Issue
Number 341
October 10, 2002
CONTENTS OF THIS ISSUE
- Childhood pertussis rate climbs when parents in
Boulder, Colorado, spurn immunization
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October 10, 2002
CHILDHOOD PERTUSSIS RATE CLIMBS WHEN PARENTS IN BOULDER, COLORADO, SPURN
IMMUNIZATION
The September 2002 issue of "The Atlantic Monthly" includes an excellent
article about parents' refusing vaccinations for their children. By
examining events in Boulder, Colorado, "Bucking the Herd" describes what
happens when a community loses herd immunity. Boulder has the lowest
school-wide vaccination rate in the state and has one of the highest rates
of pertussis in the nation, with an average of 81 cases a year in Boulder
County since 1993.
The author, Arthur Allen, has written an informative, readable, and
thought-provoking article, which should be of interest to immunization
providers and their patients. For this reason, the Immunization Action
Coalition requested permission to reprint it.
Please note that this article is copyrighted and is not to be distributed
further without permission. The full text follows.
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Parents who refuse vaccination for their children may be putting entire
communities at risk.
Boulder, Colorado, a university town of 96,000, lies in a sequestered valley
on the western edge of the Great Plains. Both geographically and
culturally it is a place apart. Ralph Nader won more than 10 percent of
Boulder's vote in the most recent presidential election. Natural-food
groceries outnumber Safeways; chiropractors' offices line the main drag; and
the city council recently declared that dog owners would henceforth be
referred to as "dog guardians." A popular bumper sticker reads, WELCOME TO
BOULDER, 20 SQUARE MILES SURROUNDED BY REALITY. Boulder is, in short, an
experiment-oriented city.
A particularly interesting experiment, from a public-health perspective, has
taken shape at the Shining Mountain Waldorf School, a campus of one-story
wooden buildings set amid cottonwood and willow trees hard by the foothills
of the Rockies. By their parents' choosing, nearly half of the 292 students
at Shining Mountain have received only a few, and in some cases none, of the
twenty-one childhood vaccinations mandated by Colorado state law in
accordance with federal guidelines. The shunning of one of the vaccines,
against diphtheria, tetanus, and pertussis, has resulted in a revival of
whooping cough, the illness that occurs when colonies of the bacteria
Bordetella pertussis attach to the lining of the upper respiratory passages,
releasing toxins that cause inflammation and a spasmodic cough. The
high-pitched whoop is a symptom heard mainly in younger children; it's the
sound of a desperate attempt to breathe.
Shining Mountain exemplifies a growing movement in American life: the
challenge to childhood vaccination. According to a survey published in
the November 2000 issue of Pediatrics, one fourth of all parents are
skeptical of some or all of the standard vaccines. Some states grant
exemptions to the law so that parents can refuse vaccinations for their
children. In Colorado parents who don't want their children vaccinated have
only to sign a card stating as much. In Oregon the rate of religious
exemptions--which are granted to all parents who choose not to have their
children immunized for philosophical reasons--tripled, from 0.9 percent in
the 1996-1997 school year to 2.7 percent in 2001.
Those skeptical of vaccines have various reasons. Some believe that vaccines
are responsible for otherwise unexplained increases in conditions such as
autism, asthma, and multiple sclerosis. Others, including the conservative
activist Phyllis Schlafly, see government attempts to track and enforce
immunization as an intrusion on privacy. Still others--parents whose
recollections of their own bouts of chickenpox or measles are bathed in
nostalgia--argue that the elimination of traditional childhood illnesses is
an attack on childhood itself. The parents at Shining Mountain are
influenced by the philosophy of Rudolf Steiner, a turn-of-the-century
Austrian philosopher who founded the Waldorf movement. Steiner (who was not
a medical doctor) believed that children's spirits benefited from being
tempered in the fires of a good inflammation.
The critics have concluded that the dangers of vaccination outweigh the
risks of vaccine-preventable disease. Like all medical interventions,
vaccination entails some risk, although the extent and gravity of potential
side effects are matters of debate. For example, febrile seizures occur in
roughly one in 10,000 children-–perhaps 1,000 a year in the United
States–-who receive the current whooping-cough vaccine. Such seizures
rarely, if ever, lead to permanent brain damage, however, and in any case
febrile seizures are triggered just as easily by a run-of-the-mill infection
as by a vaccine. Suspicions that mercury preservatives used in vaccines
inflicted neurological damage on children are worrisome but unproved
(mercury has largely been phased out of vaccines over the past three years).
To some extent vaccination is a victim of its own success. Owing to
vaccination campaigns, smallpox no longer exists in man, and polio has been
driven from the Western Hemisphere. Measles, diphtheria, and invasive
hemophilus bacterial disease (such as meningitis) are rare in the United
States, and even whooping cough is unusual enough that few parents consider
it a threat. All these diseases, with the exception of smallpox, still
infest various corners of the world, but in most of the United States even
those who have not been vaccinated against them, or in whom the vaccine is
not effective, are protected, because most of the people we meet have been
vaccinated. Epidemiologists call this phenomenon "herd immunity": the more
vaccinated sheep there are, the safer an unvaccinated one is. When
vaccination rates drop, disease returns.
