Vaccination rates among Orange County kindergartners continue to drop even as cases of two communicable diseases in the county rose over the last year.
The percentage of fully vaccinated kindergartners in some Orange County schools has dipped under 30 percent, according to data from the California Department of Public Health. Meanwhile, the average rate of all schools in the county has fallen closer to a level that could leave the overall population more vulnerable to outbreaks of illnesses.
“For the fall of 2013, we experienced another decrease in kindergarten vaccine coverage,” said Dr. David Nunez, medical director of the Family Health Division, the Orange County Health Care Agency. “There are lower rates of coverage and higher rates of exemptions.”
Nunez and other health officials are concerned that some once-common childhood diseases are on the rise as a result of parents opting to delay shots, selectively vaccinate or exempt their children from vaccinations altogether.
The number of cases of pertussis, also known as whooping cough, has increased this year in California, and an outbreak of 22 measles cases in Orange County over the winter was the worst in the state.
While the countywide decrease in kindergarten immunization rates is marginal -- from 89.3 to 88.7 percent -- health officials say it’s important to avoid slipping below a safety threshold known as the “herd immunity.” Herd immunity refers to the percentage of a population that needs to be immunized in order to avoid risk to the larger population.
Many of the illnesses for which children receive vaccines require a herd immunity of 83 percent, which is well above the rate in some Orange County schools.
Schools with exceptionally low rates of immunized kindergartners in 2013 include: Anneliese School, a private elementary school in Laguna Beach, 18 percent; Community Roots Academy in Aliso Viejo, a public charter school, 27 percent; Journey School, another public charter school in Aliso Viejo, 38 percent.
The state Department of Health data show that 60 percent of kindergarten parents at Journey School exempted their children from some or all immunizations through use of a Personal Belief Exemption.
Journey School administrators don’t take a position on whether parents should exempt or immunize, according to executive director Shaheer Faltas.
“The school meets our obligation as a public school. We’re collecting forms, making sure they are filled out properly… We obviously pull that data together and submit it to health department,” Faltas said.
Many Journey parents are not forgoing immunization entirely but rather delaying some of the shots or opting out of a small number of them, Faltas added.
New Law Leads to More Shots
This fall, schools are implementing a new state law that requires parents who wish to exempt their children from immunization to go beyond signing a personal belief exemption form. They now must also meet with a health professional for a discussion on the benefits of immunization and risks of avoiding vaccination.
The goal of the new law was to nudge some of the parents who either did not have ironclad beliefs against vaccination or had exempted their children because of busy schedules that made it hard to get to a doctor.
“This makes it harder to push it [immunization] aside. Now parents have to take extra steps. If they sign it, at least they’ve been informed and can make their own decision,” said Laurie Marrujo of the Irvine Unified School District’s Health Services Department.
Similar laws have made an impact elsewhere. For example, a 2011 Washington State law making it harder to opt out of immunization has led to in a drop in exemptions.
But even before the new California law making exemption harder, health officials in Orange County have been reaching out to vaccine-averse parents.
In the Capistrano Unified School District, lead district nurse Andrea Karolys has met with parents in high-exemption areas to discuss the benefits of immunization.
“I’ve had the chance to talk to a lot of parents individually,” Karolys said. “Because of the outbreak of pertussis they are much more open to listening to what we have to say.”
One thing many parents don’t know is that vaccines are not foolproof, and even vaccinated individuals can be vulnerable to disease. For this reason, Karolys and other experts believe it’s important to keep immunization rates high.
“When vaccination rates go down, particularly with pertussis, the amount of cases go up. That’s the herd immunity,” she said. “If everybody has the vaccine, you see a diminished amount of cases.”
Karolys and other health officials said they won’t know if the new exemption process prompts fewer exemptions until data are collected next year.
The new exemption allows parents to be briefed by a number of professionals, including doctor, nurse practitioner, physician assistant, school nurse or naturopath (working under the supervision of a doctor). However, nothing would stop a parent from getting a briefing from a health professional who doesn’t believe in meeting immunization requirements.
Some parents have contacted licensed naturopathic doctor Jean-Luc Giuliano of Laguna Beach about the new exemption, but lacking a supervisory agreement with a doctor, he is not eligible to sign it. He said his patients have a variety of stances on vaccines.
“For record, I’m not anti-vaccine,” Giuliano said. “I think certain vaccines are important and certain are not as important.”
Health officials, however, recommend against delays and selective vaccination.
In Orange County, private school rates of kindergarten immunization are more likely to be lower than their public counterparts. Public schools in Santa Ana, Garden Grove and Anaheim school districts are in the 90s or even 100. The school immunization rates follow a geographic pattern identified in recent years by health officials.
“In districts in south and coastal communities, there are lower rates of coverage and higher rates of personal belief exemptions,” Nunez said, adding that such conditions put people in those areas at greater risk of outbreak.
This winter’s measles outbreak in Orange County was the largest “in many years,” and could have been a lot worse, Nunez said. “There was the potential for the outbreak to spread quite rapidly and with more adverse outcomes…. We got very lucky.”
Since the statewide outbreak of whooping cough 2010 that left 10 infants dead, California seventh-graders were required to get a booster of the vaccine. The next year, reported incidents decreased, though they are high again this year.
“California is currently experiencing a pertussis epidemic,” according to a report from the California Department of Public Health. Orange County is ranked fourth in the state for whooping cough cases from 2010-14, with 499 known cases.
Changing Rationales for Resisting
The reason for which parents opt not to vaccinate, delay vaccination or selectively vaccinate may be changing.
The county health department conducted focus groups in 2012 in communities where exemptions are common; they learned that when asked, parents say they don’t believe vaccination causes autism, long linked by some parents of autistic children to immunization.
“The themes we heard were predominantly that these individuals do not consider themselves anti-vaccine. They didn’t want a standardized schedule. Most of them denied seeing an autism link,” Nunez said.
“The primary reason why many were choosing not to vaccinate is they perceived a low risk of illness from vaccine-preventable disease. This is important because of the recent measles outbreak in Orange County and the statewide outbreak of pertussis."
One physician who is in a unique position to hear what parents are really thinking about the vaccine-autism connection is Dr. Joseph Donnelly, director of the Center for Autism and Neurodevelopmental Disorders of Southern California, based in Santa Ana.
Parents of patients he treats regularly confide their fears of vaccinating younger siblings of children with autism. They are expressing this concern “more and more,” he said.
“I tell people there is no scientific evidence that immunization causes autism,” Donnelly said. “Most parents of patients I treat haven’t seen polio, diphtheria and tetanus. They don’t realize these were deadly diseases and they’re coming back.”
But he added that a recent medical research suggests that vaccine resisters don’t respond well to antagonistic approaches.
“The literature shows the more are aggressive about trying to convince people … the more they resist.”
Amy DePaul is a Voice of OC contributing writer and lecturer in the University of California, Irvine Literary Journalism program. You can reach her directly at firstname.lastname@example.org