Northwest Health Spring 2011

Learn What's Behind the Vaccine Controversy

Vaccines save lives. So why are more and more parents choosing not to vaccinate their kids?

Go to: Northwest Health Index

Modern medicine has put many tools in the hands of Rob Nohle, MD. The Group Health Physicians chief of pediatrics can prescribe antibiotics to cure bacterial infections, correct a heart defect by referring a young patient to a pediatric cardiac surgeon, and offer effective treatment for asthma.

But all of these tools pale in comparison with the vaccinations that prevent many diseases. "As a provider, the single most important thing that I do on a day-to-day basis is vaccinate children," says Dr. Nohle. "I've helped more families and saved more children with immunizations than anything else I've done in my career."

Before medical science ushered in the age of modern vaccinations, thousands of children died or were permanently disabled — physically or mentally — from devastating diseases that are rarely seen today: smallpox, diphtheria, polio, pertussis, measles, and others. With the exception of smallpox, these diseases haven't been eliminated. But they are being held at bay because of vaccinations.

Today, few people — including young parents and even grandparents — have direct experience with the ravages of these diseases. Experts say that's one reason a growing number of parents are choosing not to have their children vaccinated, to postpone vaccination, or to only partially vaccinate them. In Washington state, only 64.9 percent of children aged 19 to 35 months have had a complete vaccination series, according to figures from the Washington State Department of Health.

Another reason may be Washington State law. To prevent transmission of the diseases they protect against, children should be vaccinated before they start school. But in Washington, parents can exempt their child simply by stating that they have a personal belief against immunizations. The rate of exemptions has been growing, especially in some areas of the state. For instance, in Spokane County, 3 percent to 3.9 percent of children were exempted from some or all vaccinations in 1999; a decade later, it was 10 percent.

Group Health member Jeffrey Kunz of Des Moines was one such parent who decided not to have his children vaccinated. His three boys, now ages 10, 11, and 13, went unvaccinated for much of their young lives. He was persuaded by his wife, who knew of a child who she believed suffered a serious reaction to a vaccination. She was concerned the same thing would happen to their children.

"She was convinced if the boys had vaccines they would have a reaction and be blind or deaf or have major problems," he says.

The fear that vaccines may cause health problems — despite extensive scientific evidence that they are overwhelmingly safe — is another reason behind what is called "vaccine hesitancy." The increasing number of unvaccinated children is already leading to public health problems that experts fear could explode in the future.

Protection for the Community

Failing to vaccinate or fully vaccinate children has consequences beyond the possibility that the unvaccinated child will catch a preventable disease. There are also serious, even deadly, consequences for people whose immature or compromised immune systems make them more vulnerable to infections and disease, or who are unable to receive the vaccine themselves. These include fetuses, babies, children, the elderly, and people suffering from medical problems that lower their overall ability to fight disease.

Ten-year-old Ewan McCarthy is in this vulnerable group. "Ewan has a borderline immune deficiency," says his mother, Anna. "He has gotten very sick with illnesses that most people wouldn't consider a big deal. Nearly every flu-like bug he's had has meant a trip to the hospital. Chicken pox was horrible. The emergency room doctor took photos of him, it was such a bad case."

Parents should understand that their decision not to vaccinate affects other people, she says. "Your child might have a mild case of a disease that turns out to be a big deal for another child."

In the case of whooping cough, the lack of a well-vaccinated population has already had serious consequences. Last summer a Grant County, Wash., baby died of whooping cough. Babies can't receive the vaccine until they are 8 weeks old, and can catch it from older children or adults who haven't been vaccinated, or who haven't received a booster shot. Babies with whooping cough suffer violent bouts of coughing, sometimes turning blue. The cough ends with a whooping-like sound. Around 1 in 20 infants who get the disease will develop pneumonia.

A particularly large outbreak of the disease — which is also known as pertussis — occurred last year in California where more than 7,000 confirmed or suspected cases of whooping cough and 10 infant deaths were reported.

John Dunn, MD, head of the Group Health Immunization Team, points to another example involving whooping cough. In the South Whidbey School District, 12.9 percent of school children were exempted from vaccinations in 2008. In the summer of that year, a mini epidemic of 55 cases cropped up on Whidbey Island, all but seven cases in the South Whidbey area.

The risk of outbreaks could be greatly reduced if children and adults were fully immunized. When a large part of the population is vaccinated, it provides "herd" or community immunity for the portion of that population that can't be vaccinated or in whom the vaccine didn't work.

Are Vaccines Safe?

"As a pediatric provider, I regularly see parents who question vaccination," says David Grossman, MD, who is also medical director of preventive care at Group Health, and a senior investigator with the Group Health Research Institute.

"Many parents have concerns about vaccine safety, so much that they even doubt whether vaccines are necessary. People are not necessarily following current recommendations made to protect children in the United States."

The questions around vaccines are fed by an Internet culture and TV talk shows full of scientifically dubious and emotional claims. By far the most dogged and stubborn misconception holding back many parents, experts say, is that autism is in some way linked to immunizations.

