Public health vs. parent choice: The vaccination debate in Arizona
Monday, May 20, 2019
PHOENIX – Health officials warn that vaccination rates are deteriorating across Arizona, risking public health as parents continue to opt out of immunizations.
Immunization levels in the past year fell further below the necessary rate to guarantee community protection against the outbreak of vaccine-preventable diseases. The reason: Personal exemptions from vaccinations are on the rise, according to state data and a Cronkite News analysis.
Populations throughout Arizona are most vulnerable in areas where personal exemptions are favored, experts say.
“If we got rid of the personal exemption, I have no doubt vaccination rates would go up pretty substantially and we would be at a much lower risk of having the kinds of outbreaks that we’re seeing,” said Will Humble, executive director for the Arizona Public Health Association.
Arizona Department of Health Services records and a Cronkite News data analysis shows:
- Kindergarten students with personal exemptions from all vaccines have doubled in four years.
- Public health officials consider kindergarten immunization levels a marker of community protection, and the drop in vaccination rates put the state at risk for an outbreak.
- Herd immunity, a cocoon around a community that protects people from formerly devastating diseases like measles, is faltering in more than half of Arizona’s 15 counties.
- Personal exemptions rise in northern Arizona. In Yavapai County, only 83% of kindergarteners are vaccinated, while Yuma County has the highest rate of immunizations at 97.3%.
- Vaccination rates have dropped across schools statewide, with personal exemptions for kindergarteners rising to 5.9% from 4.5% since the 2015/16 school year.
Across the U.S., outbreaks of measles have reached a record high – more than 700 cases – since the disease was eradicated two decades ago. Rockland County in New York imposed a quarantine, and in March declared a county-wide state of emergency, barring anyone who was unvaccinated from entering public places for 30 days or until receiving the MMR vaccination.
Vaccine advocates aren’t sure why immunizations are dropping, but parents across the U.S. are increasingly opting out as public trust in institutions and experts erodes, fears about vaccine safety rise and state legislators create a sort of no-vaccine friendly zone. Arizona is one of 17 states allowing personal-belief exemptions from vaccines.
Arizona requires students in school to be vaccinated and the health department collects and reports information for students in child-care centers, kindergarten and sixth grade.
State law allows exceptions: religious exemptions for child care, preschool and Head Start programs, medical exemptions that require a document verifying the vaccine could harm the child, and personal belief exemptions, which require no reason be given. Medical exemptions have stagnated as personal exemptions have risen steadily.
Dueling bills introduced in the Legislature this year have either tried to remove the personal exemption or tried to expand exemptions.
Heather Wolcott and her husband, Jeff, have chosen not to vaccinate their two children because of safety concerns. She likens government officials’ statements of a public-health threat to a sky-is-falling message.
“It’s like Russian roulette, you just don’t know what you’re getting. To me, that’s way more threatening than my kids getting the measles,” said Wolcott, who lives in the Ahwatukee Foothills section of Phoenix.
Jacquelyn Phillips of Gilbert, who’s also a parent, said community health matters.
“It absolutely baffles me that my peers don’t vaccinate,” she said. “I worry what public health will look like in the coming years.”
For most health professionals, the solution is simple: get vaccinated. But the entanglement of family, community and choice has turned vaccinations into one of the most divisive – some say dangerous – public health issues this year.
The tipping point
A DHS report in April warned that higher level of personal exemptions could lead to a potential outbreak of measles and mumps after herd immunity dropped below the 95% threshold for kindergartners. Six states have confirmed measles outbreaks. According to the Centers for Disease Control and Prevention, most people contracting the disease were unvaccinated.
Personal exemptions for kindergarteners are alarming, DHS officials said, jumping statewide from 1.8 percent in 2015-16 to 3.8 percent this year.
Eugene Livar, bureau chief of epidemiology and disease control at DHS, said there is no one smoking gun that has been identified to explain the decline in vaccination rates. Public health officials do not have an answer.
Wolcott said her children, 5- and 9-years-old, rarely get sick except for the occasional cold. She’s wary of conventional medicine and treats the sniffles with elderberry, zinc and lots of fluids.
