Washington's liberal law on exempting kids from required shots, cost and fear about health risks have combined to feed a downward trend that worries some health professionals.
By state immunization standards, Elizah Jacobs is a laggard. A few months past her second birthday, the Bothell toddler is not vaccinated against measles, mumps, rubella, polio or hepatitis B.
Her mother, Susan Jacobs, doesn’t oppose all vaccines. She readily had Elizah immunized against tetanus and haemophilus influenzae type b, diseases she sees as real hazards for the toddler. But she has rejected most of Washington’s required vaccine schedule because she thinks the series of nearly 20 shots is unnecessary and maybe even dangerous.
Elizah is among a growing number of Washington youngsters escaping the tearful ritual. While the national rate of vaccinations among toddlers is at an all-time high of 75 percent, Washington’s is slipping, a trend due in part to a growing number of alternative-medicine devotees.
A recent survey by the Centers for Disease Control and Prevention (CDC) found 69 percent of the state’s 19- to 35-month-olds were current on their shots, down 3 percentage points over three years, a rate that placed Washington among the bottom 10 states in the country.
“Our rates are going in the wrong direction,” said state health officer Dr. Maxine Hayes, who worries any decrease in vaccinations can erode the community’s protection against infectious diseases. “We should be in the 90s; we should certainly at least be at the national average.”
Other factors also come into play. The state’s slumping economy has left more families uninsured. And physicians are turning away Medicaid patients because of low reimbursement rates.
Though the vaccines are free to all children in Washington, the doctor’s fee to administer the shots (up to $15 a shot plus an office-visit charge) can be prohibitive for some people. In many counties, such as King County, public-health departments offer immunizations on a sliding payment scale, but other issues, such as transportation or limited clinic hours, remain hurdles.
Opting out is easy
By the time they reach kindergarten, 86 percent of Washington’s kids are caught up on their vaccines (the federal government doesn’t track the national school-age rate). Pediatricians still worry, though, because many of the diseases hit hardest in infancy and toddler years, when children are supposed to receive most shots.
For new students, Washington requires proof of vaccination against polio, measles, mumps, rubella, pertussis (also known as whooping cough), tetanus, diphtheria and hepatitis B.
Though not yet state requirements, the government recommends children receive the varicella (chickenpox) shot and pneumococcal vaccine, which protects against ear infections and meningitis.
But Washington, like 18 other states, allows parents to exempt their children for philosophical reasons and religious or medical concerns. Across the country, about 1 percent of schoolchildren are exempted from vaccinations; in Washington, the rate is 4.1 percent, with the vast majority falling in the vaguely defined philosophical category.
Dr. Daniel Salmon, of Johns Hopkins University’s School of Public Health, is leading research into why so many Washington parents reject vaccines. He called Washington’s process one of the easiest.
When parents register a child for school in Washington, they can check a box on the certificate of immunization for philosophical or religious exemption, without an explanation. Most states require a notarized letter or other additional hurdle, he said.
“It’s easier to claim an exemption than to vaccinate a child,” Salmon said. “They can take that form and turn it over and never have to leave the school building.”
The most resistant pockets are among followers of holistic medicine and people with an anti-government streak, said Ros Aarthun, assessment coordinator for the state’s immunization program.
High exemption rates exist in scattered communities throughout the state, from rural Eastern Washington to urban Puget Sound.
In the Curlew Elementary School in Curlew, Ferry County, a shrinking Eastern Washington mining community near the Canadian border, 46 percent of children entering school are exempted from vaccination.
Judy Hutton, nursing supervisor for the county, said the area has a transient population because of high unemployment. And: “We have a population of folks that are very suspicious of vaccines.”
At some private schools in King County, vaccines are the exceptions not the norm. About 90 percent of students entering Seattle Waldorf School in northeast Seattle aren’t vaccinated. Nearly half officially claim exemptions; the rest haven’t gotten around to all their shots.
At the day-care center for staff and students at Bastyr University, one of the leading institutions in alternative medicine, where Elizah Jacobs stays when her mother attends class, many parents reject the government’s one-size-fits-all approach to vaccination and are picking and choosing just those shots they feel are necessary.
Susan Jacobs, who is studying to be a naturopathic doctor, is considering the polio and measles shots, but she is set against the shot for hepatitis B, a liver disease usually transmitted through sexual activity or dirty needles: “Why burden her body with a vaccine that’s not useful at this point in her life?”
Others adamantly oppose every childhood vaccine. Marie Van-Es, of Spanaway, stopped vaccinating her oldest son, now 8, as an infant and hasn’t given any shots to her three younger kids. She won’t even give her pets rabies shots. Ask her why and she’ll rattle off dozens of supposed links between shots and devastating illnesses.
She said DTaP, the vaccine for diphtheria, tetanus and pertussis (whooping cough), can cause seizure disorders and brain damage. MMR, the vaccine for measles, mumps and rubella, is linked to autism. The hepatitis B vaccine can cause immune-system disorders such as multiple sclerosis.
The mainstream medical community organizations such as the CDC and the American Academy of Pediatrics dismisses these links. But Van-Es receives hundreds of e-mails every day from parents who visit her Web site, Concerned Parents for Vaccine Safety.
Vaccination may be a victim of its own success, said Dr. Ed Marcuse, associate medical director at Children’s Hospital & Regional Medical Center in Seattle. In nearly eradicating childhood scourges such as polio and measles, mass immunizations also have erased the fear once attached to the diseases.
“Parents today don’t recall when people were lining up for the polio vaccine; they don’t think measles is threatening their kids,” Marcuse said.
Parents are much more fearful of disorders like autism than measles, he said, so when they hear reports linking the measles vaccine to increased risk of the developmental condition even though the mainstream medical community has repeatedly rejected the connection they are quick to forgo the vaccine.
Still the vast majority of schoolchildren are vaccinated. Jo Yee Yap, who moved with her family from Malaysia three months ago, received her final MMR and polio shot last week so she could enroll in the third grade at Montlake Elementary. Her father, Chee Yap, was much more concerned about getting his 8-year-old daughter protected against these diseases than what he sees are the remote risks of the vaccines.
“It’s part and parcel of growing up; we all went through it when we were kids,” he said, as Jo Yee braced for the two injections at King County’s back-to-school immunization clinic in downtown Seattle.
The state as a whole is not on the brink of an epidemic, Marcuse stressed, but any decrease in vaccination rates can make a community more vulnerable by offering diseases a foothold.
In Britain, where a study suggested a link between the MMR vaccine and autism, a drop in vaccinations since the mid-
1990s has fueled a threefold increase in measles, up to 308 cases last year.
When measles hit 12 people in King County in 2001, none of the victims had been fully immunized. And declining immunizations may be contributing to the state’s resurgence of whooping-cough cases: 356 through July, up from 291 for the same period last year.
Marcuse called local communities with more than 20 percent of kids unvaccinated “accidents waiting to happen.”
“Somebody is going to come from some part of the world where there’s measles and somebody may die,” he said. “And then folks will rethink their decision. Sometimes the system has to break before it gets fixed.”
Julia Sommerfeld: 206-464-2708 or firstname.lastname@example.org