More Arizona parents refusing to vaccinate kids

A small but growing group worries public-health officials:
parents who refuse to vaccinate their kids.

Thousands of Arizona schoolchildren skipped their recommended vaccines during the 2010-11 school year under a "personal beliefs" exemption allowed by state law, Arizona Department of Health Services records show. In kindergarten alone, more than 2,700 Arizona students, or 3.2 percent, skipped vaccines, more than double the exemption rate claimed by parents one decade ago.

These aren't children who lacked access to health care or had a medical reason for not immunizing. Their parents or guardians chose to keep them vaccine-free because of religious or personal beliefs such as fears that the vaccines may do more harm than good.

Public-health officials fear that the upswing may stem partly from a controversial 1998 study of 12 children that linked vaccines to autism, a study that was declared a fraud and retracted by the British medical journal that published it. Social-networking sites such as Facebook and niche websites for moms still buzz with chatter about vaccine-triggered illnesses and links between the measles, mumps and rubella vaccine and autism, although multiple scientific studies have debunked any ties.

Arizona health officials acknowledge that parents decide what is best for their kids, but they say the uptick in parents rejecting the recommended schedule of vaccines is troubling. There have been outbreaks of the measles, whooping cough and the mumps in the United States over the past two years, and health officials fret that such outbreaks may become more common. These diseases were a widespread and deadly threat in the last century before modern vaccines were developed and deployed. Measles infected 3 million to 4 million Americans and killed hundreds each year in the late 1950s. The U.S. declared measles virtually eliminated domestically at the close of the century, but outbreaks have become more frequent in recent years among the unvaccinated. These diseases that were deadly to thousands of young children in the early 20th century have resurfaced in recent years as a public-health threat. Last week, new research disclosed that 214 children have been infected with measles so far this year, the largest U.S. outbreak in 15 years. Most of those children were either not vaccinated or were too young to be vaccinated.

"Parents of young children have no recollection of these diseases," said Elizabeth Jacobs, a University of Arizona College of Public Health associate professor of epidemiology. "There is a sense that measles are not that serious. They don't think it is that scary anymore."

Gaps in coverage

Although just a tiny percentage of Arizona schoolchildren are enrolled under personal-beliefs exemptions, some communities have relatively large clusters of non-vaccinated children.

Public-health officials recommend that no more than 5 to 10 percent of the population be vaccine-free. Arizona health officials say that anytime non-protected students exceed 10 percent of the total population in any school or community, public-health threats can emerge. When so many kids are left unprotected, it substantially raises the risk of spreading disease.

Those who choose not to vaccinate can expose risk to others, too. Infants are often too young for vaccination and can be sickened with illnesses such as measles or whooping cough, which can be fatal. Adults also are susceptible because the effectiveness of some vaccines wanes over time.

"I worry about a decrease in vaccine coverage," said Dr. Karen Lewis, medical director of the Arizona Department of Health Services' immunization program. "Viruses are very sneaky. If there are a lot of people who are unimmunized, viruses will come in and spread very quickly."

In response to an Arizona Republic records request, the state health department released data on personal-beliefs exemptions by school ZIP code for the 2008-09 school year.

The data reflects the ZIP codes of the schools, not where the students live. Most ZIP codes reflect a school's location. In a handful of cases, the ZIP codes likely represent a school's mailing address at a post-office box.

Public-school districts and private and charter schools all must report exemption rates to the state. The health department would not provide data on individual schools, so how many schools or students are included in each ZIP code is uncertain. It did not provide data for ZIP codes with fewer than 10 students.

The data shows that in schools in 14 Arizona ZIP codes, at least 10 percent of all enrolled children were not immunized because of the personal-beliefs exemption.

One Sedona-area ZIP code had the state's highest non-vaccination rate of nearly 48 percent, followed by a Mesa ZIP code at nearly 31 percent. The data may reflect only schools' post-office box addresses.

Jacobs said she suspects that families with children who attend schools with higher exemption rates disproportionately use alternative health care, but she plans to investigate why the exemption rates are so high.

"You need 95 percent coverage to protect from an outbreak," Lewis said. "If you drop down to 90 percent or 85 percent, an outbreak can spread like wildfire."

Arizona has had its own experience with disease outbreaks in recent years. The most recent case involved a cluster of measles cases at two Tucson hospitals.

