing factor to the pertussis epidemic but not a primary cause, as 91 percent of the 5 to 10 year olds in Marin who contracted whooping cough were vaccinated. Many were in higher elementary grades when their immunity from the vaccine begins to wane.

For many years California’s overall exemption rate was below one percent but in the last decade, the numbers started to climb steadily.

Much of the blame is directed at discredited British doctor Andrew Wakefield for linking autism to the vaccine for measles, mumps and rubella. His research was endorsed by celebrities such as Jenny McCarthy and Jim Carrey. It was also widely disseminated through the Internet where a plethora of Web sites and blogs focus on vaccine problems.

“We’ve just got this perfect storm of a lot of information — some accurate, some not — mistrust of government and not seeing these diseases and not feeling like they are at risk,” said Catherine Martin, director of the California Immunization Coalition, a group that works to increase vaccination rates.

In the last few years, vaccine advocates have pushed back with Internet and traditional advertising campaigns of their own.

The “Why I choose” and “Shot by Shot” campaigns sponsored by the coalition and the California Department of Public Health feature testimonies by those who have chosen to vaccinate and stories of families and individuals who have suffered from vaccine preventable diseases.

“The people who are personal belief exemptors, I don’t think, have seen polio,” Benjamin said. “I don’t think they have seen widespread measles. They certainly haven’t seen diphtheria. Aren’t these diseases of the past? Well, almost, but not quite.”

Helen Gao reported this story for inewsource. She can be reached at

Versions of this story appeared in the San Diego Union-Tribune, on ABC 10News, and KPBS.

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