Precisely at what point herd immunity fails is difficult to calculate, but
there is ample evidence that it does. Since the collapse of the Soviet
public-health system diphtheria has returned to Russia with a
vengeance, killing thousands. Sweden suspended vaccination against whooping
cough from 1979 to 1996 while testing a new vaccine. In a study of the
moratorium period that was published in 1993, Swedish physicians found
that 60 percent of the country's children got whooping cough before they
were ten. However, close medical monitoring kept the death rate from
whooping cough at about one per year during that period.
Boulder, which has the lowest school-wide vaccination rate in Colorado, has
one of the highest per capita rates of whooping cough in the United States.
The problem started in 1993, when fifty-two people in Boulder County
contracted the disease. Since then the county has seen an average of
eighty-one cases a year. Although unvaccinated children are six times as
likely as vaccinated children to get whooping cough during an outbreak,
about half the cases in Colorado have involved vaccinated children;
the whooping-cough vaccine sometimes fails to produce effective immunity,
and even successful pertussis immunity generally wanes by age ten. "At
first we called it an outbreak; then we started calling it a sustained
outbreak; now we just say it's endemic," Ann Marie Bailey, the county nurse
epidemiologist when I visited Boulder last year, told me.
To many in Boulder, endemic pertussis is no cause for alarm. Shining
Mountain's director, Robert Schiappacasse, says that his daughter, who
had been immunized, got whooping cough but suffered no lasting effects. He
became a little concerned, he told me, when the baby of one of the school's
secretaries "coughed himself into a hernia" after visiting the school during
an outbreak. Still, "parents here," Schiappacasse said, apparently including
himself in the category, "are more likely to be worried about fumes from a
new carpet than they are about any infectious disease."
I also spoke with Johnnie Egars, a Shining Mountain parent whose three
children, all unvaccinated, got whooping cough in 1994. Her youngest child
was particularly sick. Egars's description of the experience was harrowing.
"It was a loud cough that went down to her toes, and the whoop was a sharp
intake of breath," she recalled. "She coughed and coughed until she threw
up; then she slept an hour or two. Then she'd wake up and start over again."
The daughter, who was two at the time, was undergoing treatment for cancer;
she was hospitalized for three days in the infectious-diseases ward of
Children's Hospital in Denver. Nonetheless, Egars is comfortable with her
decision not to vaccinate her children. A niece was hospitalized with
febrile seizures following a pertussis vaccination, and in her view,
"immunization just weakens the immune system." She adds, "We have a history
of cancer in my family, so we try to do everything we can to strengthen the
immune system."
From its reservoir in the under-vaccinated population of Boulder pertussis
has branched out: neighboring Jefferson and Denver Counties had more cases
in 2000 than Boulder did. Some of the people who live near Boulder are
angry. "There is a constant presence of whooping cough here, and it's
because of Boulder Valley;" says Kathy Keffeler, the chief school nurse for
Longmont, a growing city just north of Boulder.
Pertussis is on the rise not just in Colorado but across the country: there
were 7,600 cases last year, as compared with 4,600 in 1994. It can be fatal,
especially in countries--like ours--with spotty health- are coverage. In
2000 it killed seventeen people in the United States, including two Colorado
babies, both of whom were taken to the hospital too late. "It was very
sad," Tina Albertson, a pediatric resident who cared for one of the infants,
told me. "She was a six-week-old girl with a sister and a brother, four and
six. The family had chosen not to immunize, and the week she was born, her
siblings both had whooping cough. When they're real little, the babies don't
whoop--they just stop breathing. This little girl was septic by the time
they got her here."
Like most in Boulder, Ann Marie Bailey, the nurse epidemiologist, is
tolerant of the alternative health-care scene; she cedes nonvaccinating
parents the right to decide what's best for their children. But she gently
points out that they're fooling themselves if they think no one else is
affected by their decisions. "We've been able to show very definitely that
whooping cough spreads from these pockets in small communities. If they
lived in a vacuum at Shining Mountain--if they never went out to go swimming
or to church or the YMCA or the Boy Scouts--it would be a different ball
game," she told me.
Jia Gottlieb, a family practitioner who offers acupuncture and breathing
exercises along with traditional medicine, said, "When I get parents who
don't vaccinate, I tell them, 'When your boy gets a vaccination he takes on
a risk for the public good, just like the firemen [at the World Trade
Center] who went back into the buildings.'" But Gottlieb's words usually
fall on deaf ears. "These are probably people who donate a lot of money to
good causes," he said, "but their view is 'I'm going to let everyone else's
child take a risk but not my own.' That's not avant-garde. That's not
enlightened. It's pretty primitive. And ironically, in a town like Boulder
the selfish strategy is probably not in the best interests of your child
either."
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For an HTML version of the article, go to:
http://www.immunize.org/exemptions/allen.htm
For a camera-ready (PDF) version, go to:
http://www.immunize.org/exemptions/allen.pdf
For related articles, go to IAC's "Immunization Exemption Issues" web page
at
http://www.immunize.org/genr.d/exempt.htm
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