Much of the fear about autism goes back to a British study from the late 1990s that linked the measles, mumps, and rubella vaccine to some children developing autism.

But that study has since been retracted by the medical journal that originally published it, repudiated by 10 of the 12 original authors, and the lead doctor who conducted the study was stripped of his right to practice medicine in Britain. Earlier this year, another report found that facts about patients in the study had been altered so the data was, in fact, false.

Numerous other studies have failed to demonstrate any link between that vaccine combo and autism, say experts with the Centers for Disease Control and Prevention and with Group Health. But the strength of the fear raised by that study continues to hamper efforts to vaccinate children, to the dismay of health care workers.

Combating Vaccine Hesitancy

Finding an effective way to talk to parents about their vaccine concerns is the goal of a major initiative the Group Health Foundation is leading, with research and evaluation conducted by the Group Health Research Institute. The initiative, funded by Foundation donors, will put evidence-based resources about the importance of immunization directly into schools, especially ones where vaccination rates are low.

"We want to get people engaged in why we need a well-vaccinated community," says Joe Turcotte, communications director for the Foundation. "We want to find volunteer health advocates in schools who will promote better vaccination rates. "The Foundation's partners in this effort include Seattle Children's, WithinReach (a nonprofit organization that promotes improvements to the health of families, mothers, and children), the Washington state chapter of the American Academy of Pediatrics, and the Washington State Department of Health.

The Foundation is also helping health care providers to talk more confidently with parents who are reluctant to vaccinate their children or want to delay immunizations. "We give them tools that will help them have more effective conversations with families," he says.

Many doctors are finding ways on their own to talk about vaccinations with their patients. "A lot of families come in with questions about vaccinations," says Dr. Nohle. "It comes to sitting down, making the case for vaccinations, the reasons for doing it, listening to what their concerns are, and making sure they're really heard. My job is to offer input and guidance around vaccinations."

Being able to have a series of open conversations about vaccines is what finally tipped the scales in favor of vaccinations for Jeffrey Kunz and his three boys.

His concern about vaccines came from his wife. She supported her concern with books critical of vaccines. They raised enough doubts for him that he agreed that the three boys be kept unvaccinated. "Because of her fears, I supported her on that," he says.

Then seven years ago, his wife died from breast cancer, and he found himself the sole decision maker for his sons' health care. He spoke with medical professionals about vaccines, but felt frustrated. "Most of the nurses and doctors I talked to were so confrontational and so in your face — 'I can't believe you're not vaccinating. You have to do this or you'll be spreading diseases.' It was such a turnoff."

Then Kunz started working for Group Health as a project manager, and his family began getting their medical care at the Group Health Medical Centers Burien clinic. Spread over a year, Kunz had several respectful, heartfelt conversations about vaccination with his personal physician, Jason Wong, MD.

"He said, 'I know your chart says you do not vaccinate for personal reasons and I'd like to hear what those reasons are,' "Kunz recalls. Dr. Wong didn't try to change his mind, says Kunz. Instead, he presented the risks, and the reasons for vaccination. "He's an awesome, amazing, down-to-earth regular guy who really wants to work it out for you."

Doctor and patient developed a trusting relationship, which eventually led to a pivotal conversation, says Kunz. "He challenged me on how much of my fears were actually what my wife was feeling when she was alive, and he asked me, 'Are you holding on to this because she's gone?'" he recalls. "I had to answer yes."

And so his three sons got their vaccinations two years ago and it proved pretty anticlimactic: just some complaints from the boys about getting poked. "They weren't too happy about it," Kunz says. "But it was actually kind of a non-event."

The Vaccine Impact

Vaccines have led to a dramatic decline in the infectious diseases they protect against.

Disease — Symptoms & Complications Vaccine Introduced Peak Year Cases Pre-Vaccine 2007 Cases
Diphtheria — Respiratory infection. Classic sign is the thick membrane that coats tonsils and throat. Can lead to airway obstruction, coma, and death.Early 1920s200,000 (1921)0
Pertussis (also called whooping cough) — Respiratory infection with violent coughing fits. Can lead to pneumonia, convulsions, apnea, and death. Most serious in infants.Mid-1940s265,000 (1934)10,454
Polio (specifically, paralytic polio) — Often symptomless. About 5 percent have flu-like symptoms. Can cause paralysis of legs and respiratory muscles, and death.195521,269 (1952)0
Measles — Rash, fever, cough, sore throat, white spots in mouth. Can lead to pneumonia, ear infections, encephalitis.1963900,000 (1941)43
Hib (Haemophilus Influenzae type B) — Fever, lethargy, vomiting, and a stiff neck. Can lead to bacterial meningitis, pneumonia, deafness, mental retardation, and death.198520,000*202

Source: Centers for Disease Control and Prevention
* Estimated average yearly cases prior to 1985, children under 5 years of age

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