To immunize or not?

[Zeno Swijtink]

To immunize or not? | PressDemocrat.com | The Press Democrat | Santa Rosa, CA
By GUY KOVNER
THE PRESS DEMOCRAT

Published: Thursday, April 2, 2009 at 3:00 a.m.
Last Modified: Thursday, April 2, 2009 at 10:31 p.m.

A declining level of vaccinations among Sonoma County children worries public health officials who say the risk of a serious outbreak of an infectious disease is growing — and must be stopped.

AT A GLANCE

In Sonoma County, the five elementary districts with the lowest vaccination rates are all in west county: Twin Hills Union, 55.6%; Sebastopol Union 58.93%; Harmony Union, 67.65%; West Side Union, 68.12%; and Gravenstein Union, 71.92%.

Statewide, 2% of kindergartners have vaccination waivers. At five Sonoma County schools, that rate exceeds 50%: Sunridge Charter, 76%; Sebastopol Independent Charter, 75%; Orchard View, 67%; Summerfield Waldorf, 55%; and Village Charter, 53%.

The county’s rate of student exemption from the federal standard for childhood vaccinations is six times higher than the national rate and three times higher than the state average. And the gap is widening rapidly.

But some parents and physicians are challenging the federal standard, which prescribes about 35 doses of 14 different vaccines in the first 18 months, contending it may not be the best medicine.

The tension over a medical decision that all parents must make while their children are in diapers also reflects an underlying conflict between individual rights versus state regulation at a time when both medical technology and government policy are increasingly challenged.

“It was a heart-wrenching decision,” said Patricia Bernard of Sebastopol, who chose to forgo all vaccinations for her daughter, Brigitte, now 11.

The issue is charged on both sides.

“We are turning back the clock to a time when children did not have protection,” said Dr. Mary Maddux-Gonzalez, Sonoma County’s public health officer. “We have to reverse this trend.”

Some physicians, however, are sympathetic to their patients’ concerns about repeatedly dosing infants with vaccines against measles, mumps, whooping cough, diphtheria, influenza and other diseases.

“There are people in our community who think vaccines are poison,” said Dr. Tory Davis, a family practice doctor in Occidental.

Davis believes vaccines are safe but said the dosing schedule can be extended, with some inoculations postponed, at “almost no risk.”

The percentage of fully immunized students entering Sonoma County kindergarten classes has steadily dipped from 91.6 percent in 2002 to 87.7 percent last fall, according to state records. The statewide average is down by only 0.6 points over the same period.

Roughly half of this year’s kindergartners who are not fully vaccinated have exemptions that cover all diseases. The other half are missing some vaccinations.

The county’s nearly 4-point drop in the vaccination rate might seem small, but officials say it comes close to the level — about 85 percent — at which “herd immunization,” the safety in numbers from widespread inoculation, breaks down.

In nine county school districts, six of them in the west county, the percentage of fully immunized kindergartners is below 80 percent, a Public Health Department analysis said. The figures exclude private schools.

At six North Bay schools, all charter or private schools, more than half the families had received exemptions from the required vaccination regimen. Such concentrations of partially immunized or unimmunized students pose “a significant risk of an outbreak of a vaccine-preventable disease,” Maddux-Gonzalez said.

State law allows parents, by merely signing a waiver form, to gain exemption from the vaccinations required to enter kindergarten at public and private schools.

At Sunridge Charter School in Sebastopol, 25 out of 33 kindergartners, or 76 percent, had exemptions last fall, the highest rate in the North Bay — and fifth highest in the state.

Brigitte Bernard is a fifth-grader at Sunridge, and her mother said she’s not concerned about an elevated risk of disease there.

“It seemed like I would be putting her at more risk to immunize her,” Patricia Bernard said she concluded after researching immunization. “I believe in free choice, especially when it comes to the health of our children.”

A healthy diet, mostly vegetarian and organic with minimal refined sugar, and healthy lifestyle — her daughter doesn’t surf the Internet, play video games or watch TV — are the best defense against disease, Bernard said.