In February 2008, a Switzerland resident visited a Tucson hospital and triggered a small measles outbreak of 14 confirmed and 363 suspected cases. Among those who contracted measles were two children, ages 3 and 5, whose parents opposed vaccination. The children were exposed to the virus while visiting their mother at a Tucson hospital, and the younger child later was in contact with 130 other young students.

Hospital and public-health officials reacted swiftly to stem the spread. Patients with suspected or confirmed measles were isolated and given breathing masks. Unvaccinated people who were in contact with suspected or confirmed measles patients were offered vaccines.

In addition to the public-health toll, the mini-outbreak cost two Tucson hospitals about $800,000 to halt the spread and was the nation's largest measles outbreak in a health-care setting since 1989, according to a study published this June in the Journal of Infectious Diseases.

The outbreak was the most recent glimpse of how a disease ofyesteryear can quickly re-emerge.

Parents skeptical

Parents' skepticism about vaccinations isn't limited to Arizona. Facebook sites such as Proud Parents of Unvaccinated Children and The Truth About Vaccines buzz about vaccines that contain mercury and offer tips on finding "pox parties" where unvaccinated children attempt to get the virus that causes chicken pox to build their immunity.

But it's easier in this state than in many others for parents to exempt a child from immunization.

A study published this month in the journal Pediatrics showed that 13 percent of parents nationwide are following an "alternative" immunization schedule for their children, with some skipping vaccinations altogether.

The study also found that 20 percent of parents who get their kids vaccinated harbored doubts about the safety of the regimens. The Internet-based survey included responses from 648 parents of children ages 6 months to 6 years.

The study's authors warned that delaying or skipping immunizations puts the kids at risk. A 2000 study published in JAMA showed that children whose parents skip one or more recommended vaccines were 22 times as likely to get measles and six times as likely to get whooping cough compared with vaccinated children.

Matthew Baral, a naturopathic doctor in Tempe, said he treats many patients with questions about vaccines. Parental concerns aren't limited to autism. Some question other potential side effects from eight common childhood vaccines.

"For some parents, (the benefits) don't outweigh the possible risks from getting the vaccine," Baral said.

An exhaustive federal study released in August that reviewed more than 1,000 research papers concluded that adverse events from vaccines are rare.

The Institute of Medicine report documented 14 cases in which vaccines were linked to rare reactions such as seizures, brain inflammation and fainting, but most of those cases involved kids with immune-system deficiencies. The report did not seek to evaluate whether children faced greater risk from a vaccine-triggered adverse event or the actual disease if they were not vaccinated.

The report found that there was no evidence linking the measles, mumps and rubella vaccine to autism, but it noted rare cases when the vaccine triggered fever-caused seizures in children with immune deficiencies.

Arturo Gonzalez, a Scottsdale pediatrician, said he often discusses vaccines with concerned parents. Some of the biggest skeptics are well-educated parents who have read books about "alternative" immunization schedules that recommend delaying or spreading out shots over a period of time.

Gonzalez said he attempts to reassure parents who have questions about the timing and necessity of vaccines, including parents who ask about autism.

"They think that there was a conspiracy against them, and it saddens me," Gonzalez said. "Why would we want to forcibly give something that harms your child?"

Most parents of autistic children accept that existing scientific data shows no link between autism and vaccines, said Raun Melmed, a developmental and behavioral pediatrician and medical director of the Southwest Autism Research & Resource Center.

Melmed said the frustration among the autism community is that there are so many forms of the disease and scientists don't know whether it's triggered by genetic or environmental factors or a combination of both.

"We don't know precisely what autism is. . . . It is something I don't see us figuring out in the foreseeable future," Melmed said.

As the autism controversy lingers, public-health officials worry that parents may not base their decisions on the best scientific evidence. And they say Arizona's policies that allow parents to easily claim vaccine exemptions may contribute to the growing ranks of vaccine-free kids.

Jacobs, of the University of Arizona, is studying all states' policies on personal exemptions. Arizona is among the easiest states for getting such exemptions, Jacobs said.

Parents are required to submit immunization records to schools for their children when they begin kindergarten, sixth grade or 10th grade. If parents want to claim a personal-beliefs exemption, all they need to do is sign a form and submit it to the school.

States' policies on vaccine exemptions for non-medical reasons vary. Some, such as Mississippi and West Virginia, don't allow religious or personal-beliefs exemptions. Arkansas and Florida require health-department approval for exemptions.