“I think people who don’t vaccinate look for healthier solutions. I think it’s part of that culture and part of that community,” she said.
Phillips, who has a son in sixth grade, said the personal exemption becomes a problem when unvaccinated children are enrolled in schools and put other children at risk.
“Every parent is going to parent differently, and that’s totally fine,” she said. “But if your child is going to interact with other children, that’s when you have to start taking that into consideration.”
Humble, a former DHS director, said vaccinations are a social contract for the community.
“There are certain members of the community, people with disabilities, people with medical conditions that can’t get vaccinated or don’t form a full antibody titer and are not fully protected,” he said. “And when we vaccinate all of us, we protect all of us.”
Herd immunity in Arizona, however, is faltering – DHS data shows nine of Arizona’s 15 counties fell below the necessary threshold this year. Pockets in the state, mostly in northern Arizona, harbor dangerously low vaccination levels. The most striking is Yavapai County, with an 83.3 percent immunization rate among kindergarteners, although vaccinations ticked up from the previous year.
Leslie Horton, director of Yavapai County Community Health Services, said the county’s low rates have been “a challenge” for years.
Horton cites unfounded fears of autism as one of the most common reasons for not vaccinating, with those opposed to vaccinating their children relying on a coincidence in timing. According to the 2019 CDC immunization schedule, infants receive their first MMR dose at about 12 to 15 months old. The onset of autism diagnosis in toddlers is about 18 months, Horton said.
“We see MMR is probably the most commonly exempted vaccine,” Horton said.
Vaccines as a cause of autism have largely been been debunked in the medical community but the myth persists.
Mohave County, in northwestern Arizona, also has seen exemption rates rise steadily.
Personal exemptions cluster in schools such as that county’s small Cottonwood Elementary School , where 85% of kindergarten students are not vaccinated for measles, mumps and rubella.
In Maricopa County, the state’s most populous, personal exemptions in private and charter schools reached nearly 10%.
“You see a trend for parents who choose to send their kids to charter schools also choosing not to vaccinate their kids,” Humble said.
He sees another trend: The higher the family income, the more likely the children are not vaccinated.
“It sounds kind of counterintuitive because a lot of the problems we have in public health is a lack of access to care because of resources or transportation or other barriers low-income people face,” Humble said.
Dr. Nina Shapiro, director of pediatric otolaryngology at UCLA, theorizes that people with higher incomes treat health care is a commodity.
The idea that vaccines are a topic of controversy, according to Shapiro, is a luxury.
“I think many people who are in these higher income communities and brackets don’t even realize that it’s a detriment to themselves, to their families and to the public to make something that is really a public health decision into an individual decision,” she said.
Dr. Jack Wolfson, an Arizona cardiologist, has garnered national attention as a vaccine opponent who posts Facebook videos to followers.
“You have to get educated on the dangers of vaccines, why vaccines are totally unnecessary,” Wolfson said in one video.
Farra Swan, a doctor of naturopathy and midwife since 1984, is not alarmed by the drop in immunization rates, saying immunity does not come from vaccinations but from contracting the disease. Swan said she got the measles when she was 5 and remains immune at 72.
“What happens when you’re getting vaccinated?” Swan said. “The vaccine wears off.”
Vaccines are much less potent today for safety reasons, and antitoxins can wane over time, requiring booster shots to serve as reinforcements for antibody concentrations, according to the CDC and Shapiro.
Someone up-to-date on all vaccinations on the CDC’s schedule has an assumed immunity, public health officials say, but immunity can wear off over time and require additional doses of vaccine.
Statements like Swan’s puzzle public health officials, including Livar, the DHS epidemiologist.
“It’s such a shame, because we know that these are preventable – we know that we have tools available to us,” Livar said.
Trust, the government, and choice
Whether people trust government and health institutions to decide what’s best for them is one reason for the schism over vaccinations.
Gov. Doug Ducey in February declared Arizona as “pro-vaccination” as a flurry of bills surrounding immunization consent and religious exemptions made their way through the Legislature.
Ducey announced he would not sign any bills that chip away at state vaccine coverage rates.
President Donald Trump, once skeptical about the CDC immunization schedule, has encouraged people to get their shots, saying vaccinations are important.
