Under new law, school nurses aim to stop rise in vaccination opt-outs

April 6, 2014

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In her 33 years as a school nurse, Robyn Ettl has listened, sometimes quietly, sometimes not, to parents in rural Nevada County explain why their children don’t need vaccinations against contagious and potentially fatal diseases, including polio, diphtheria, measles and pertussis.

Now, with nearly a half a million 5-year-olds and soon-to-be-5-year-olds registering for kindergarten in the fall, school nurses like Ettl are more invested than ever in a delicate task: trying to change the minds of parents intent on opting out of school-entrance immunizations.

Under a state law that took effect Jan. 1, parents are required to consult with a health practitioner – doctor, naturopath or credentialed school nurse – before they’re allowed to obtain a personal-belief exemption from their child’s required immunizations. Prior to the legal change, parents could receive an exemption by stopping by the school secretary’s desk and signing the back of their child’s blue immunization card.

Nowhere is the impact of the law, Assembly Bill 2109, more anticipated than in Nevada County, a former gold mining haven in the Sierra foothills where 20 percent of kindergartners have been exempted from the vaccination law – the highest opt-out rate in the state for many years and now a close second to sparsely populated Trinity County.

That exemption rate is driven by huge percentages of vaccination opt-outs at public charter schools in the county, led by Yuba River Charter School in Nevada City. At this Waldorf school, which emphasizes learning through art and movement and eschews technology, 81 percent of kindergartners in 2013-14 received personal-belief exemptions.

Caleb Buckley, director of the Yuba River Charter School, said many students’ parents steer clear of Western medicine and, by association, its core tenet that immunizations save lives. “I don’t know too many that go to see the local pediatrician group, unless they really have to,” Buckley said.

As Trevor Michael, president of the Nevada County Board of Education, explained, “Our county is rural. People live alternative lifestyles and have alternative beliefs.”

At Grass Valley Unified, Ettl hears parents state that it is better for a child’s immune system to get the disease than the vaccination, and that polio is passé. And even though a research paper alleging a link between vaccinations and autism was retracted, deemed a fraud by the British Medical Journal and its author stripped of his medical license, they say they’re still not sure that a vaccination won’t give their child autism.

“I don’t argue with them,” Ettl said. In the past, when she has refuted their claims, “They get mad and head right to Holly,” she said, referring to Holly Hermansen, superintendent of the Nevada County Office of Education.

At some charter schools in the county, a philosophical opposition to vaccinations has become a defining feature of the culture, said Sharyn Turner, coordinator of school health services at the Nevada County Office of Education.

“All of a sudden it becomes socially unacceptable to be one of the few parents immunizing your child,” Turner said.

Public charter schools lead the state in enrolling the highest percentage of kindergartners with personal-belief exemptions – 10.1 percent in 2013-14, according to new data from the California Department of Public Health. At private schools, 5.6 percent of kindergartners received personal-belief exemptions, while 2.3 percent opted out at public schools.

Those high rates are driving an overall increase in personal belief exemptions statewide. The percentage of exempted kindergartners has more than doubled, from 1.4 percent in 2007 to 3.1 percent in 2013-14, according to the state Department of Public Health. 

And those figures don’t include children attending 12,500 small home schools, defined as enrolling five or fewer students. The California Department of Education does not collect immunization data from those schools.

If roughly 90 percent of a population is fully vaccinated, “herd immunity” helps keep at bay infectious diseases like rubella, which in the pre-vaccination era sparked an epidemic among pregnant women, causing 2,100 newborn deaths and nearly 17,000 infant cases of deafness, blindness or intellectual disability, according to the Centers for Disease Control and Prevention. For children and adults who have not been vaccinated, herd immunity protects them, too, along with newborns too young to be vaccinated, people whose immune systems have been compromised by chemotherapy or other factors, and the elderly.