Jacobs cites Washington state as a good model for Arizona to follow. There, parents must have a licensed doctor sign a parent's personal-exemption form. The doctor answers parents' questions and provides written material about the vaccinations.

Jacobs also is studying the influences that prompt clusters of parents to choose not to vaccinate their kids. Jacobs said peers often influence decisions to not vaccinate, whether through recommendations from social-networking sites or conversations on playgrounds.

"It is almost trendy to be opposed to vaccinations," Jacobs said.

Vaccine-free clusters

No Arizona community had ZIP codes with a higher rate of vaccine-free children than Sedona and west Sedona.

The northern Arizona community had three ZIP codes in which exemption rates far exceeded the state average during the 2008-09 school year. The number of students in each ZIP code was not reported.

Sedona is in Yavapai County, which had the highest exemption rates in the state for kindergarten and sixth-grade students.

Sedona school administrators and nurses say they don't know why their area has a higher percentage of non-vaccinated children.

Lisa Hirsch, principal of West Sedona School, said she understands that some parents have expressed worries about potential adverse effects from vaccines.

West Sedona School is located in a ZIP code that had an exemption rate of 9 percent during the 2008-09 school year.

"It's a personal choice," Hirsch said of parents seeking vaccine exemptions. "I understand it (the exemptions issue) can be serious. I also understand that parents have very serious concerns about the effect immunizations" can have on children.

Although Hirsch did not provide data on personal exemptions for her 475-student school, which teaches kindergarten through eighth grade, she said she doesn't believe a lot of students are exempt.

Hirsch said some parents expressed objections over flu vaccines when the swine-flu epidemic hit a couple of years ago.

She said she understands parents have the right to choose whether their kids will be vaccinated, so her staff has tried other means to promote good health among students.

The school emphasizes personal hygiene and hand washing to prevent the spread of germs. The school also has a nurse available to students.

West Sedona School nurse Goldie Wolin said that she doesn't try to persuade parents to immunize their kids. It's their right to not immunize, and some parents exercise that right, she said.

"Sedona is its own community," Wolin said. "They just come in, and they don't want to immunize their kids."

The high rate of exemptions in parts of Sedona is not lost on public-health officials. Yavapai County Community Health Services has sent representatives to Sedona schools to underscore the benefits of booster shots. County health officials also mail immunization reminders to parents.

"When you get to about a 10 percent rate of exemption, you are bordering on breakout (risk)," said David McAtee, a spokesman for Yavapai County Community Health Services. "We monitor that very closely."

More than 340 kindergarten and sixth-grade students were exempt in Yavapai County in the 2008-09 school year. The exemption rate for kindergarten was 8.5 percent; the rate for sixth grade was 9.8 percent. Both rates were the highest in the state when exemptions were tallied by counties.

Two Mesa ZIP codes have among the highest rates of exemptions in the state, though they may represent only post-office-box addresses for schools. A Mesa Public Schools representative said no district schools exist in either ZIP code.

The district's average exemption rate was about 4 percent among all elementary-school students, higher than the state's average.

Public-health officials have raised concerns about the increasing rate of exemptions, but parents say it's their right to choose what's best for their children.

"Parents of children who do not want to vaccinate their children are incredibly vigilant," Melmed said. "They are very serious, they know the information and they sometimes get put off by the disdainful attitudes that are sometimes directed toward them."

Dangers persist

Natalie Norton knows too well that the lack of timely immunizations can have fatal consequences.

Two months after giving birth to her fourth son in late 2009, Norton became sick with what she assumed was a common cold or minor infection. Her newborn son, Gavin, soon developed a minor cough.

After a trip to a pediatrician, the boy was misdiagnosed with the beginning stages of RSV, or respiratory syncytial virus.

Gavin ended up in a hospital's pediatric intensive-care unit, where tests revealed the cause of his illness: pertussis, better known as whooping cough. The boy, who was too young to be vaccinated, fought and fought, but he died from the illness in January 2010.

Still grieving, the San Tan Valley woman has sought to urge children and caregivers to get vaccinated.

Like many, Norton and her husband never received a whooping-cough booster vaccine recommended for teens and adults. The childhood vaccine can wear off after five to 10 years.

Norton understands that some parents choose not to vaccinate based on what they believe is best for their child. But Norton said that vaccinations can mean the difference between life and death.

"When you make a decision not to vaccinate, you are not just making a decision just for your family," Norton said. "You are making a decision for anybody your child comes in contact with. We can do a real, real danger."