As more parents choose not to vaccinate and vaccine-preventable diseases are on the rise, public health officials realize they’ve got a PR problem.

In September, Dina Martinson got a call from her son’s preschool. Three children from two separate families at the Minneapolis center had come down with whooping cough. None had been vaccinated.

Martinson, who asked us not to use her real name, was horrified. Her 2 1/2–year-old son had been immunized, but vaccines aren’t always 100 percent effective. Whooping cough, also known as pertussis, is only occasionally fatal, but children with the disease can cough so hard they turn blue for lack of oxygen. At the very least, if her boy contracted the disease he would likely spend months recuperating. 

More worrisome, Martinson’s 4-month-old daughter, who was in a different daycare center, hadn’t yet received a full course of DTP [diphtheria tetanus and pertussis] vaccine. The family’s pediatrician put Martinson’s son on prophylactic antibiotics so that, if he did pick up the disease, he wouldn’t be contagious. But the drugs wouldn’t be effective for several days. In the meantime, Martinson had to quarantine the children in different parts of the house.

She also called the mother of the first patient, only to learn that the woman opposed immunizations on philosophical grounds, trusting alternative medicine instead. In fact, the woman cheerfully opined, she wasn’t entirely sure whooping cough really needed treatment. "She seemed to think it was an option not to get her tests and not to go on antibiotics," says Martinson. "She seemed to think that she [the pro-vaccinating mom] was bowing to Western medicine."

Whooping cough was something Martinson never thought she’d need to worry about, just like polio and rubella and a host of other diseases that plagued her grandmother’s generation but whose horrors have been virtually unknown during her lifetime. She was stunned to learn that pertussis is just one of several vaccine-preventable diseases on the rise in Minnesota in part because a growing number of parents are choosing not to immunize.

The popular image of parents who don’t vaccinate is of people without health insurance or the wherewithal to get their children to a clinic. But over the last decade, a growing number of affluent, educated parents have chosen to forgo the shots. The trend can be traced to frightening headlines in the late 1990s suggesting that the combined measles-mumps-rubella vaccine caused autism in some children. The lone study suggesting a link was discredited, but not before a host of other fears about vaccines and their potential side effects came rushing into the mainstream consciousness. Complicating matters, few of the parents frequenting the chat rooms and playgroups where the pop science is now common currency are old enough to have seen vaccine-preventable diseases in real life.

"People know so many people with autistic kids," says Martinson. "The possibility of dying of measles seems pretty remote compared to something they’ve seen themselves."

Herd immunity

As soon as vaccines became available for widespread use in the mid-1800s, organized opposition sprang up in England and the United States. In fact, the term "conscientious objector" was first coined to describe vaccine opponents.

Vaccines protect those who receive them, but they also protect those who can’t or don’t get shots by denying the disease a human beachhead from which to spread. If as many people as possible are immunized, it won’t matter that the shots don’t create immunity in a few people, or that a small number shouldn’t get them for medical reasons — an immune disorder or organ transplant, say, or an allergy to an ingredient. Without this ripple effect, called herd immunity, vaccines’ benefits to everyone are compromised. 

Reasoning that public health was everyone’s obligation, in 1905 the U.S. Supreme Court gave states the power to require immunizations. Most did this by denying unvaccinated children admission to public schools. Some parents objected on religious grounds, ranging from a belief that disease is a punishment from God to objections to the use of animal and human tissue in vaccine manufacturing. But most were too scared of polio and other life-threatening diseases to think of missing their kids’ shots.

Minnesota first made immunizations mandatory for schoolchildren in 1967, when a measles vaccine became available. Parents could only opt out for medical or religious reasons until 1978, when the law was changed to allow parents to refuse vaccines for "conscientiously held beliefs." In order to forgo one or more shots, a parent must sign a state form and have it notarized. For decades, herd immunity went unchallenged; fewer than 1 percent of parents nationwide refused for philosophical reasons in 1991.

In the mid-’90s, a number of parents reported that their children’s symptoms of autism first appeared after they received the measles-mumps-rubella vaccine. Their compelling anecdotes got a boost from a study published in the medical journal The Lancet by controversial British surgeon Andrew Wakefield in 1998.

Wakefield purported to tie the onset of autism to an overload of the mercury derivative thimerosal, used as a preservative in vaccines. Because children now get so many vaccines, they get toxic amounts of thimerosal, he posited. Congress threw kerosene on the fire, proposing to grant vaccine manufacturers immunity from thimerosal lawsuits. Wakefield’s co-authors quickly recanted the study.

The preservative was removed from most vaccines by 1999, but thanks in part to the rise of the Internet as a source of (frequently unreliable) information about health care and parenting, the toxic-vaccine thesis had taken root, spawning concerns about other inoculations. Opposition was swift when the HPV vaccine came on the market in the U.S. in 2006.

Immunization rates remained high in the two states that don’t allow any exemptions and in the 28 that allow only medical and religious refusals. But in the 20 states that allow conscientious objection, including Minnesota, rates dropped quickly. By 2004, more than 2.5 percent of children nationwide were unvaccinated for philosophical reasons. States allowing parents to opt out only for religious reasons had rates of pertussis two times lower than states that also allowed philosophical exemptions.

Unvaccinated rates can run as high as 19 percent in communities with clusters of natural-health proponents, like Boulder, Colo., and Ashland, Ore. Sometimes researchers can even pinpoint neighborhoods populated by like-minded "exempters."

Minnesota’s opt-out rate is a striking 5 percent. Despite this, disease rates are lower here than in other states with large numbers of conscientious objectors because our objectors are spread across a large metropolitan area.