With longstanding herd immunity comes fading awareness of dire infectious diseases. “There’s no fear,” said Lindsay Dunckel, executive director of First 5 Nevada County, which funds community programs for babies and young children. “These diseases that were once so frightening have disappeared.”

Now some of them are coming back, and the role of unvaccinated people in spreading disease is under scrutiny. In 159 cases of measles across the country between January 1 and August 24, 2013, 82 percent of those infected were unvaccinated and of those, 79 percent had philosophical objections to vaccinations, according to the CDC.

Robyn Ettl, Grass Valley Unified school nurse, gives a vision test to second grader Chase Littlejohn at the Grass Valley Charter School. Credit: EdSource Today/Jane Meredith Adams

So far in 2014, the California Department of Public Health has received reports of 51 cases of measles in the state, the largest number since 2000, when measles was declared eliminated in the U.S. In the decade before the introduction of a measles vaccine in 1963, the disease killed about 450 people a year in the U.S., according to the CDC.

Also increasing in California is the number of cases of pertussis, better known as whooping cough. Reported cases in 2013 hit more than 2,300, including an infant who contracted the disease at 4 weeks old and died. During a 2010 California outbreak of pertussis, in which 10 infants died and more than 9,000 cases were reported, children with personal-belief exemptions played a role in transmitting the disease, according to research published in the journal Pediatrics. Communities with high rates of personal-belief exemptions were 2.5 times more likely to also have pertussis clusters, the researchers found.

Eager to drive down exemption rates, Cindy Wilson, director of public health nursing at the Nevada County Public Health Department, interviewed six Nevada County families in 2013 who were opposed to some or all of the required childhood vaccinations. She wanted to suss out what might change their minds.

She found the parents didn’t like the ingredients in vaccines – the additives and preservatives – and that they worried the vaccinations would cause neurological problems in their children, as alleged in the debunked research by Andrew Wakefield. Some said being sick would strengthen their child’s immune system and character.

“Their bottom line was that nothing could change their minds,” Wilson said. “I was looking at what interventions are going to work and the answer was, basically, none.”

Dale Jacobson, a Nevada City chiropractor, and his wife, Diane, who has been active in Waldorf education and breastfeeding advocacy, raised their now-grown children on a diet of organic foods on their 20-acre farm. Jacobson credits his children’s good health to healthy living. At work, he advocates for preventative health measures such as pesticide-free foods, natural childbirth and breastfeeding. Vaccinations aren’t in the equation.

“Four kids, no vaccinations,” Jacobson said.

“We’re pretty much anti most vaccinations,” he said. “The reason is because there is no research, especially on the flu vaccine, that they make any difference. The whole thing is a big business scam.”

At Grass Valley Unified, Ettl met recently with a parent of an incoming kindergartner who was dead-set against immunizations. The meeting was perfunctory: The parent read the vaccination information sheet, and Ettl explained that an unvaccinated child may not attend school for 21 days if an outbreak of whooping cough or measles occurs. Then Ettl and the parent signed the new personal belief exemption form.

Ettl’s hopes, and the hopes of public health officials, rest largely with parents whose opposition to vaccination is not entirely locked in. “‘I’ll ask, ‘Are you against every vaccine or some of them?’” she said.

One mother of a kindergartner recently told Ettl that although her child had received one vaccination, she was now inclined to opt out of the rest. Ettl talked to her about the risk of tetanus, a bacterial infection in soil and dirt that can be contracted through wounds. “We live in a rural place and tetanus is a serious disease,” Ettl recalled telling her. “I said, ‘Why don’t you start with one?'”

The mother left without a personal belief exemption in hand, saying she would think about it.

That’s just what the law is intended to do.

“Some parents are never going to change their mind,” said Catherine Flores Martin, director of the California Immunization Coalition, “but there is a larger number that want to have their vaccine concerns acknowledged and answered.”

Jane Meredith Adams covers student health. Contact her or follow her @JaneAdams.

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