Nonetheless, Bernard said it’s tough to buck the mainstream, with the government and medical establishment backing immunization, compounded by criticism from relatives who said she was “putting my daughter’s life in danger.”

Public health officials cite an outbreak of 12 measles cases last year in San Diego, triggered by an unvaccinated 7-year-old boy who acquired the disease on a trip to Switzerland. Eight of the 11 other infected children were unvaccinated due to exemptions.

Measles is making a comeback, Maddux-Gonzalez noted, with an average of 63 cases a year nationwide from 2000 to 2007, followed by 131 cases in the first seven months of 2008. A child died of whooping cough in Sonoma County in 2007: Davis called that disease — a nuisance for adults but often deadly to infants under six months — a “huge threat in our community.”

Two widely publicized objections to immunization have been eliminated, Maddux-Gonzalez said. An alleged link between autism and the measles, mumps and rubella vaccine reported in 1998 has been debunked, and mercury has been removed from all pediatric immunizations, except some flu vaccines, she said.

Mark Rice, Sunridge director, said he shares the public health concern about a possible outbreak of disease. “But the choice not to inoculate is entirely a parent’s,” he said in an e-mail message.

Carl Wong, county schools superintendent, said he is disturbed by the trend to avoid or delay immunizations for children who spend school days close together, an environment ripe for transmitting communicable disease.

“That action puts other children at risk,” Wong said, referring to the exemptions.

He and Maddux-Gonzalez advocate a change in the vaccination waiver law, perhaps requiring parents to take a class before gaining the exemption to ensure it is “more of an informed decision.”

Dr. Carlisle Holland, a Sebastopol osteopath, defended parental choice. “Vaccination is not benign,” he said, describing it as “an insult to the immune system” intended to strengthen its resistance to disease.

“I don’t think that parents who refuse vaccinations altogether are crazy,” he said.

Generally, Holland said, families and physicians should determine which vaccinations each child needs and when they should be administered. “Trying to make one size fit all (through the standard inoculation schedule) is lousy medicine,” he said.

Dr. Mark Netherda, deputy county public health officer, rejected the idea that people can pick and chose the vaccinations they want.

“You wouldn’t wear a seat belt half of the time,” he said.

Davis, whose Occidental Area Health Center practice includes plenty of vaccination skeptics and opponents, said she tries to meet them halfway.

“Maybe it’s misinformed, maybe it differs from the western medical model, but it doesn’t help to ostracize these people,” she said. “You’re not going to win people over just by telling them they’re wrong.”

You can reach Staff Writer Guy Kovner at 521-5457 or [email protected].

HOW DOES YOUR DISTRICT STACK UP?
Of the 10 school districts in Sonoma County with the lowest kindergarten vaccination rates, eight are in the west county. Percentage figures represent kindergartners who have received all their required vaccinations.
Twin Hills Union Elementary, 55.66%
Sebastopol Union Elementary, 58.93%
Harmony Union Elementary, 67.65%
West Side Union Elementary, 68.12%
Gravenstein Union Elementary, 71.92%
Liberty Elementary, 73.17%
Windsor Unified, 76.11%
Guerneville Elementary, 77.88%
Forestville Union Elementary, 79.46%
Two Rock Union Elementary, 84.04%
Petaluma City Elementary, 86.26%
Geyserville Unified, 88%
Dunham Elementary, 88.89%
Oak Grove Union Elementary, 89.10%
Wilmar Union Elementary, 89.66%
Cinnabar Elementary, 89.69%
Santa Rosa Elementary, 89.73%
Bennett Valley Union Elementary, 91.71%
Mark West Union Elementary, 91.74%
Healdsburg Unified, 92.45%
Rincon Valley Union Elementary, 92.60%
Bellevue Union Elementary, 92.68%
Sonoma Valley Unified, 93.68%
Roseland Elementary, 94.08%
Piner-Olivet Union Elementary, 94.49%
Waugh Elementary, 95.52%
Cloverdale Unified, 95.70%
Wright Elementary, 96.15%
Cotati-Rohnert Park Unified, 96.54%
Old Adobe Union Elementary, 97.82%

SCHOOLS WITH THE MOST WAIVERS
These are the 20 schools in Sonoma County with the highest number of kindergartners last fall whose parents had received exemptions from all vaccination requirements. Statewide, 1.9 percent of kindergartners had been exempted.

