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Saturday, November 30, 2002

Vaccination foes worry health officials, here and nationwide

By DONALD G. McNEIL JR.
THE NEW YORK TIMES

VASHON ISLAND -- Kate Packard, the school nurse here, has a nightmare that she sums up in five words: "measles coming across the water."

If measles did make the 20-minute ferry ride across Puget Sound from Seattle -- hardly unthinkable, since a case broke out last year near the ferry terminal in West Seattle -- public health officers say the whole Vashon Island school district could be shut down until the island's last case disappeared or an emergency vaccination drive took effect.

On Vashon Island, a haven for the counterculture where therapies such as homeopathy and acupuncture are popular, 18 percent of the island's 1,600 primary school students have legally opted out of vaccination against childhood diseases, including polio, measles, mumps, rubella, diphtheria, whooping cough, tetanus, hepatitis B and chicken pox. Most of their families have obtained "philosophical exemptions" -- that in Washington and several other states, including California and Colorado, can be claimed simply by signing a school form.

Across America, about 1 percent of all children are exempt from vaccination, said Walter Orenstein, director of the National Immunization Program at the Centers for Disease Control and Prevention. The agency's surveys suggest that more than 90 percent of all American children have actually had most of their shots, except for the new chicken-pox vaccine.

But from Vashon Island to Boulder, Colo., to towns in Missouri and Massachusetts, there are "hot spots" where many children go unprotected. In a 1999 survey, 11 states reported increases in exemptions.

Clusters of unvaccinated children are not only potentially in danger themselves, health officials say. There is also a threat to the "herd immunity" that walls out epidemics, sheltering fetuses, infants too young to be immunized, old people with weakened immune systems and even vaccinated classmates who are at risk because no vaccine is 100 percent effective.

When only a few parents take advantage of "herd immunity" to let their children escape the small risks of vaccination, the system still works.

But health officials become concerned in states such as California, where it is easier for a parent to sign the waiver form than to have the child vaccinated. "People take the path of least resistance," said Daniel Salmon, a vaccination expert at the Johns Hopkins School of Public Health. "What I do to my child can put other children at risk."

In 1989-90, measles broke out among unimmunized immigrant children in Southern California, causing 43,000 cases and 101 deaths.

Resisters cite an array of reasons. "Sometimes it's distrust in government, feeling it's in bed with the vaccine industry and 'everyone's making money off our kids,' " Salmon said. Sometimes the objections are religious. Sometimes a small community is scared when a child is genuinely harmed by side effects; the live polio vaccine, for example, is thought to kill about eight people a year.

Some parents are upset at the sheer number of injections a child normally gets -- about 20 by age 2, beginning with hepatitis at birth. And others are convinced -- despite evidence to the contrary -- that vaccines are highly likely to cause severe problems from seizures to autism.

Here on Vashon Island, a community of 10,000, word spread quickly when the 10-month-old baby of Gail O'Grady, a midwife who also works at Minglement Natural Foods, died unexpectedly in his crib in 1984 two weeks after his first immunization; when Pam Beck's daughter Rachel suffered four years of terrifying seizures that began minutes after her first whooping cough shot; when Nancy Soriano's son, Alex, developed autism after his tetanus and polio vaccinations. Some doctors they consulted disagreed that vaccines were to blame, but all three mothers were sure they were.

Alex, his mother said, changed from "a bright-eyed, happy, beautiful kid," to a severely autistic 4-year-old who "lived curled up in a ball, screaming and screaming and screaming." She says she has nearly cured him by removing milk and glutens from his diet.

By contrast, public health specialists say, people no longer fear diseases they've never seen.

"I remember how the fear of polio changed our lives -- not going to the swimming pool in summer, not going to the movies, not getting involved with crowds," said Dr. Edward Rothstein, 60, a Pennsylvania pediatrician who helps the American Academy of Pediatrics make immunization recommendations. "I remember pictures of wards full of iron lungs, hundreds in a room, with kids who couldn't breathe in them. It affected daily life more than AIDS does today."

Now, with the rare side effects of the live vaccine, "there's a risk of about eight kids a year dying, so people don't want to be vaccinated," he said. "When polio was around, people gladly took that risk."

Rubella, Rothstein said, "is, for the most part, a nothing disease"; the reason to continue vaccinating against it is to protect fetuses. "In the 1960s," he said, "50,000 to 60,000 babies were born with small heads, or deaf, or blind or with cataracts" because their pregnant mothers had been exposed to rubella.

All 50 states allow medical exemptions for children who are immuno-compromised or allergic to vaccines; 47 states (all but Arkansas, Mississippi and West Virginia) allow religious ones; and 17 allow personal or philosophical ones. But how many parents receive exemptions depends partly on how much red tape is involved, a study in the American Journal of Public Health found. In states where parents must go to a state office for forms, get their signatures notarized or produce letters from a religious authority, exemption rates tend to be lower. The only statewide exemption rates greater than 2 percent, according to the CDC, are in Washington, Wisconsin and Michigan.

Still, health officials say that in recent years public sentiment has often run against vaccination. The news media publicize the stories of autism, seizures and crib death that followed vaccination. More than a dozen Web sites specialize in describing the dangers of vaccines.

In interviews on Vashon Island, parents who have signed forms to exempt their children from vaccination appeared to be educated, very attuned to their children's health and full of opinions about vaccines. Most used a mix of therapies such as homeopathy, acupuncture and chiropractic and conventional medicines, and most said they were suspicious of the vaccine industry. "I consider well-baby care to be a capitalist plot," Maryam Steffen, a mother of four, said half-jokingly.

If anyone would seem to be a living argument for tetanus vaccination, it is Camille Borst, 25. When she was 12, she stepped on a nail. Her mother, who opposes vaccination, didn't take her to a hospital until her foot was so inflamed she could not stand on it. But Borst says proudly that she has not immunized her own children, Deven, 9 or Casper, 4.

Her mother, Adrienne Forest, 47, who is home-schooling her grandchildren in her neat, shingled mobile home in a clearing of fir and alder trees, said she was sorry she let the hospital give Camille other vaccines. "It was a moment of weakness," she said. The nurses who angrily told her that Camille could have died "totally freaked me out," she said.

From 1995 to 1999, said Packard, the school nurse, a whooping cough epidemic here hospitalized some infants and left some children with chronic asthma.

Forest's grandson Deven came down with whooping cough two years ago and, she concedes, passed the disease to 10 other children, including an infant.

"Yeah, that bothered me," Forest said. "But I called everybody and we studied up on what you can do to build up the immune system."

The baby "did just fine," she said. "On Vashon Island, you have middle class people who eat healthy and keep warm. If everyone was poor-poor, not breast-fed, not eating right -- that might be a reason to vaccinate." But she and her daughter remain steadfastly opposed.

Meg White, 45, on the other hand, now somewhat regrets that she did not vaccinate. Three years ago, her whole family, including her infant son Julian, had whooping cough "really, really bad."

"My son would turn all shades of purple," she said.

Now, she said, she would advise other mothers to vaccinate against whooping cough, polio and tetanus, but only with the newest vaccines, and she still has not vaccinated Julian, now 3, against measles, mumps, rubella or chicken pox.

Julian is in nursery school at Puddlestompers, whose director, Tressa Aspiri, also changed her mind about not vaccinating her own older children after they got whooping cough.

Yet she makes no recommendations to parents when they fill out the school's vaccination form, she said.

"I still feel strongly that it's the parents' choice."

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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.