"To the average parent, 5 percent sounds like nothing, but from an infectious-disease standpoint, every percentage point is that much more chance for disease to take hold," says nurse-practitioner Patsy Stinchfield, director of infectious disease and immunology for Children’s Hospitals and Clinics of Minnesota. "Even 1 percent is worrisome to us. [Vaccination rates] need to be as close as possible to 100 percent to avoid outbreaks like the ones we’re seeing now with pertussis and measles."

In 2008, some 131 cases of measles were reported in Minnesota. Ninety percent of those cases were "imported" from parts of the world with low immunization rates, says Stinchfield. "But they are taking hold in these under-immunized pockets." There have been several measles fatalities in recent years, although no child died of the disease in Minnesota in 2008. Four cases were in babies too young to be immunized, and there were several cases of encephalitis, a life-threatening side effect. And last fall, a 7-month-old died of hemafluous influenza, a bacterial infection that was all but eradicated after vaccine was introduced in the mid-’80s, back when vaccinating was right up there with "baseball and apple pie," says Kris Ehresman, section manager for immunizations, tuberculosis, and international health for the Minnesota Department of Health.

With its relatively loose opt-out procedure, Minnesota’s exemption rate is on "the low end of high [nationally]," says Ehresman. She expects the current whooping cough outbreak to peak in 2009.

Some public health workers would like to make parents have to work harder to opt out. Under a model law proposed by the Centers for Law and the Public’s Health, a joint effort by Johns Hopkins and Georgetown universities, parents would have to get counseling on the issue and present a statement outlining how long they have had their beliefs. Still other public health officials want to end exemptions for diseases that are quick to spread to epidemic levels in schools, such as measles and polio.

Ehresman is quick to defend Minnesota’s philosophical exemption. Tougher mandates could simply trigger a bigger backlash, she says, and parents have a right to make decisions concerning the welfare of their children. It’s her hope those decisions are carefully made.

"It’s a significant decision," she says. "We think that a thoughtful parent who chooses not to vaccinate needs to put a significant amount of energy into it." 

A level playing field

Elizabeth Reisinger describes herself as "more on the holistic side." Even before delivering her son eight months ago, she read everything about the issue she could get her hands on, including The Vaccine Book, by physician Jim Sears, son of attachment parenting icons Bill and Martha Sears.

Although she has no scientific background, Reisinger plowed through the books’ detailed primers on each disease. "Really, what it came down to is I wanted to know what each disease was, what the vaccine does, and why it is given at a certain age, right down to the contents of each [vaccine]," she says.

She made an appointment with her pediatrician for an immunization consult, a special visit wherein doctor and patient only talk about shots, not administer them. She arrived armed with her own alternative schedule for administering the shots and asking for a particular brand of one vaccine because the standard brand contains traces of aluminum.

"I felt like I really walked into our pediatrician’s office knowing what the pediatrician knew," she says, "like we had a level playing field."

A few short years ago, Reisinger would have been a pediatrician’s worst nightmare. Many doctors initially confronted dropping immunization rates by trying to shut down talk of nasty vaccine side effects. Many of the side effects are real, if incredibly rare, and some parents reacted by walking away from the mainstream, laments Ehresman: "Initially, [health care] providers were completely unprepared."

Ehresman and Stinchfield are among a number of public health officials who are urging doctors to respond by hearing parents out. "Providers are frustrated because, like us in public health, they think this isn’t an issue, [so] why do they have to spend precious time on it?" says Ehresman.

"Parents’ concerns can come from different sources," Stinchfield adds. "Are they more fearful of side effects than of diseases?"

Physicians need to listen carefully and tailor their response to what they hear. When someone believes illness builds a child’s immunities, for instance, she points out that vaccines do much the same thing with less risk than the disease. "I’ll say, ‘Let’s talk about how the same wonderful, natural response is triggered by the vaccine,’" says Stinchfield. "Then I’ll talk to them about the potential risks of the vaccines and the diseases."

In her practice at Hennepin Faculty Associates, pediatrician Teresa Reid emphasizes alternative and holistic approaches and has acquired a reputation on the Internet as a pediatrician who will work with objectors. "I do believe in vaccines," she says. "But I also believe in parents’ right to make decisions."

Many families come to her practice with requests like Elizabeth Reisinger’s. She typically spends half an hour reviewing issues with them, telling them which immunizations she thinks are crucial — often very different from priorities established by a layperson who has tried to educate themselves through a hodge-podge of sources. "If I can get them to do the two I think are most important, then we’re getting somewhere," she says. "It’s all about trust."

Reid says she ends up with a lot of parents who left other practices because they clashed with their doctor. "I think if a parent comes in and says to the doctor, ‘I’m not really interested in immunizations,’ and I say, ‘No, no way,’ they leave mad," she says. In contrast, she believes her process increases compliance among reluctant families.

After a long discussion, Reisinger and her pediatrician agreed on a schedule that has her son receiving the vaccinations, over several months’ time, that prevent illness that are particularly dangerous to infants. 

Reisinger and Reid both say they understand the danger their positions present to herd immunity. Reisinger’s defense is that her son will get all of his vaccines after he turns 2. In the meantime, she’s not worried, she says, because she cares for her son at home, and "the playgroups we do go to are of like-minded parents."

For her part, Reid says lecturing parents will only make them feel guilty.

Dina Martinson, meanwhile, wishes the parents of the family that exposed hers to whooping cough felt guiltier. The other family was counting on the herd immunity maintained by families like Martinson’s that do vaccinate to keep disease rates low. Instead, they all found out that it’s easier to opt out of the vaccination program than to opt out of the herd.

Beth Hawkins is a Minneapolis writer.

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