Sunridge Charter, Sebastopol, 25 of 33 kindergartners —76%
Sebastopol Independent Charter, Sebastopol, 33 of 44 —75%
Orchard View, Sebastopol, 8 of 12 —67%
Summerfield Waldorf, Santa Rosa, 17 of 31 —55%
Village Charter, Santa Rosa, 9 of 17 —53%
Pathways Charter, Santa Rosa, 12 of 28 —43%
California Virtual Academy At Sonoma, Petaluma, — 19 of 45 —42%
Live Oak Charter, Petaluma, 21 of 55 —38%
Harmony Elementary, Occidental, 8 of 25 —32%
Forestville Elementary, Forestville, 10 of 37,27%
West Side Elementary, Healdsburg, 6 of 24 —25%
Apple Blossom, Sebastopol, 19 of 78 —24%
Pine Crest Elementary, Sebastopol, 4 of 21 —19%
Brush Creek Montessori, Santa Rosa, 2 of 11 —18%
Woodland Star Charter, Sonoma, 6 of 34 —18%
Santa Rosa Charter School for the Arts, Santa Rosa, 7 of 41 —17%
Guerneville Elementary, Guerneville, 6 of 42 —14%
Park Side Elementary, Sebastopol, 8 of 59 —14%
Windsor Christian Schools, Windsor, 3 of 28 —11%
Oak Grove Elementary, Sebastopol, 5 of 48 —10%
Alexander Valley Elementary, Healdsburg, 2 of 22 —9%

***
https://www.sciencemag.org/cgi/content/full/324/5923/20

Science 3 April 2009:
Vol. 324. no. 5923, pp. 20 - 21
DOI: 10.1126/science.324.5923.20
Prev | Table of Contents | Next
NEWS OF THE WEEK
INFECTIOUS DISEASE:
Hitting Early, Epidemic Meningitis Ravages Nigeria and Niger
Leslie Roberts

Nigeria and Niger are reeling from one of the worst meningococcal meningitis epidemics in years. Already, the epidemic has sickened at least 25,000 people, more than 17,000 in Nigeria alone, and killed 1500. World Health Organization (WHO) experts caution that those numbers may be underestimates and warn that the worst is yet to come. F. Marc LaForce of the Meningitis Vaccine Project (MVP), a nonprofit effort to develop an affordable vaccine to prevent such epidemics, worries that "this may be a repeat of 1996-97," when the largest epidemic ever to hit Nigeria caused more than 100,000 cases and 11,000 deaths.

WHO, Médecins Sans Frontières (MSF), and others have rushed in teams to help state and local health officials deal with the outbreak. Several million doses of the scarce and outmoded emergency vaccine, which has limited effectiveness, have been released from the global stockpile and have begun arriving in both countries. Antibiotics have been sent as well to supplement country supplies. But meningitis experts fear these efforts may be too little, too late to curb the epidemic, which started unusually early this season, now in its 14th week.

The grim task now is triage. There is simply not enough of the existing, 1960s-era vaccine to protect everybody at risk--50 million in Nigeria alone. That leaves the International Coordinating Group (ICG) on Vaccine Provision for Epidemic Meningitis Control, a collaborative effort of WHO, MSF, UNICEF, and the International Federation of Red Cross and Red Crescent Societies, with the unenviable task of deciding which countries and states get how much.

Caused by the bacterium Neisseria meningitidis, meningitis is an infection of the thin membranes that line the brain and spinal cord. It is a frequent scourge of the countries of the African meningitis belt, which stretches from Ethiopia to Senegal. Almost every year, waves of meningococcal meningitis arrive with the harmattan, the hot, dry wind that signals the start of the dry season in December or January, and then dissipate with the first rains, usually in May. Left untreated, meningitis kills roughly half of its victims; even with prompt treatment, up to 10% die and up to 25% are left with deafness or other disabilities.