But Horton, the health official in Yavapai County, said people often move there to get away from government control.
“If they don’t trust the government, then they sometimes don’t trust that immunizations are in the best interest of their children,” Horton said.
Mistrust of other institutions, like the mainstream news media, also account for the gap.
Wolcott, the Ahwatukee mom who opposes vaccinations, said news outlets overblow the consequences of not vaccinating as if it were life threatening.
“I think that’s completely bogus and I don’t trust what they’re saying,” Wolcott said.
Wolcott and others who oppose vaccination also wonder who’s profiting from vaccines, noting that pharmaceutical companies are a major lobby in Washington, D.C., and a source of political donations.
“It’s just a big conglomerate of business. I don’t think it’s necessarily the business of making people healthier and saving lives,” she said. “I just think it’s really shady.”
Swan, the naturopath, who’s already wary of complex ingredient lists, said the push to vaccinate is a manifestation of the power that drug companies exert.
Phillips, the Gilbert mom who says vaccinations are a community responsibility, said opponents are in denial.
Because of vaccines, she said, her Gen X generation has not experienced the devastating effects of preventable diseases – not only measles and mumps, but hepatitis B, tetanus and even polio. Only a resurgence will remind parents of the danger, Phillips said.
“We don’t know what that looks like, so we can’t be afraid of it,” she said. “But it’s that spiral of noncompliance that’s bringing this outbreak.”
However, parents worried about safety argue they are justified in questioning vaccines.
Trust in vaccinations was rattled in the late 1990s when a mercury-containing preservative in vaccines, thimerosal, exceeded a recommended limit set by the Environmental Protection Agency, but not the Food and Drug Administration. In 2001, thimerosal was removed from all vaccines except influenza.
Wolcott not only worries about other metals that are found in vaccines, including aluminum, but the fact that vaccines are marketed as a “one-size-fits-all” solution.
The CDC and the FDA stress the rigorous safety testing vaccines go through before approval and medical exemptions are available to children who may have an adverse reaction to vaccines.
Laws of the land
Nationwide, lawmakers have proposed more than 100 vaccination bills across 30 states.
More than half of the proposals advocate for religious exemptions or a parent’s informed consent before administering a vaccine.
Sen. Paul Boyer is among Arizona lawmakers who proposed a bill that would inform patients of all the risks and benefits of vaccines as well as a full ingredient list. He says he trusts parents to make decisions that are best for their children.
“I really think that parents love and care for their children. They should know what’s going into their children’s bodies,” said Boyer, a Republican representing Glendale and north Phoenix.
He believes there are limitations and benefits to all vaccines, and that parents deserve to be informed.
As a father-to-be, he said, the controversy is important to him, and he’s navigating whether vaccinations are the right way to go.
On the other side of the issue, Rep. Alma Hernandez aims to remove the state’s personal exemptions, which she considers a threat to the state’s herd immunity. She doesn’t see the need for any exemption other than medical.
Hernandez, a Democrat representing Tucson, advises parents to not confuse their passions for facts.
“Every parent has a right to make decisions for their child, but it’s not their right to put other people at risk and other parents’ children at risk,” Hernandez said.
These and two other bills regarding vaccines appear to be dead for this session.
Love of family and vaccine’s future
Health officials are grappling for a way to slow the drop in vaccination rates in the face of parents’ belief that they are making the best decision for their children.
“Some people really have a natural approach to raising their children and don’t want anything injected into their children that’s not natural or chosen by them,” Horton said.
The passion over vaccinations – pro and con – proliferates on social media, particularly on Facebook.
The only common ground, parents and public health experts say, is love for their children.
“Every decision you make as a parent matters,” Wolcott said. “Don’t shame me for what I’ve done, because I’m doing it with the best interests of my kids. I’ve done a heck of a lot of research on it.”
Phillips is just as certain.
“It just boggles my mind that someone would go out of their way because of a belief they have, and put so many others in danger,” she said. “I’m counting on everybody else to make the same choice that I did to protect the people that can’t protect themselves.”
— Top video by Cronkite News reporter Jennifer Alvarez.
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