Although epidemic meningitis comes like clockwork to Africa--for reasons that remain largely a mystery--no one can predict exactly where it will hit or how severe the outbreak will be. Nigeria and Niger have been largely spared in recent years--the disease tends to "jump around," says LaForce. Every 10 years or so, a perfect storm of environmental and population conditions combine to spawn massive outbreaks across the entire belt, like the one in 1996-97 that killed more than 25,000 in 10 countries and sickened 250,000.

Because of this unpredictable epidemiology and the shortage and limited efficacy of the existing polysaccharide vaccine--immunity lasts just 3 years--WHO recommends that it be used in mass campaigns to control epidemics, not to prevent them. ICG releases the vaccine, effective against the main epidemic strain, serogroup A, only when a country can demonstrate that an epidemic has begun and the strain has been confirmed by lab analysis--a tall order in some remote areas. (This year, as usual, the predominant strain is serogroup A, but some W135 is circulating.)

WHO estimates that if a country can launch a mass vaccination campaign within 3 to 4 weeks of the epidemic's onset, roughly 70% of cases can be prevented. But the application request can be onerous, concedes epidemiologist William Perea, who coordinates WHO's epidemic readiness and interventions in Geneva, and often the vaccine arrives too late to do much good. In Nigeria, the first batch of 1.5 million doses of vaccine arrived in early March, in week 8 of the season; several million more doses are on the way. By week 5, six local government areas had already passed the epidemic threshold, and that number skyrocketed to 28 in week 8 and has kept climbing. Says Perea, "It is too soon to say whether it is having an effect on the epidemic curve," which usually peaks 14 or 15 weeks into the season. Niger was better prepared this year, as it had 2 million doses of vaccine prepositioned and also applied earlier to the ICG.

Similarly, antibiotics can save lives, and overall supplies seem sufficient in both countries. But "they are not close enough to the patient," says Stéphane Hugonnet, a WHO epidemiologist working with the hardest hit states in northern Nigeria. "The end result is either the drug is given quite late or another drug is given. Overall, case management is quite poor."

Right now the biggest struggle is to get the vaccine where it can do the most good, say Perea and Hugonnet: to densely populated areas where the epidemic is still on the rise or is expected to hit hard. If the epidemic is already waning, "it's a waste of resources," says Perea. "Unfortunately, countries don't always follow our epidemiologic recommendations." Nigeria, for instance, has been distributing the vaccine evenly among all states, "even if it is not needed." It's a tough call, he says. "Can you imagine being a minister of health of one of the states trying to explain that the curve is going down and they don't need vaccination?"

The rising toll is especially frustrating to LaForce of MVP, a partnership of the nonprofit PATH and WHO, because their inexpensive long-lasting conjugate vaccine designed to prevent such epidemics is almost ready (Science, 27 June 2008, p. 1710). Plans are being readied to vaccinate 5 million people, roughly half the vulnerable population, in Burkina Faso later this year; by then sufficient vaccine should be ready for a phased 6-year roll out across the rest of the meningitis belt. Citing the financial crisis, last year the GAVI Alliance, which was expected to fund the entire $370 million introduction package, provided just $29 million for 2009-10, as well as $55 million for the emergency stockpile. GAVI's decision was "very surprising" and "very, very frustrating," says Perea. "It is not clear what will happen in 2 years."

Meanwhile, Kader Konde, who directs WHO's Multi-Disease Surveillance Center in Burkina Faso, worries that there will not be enough of the emergency vaccine to get through this season. By week 11, ICG's emergency stockpile was down to 10 million doses. (Manufacturers held another 6 million.) Perea thinks they will squeak by. But if the stockpile drops too low and the epidemic doesn't wane, he says, "we are ready to consider the use of fractional doses. We are developing contingency plans."