Mon April 7, 2014
How Public Health Advocates Are Trying To Reach Nonvaccinators
Originally published on Tue April 8, 2014 10:54 am
Whooping cough made a comeback in California last year, which researchers have linked to vaccine refusals. And with new measles outbreaks in Southern California, New York and British Columbia, the debate over vaccination is also spreading.
Forty-eight states allow parents to sign a vaccine exemption form — only West Virginia and Mississippi don't. California now requires a doctor's signature on the school form, but parents are still able to find doctors who will sign.
It can be a touchy subject, and even some physicians are unsure of how to approach parents who don't want to vaccinate their children. Still, health professionals and pro-vaccine parents are trying new ways to share their message.
Matt Willis, a public health officer for Marin County, says if pediatricians know why parents aren't vaccinating, they can come up with responses to try to change parents' minds.
He helped design a survey to figure out what parents are worried about. They canvassed parents in Marin County, just north of San Francisco, the site of the whooping cough cases.
"Some of the themes that came out of the survey [were] ... preference for natural immunity over immunity conferred by vaccines; children perceived as low risk for some vaccine-preventable diseases; and lack of trust for the health care system or pharmaceutical industry," he says.
Physicians use that kind of information in different ways. Michael Yamaguchi, attending a presentation by Willis, says he gives parents articles from scientific journals.
"I hand them the article and I say, 'Look, if you're going to disbelieve this, you have to say these eight authors [and] the entire editorial board are all in somehow collusion to create some sort of data that's untrue," he says.
Other doctors say changing minds is not easy.
"I think there are those parents that come in with their mind made up, and there's nothing you can say to sway them," says Lisa Leavitt.
A study at Dartmouth College supports that theory. Political scientists surveyed nearly 1,800 parents about the vaccine for measles, mumps and rubella (MMR). What they found was that the more skeptical parents are about vaccines, the less likely they are to listen to public service ads or to their pediatricians.
Marin County pediatrician Nelson Branco hasn't given up on convincing nonvaccinators. He gave parents an ultimatum in 2012: Vaccinate your toddler against measles, mumps and rubella by the time the kid is 2 years old, or find a new pediatrician.
And for some people, it worked.
"There were many families who were on the fence about vaccines who chose to get the MMR vaccine and stayed in our practice," he says. "There were very few families that left our practice."
Fewer than 20 families left, and about 150 families chose to vaccinate.
A Mom's Plea
Mother Sonia Green has also taken up the cause of convincing parents to vaccinate. Her three boys have an immune disorder called XLA. Ten-year-old Holden and his two brothers are basically "walking around with half their immune system missing," Green says.
Because of their condition, the boys can't be vaccinated. If they were, Green says, the best-case scenario would be that the vaccination would do nothing. The other scenario is that they wouldn't develop the immune response from the vaccine and would instead become very sick.
If enough people in a community are vaccinated, then even those who didn't get vaccines are likely to be protected. If other children aren't vaccinated, kids like the Green brothers are at greater risk.
Last spring, Holden was exposed to something that for another kid might not have been a problem, Green says. But for Holden, it caused a skin infection that required him to be in the hospital for about a week.
Green wrote a blog post explaining why vaccinations are important to families like hers. She says she has talked to other parents about the issue and that some decided to vaccinate after hearing her story.
Part of what keeps Holden and his brothers healthy, Green says, is that she lives in a community where most people are vaccinated. But she says she's ready to pull her kids from a school or situation where she knows most people around her kids are not vaccinated.
"To me, they're gambling with my kids' lives when they don't vaccinate their kids," she says.
KELLY MCEVERS, HOST:
It's ALL THINGS CONSIDERED from NPR West. Arun Rath is away. I'm Kelly McEvers.
So on the road here...
I recently spent a few days in Marin County, just north of San Francisco, consistently ranked one of the richest counties in the U.S.
This is a beautiful mountain area. There are signs all over the town that talk about composting and recycling and how to help your community.
Not far from here is a private preschool with wooden toys and discovery gardens. I talked to people from the school, but I didn't go there. The story officials had to tell was so controversial, they said, they didn't want to talk about it on tape.
Last year, two children whose parents had chosen not to vaccinate them got whopping cough. Eventually, school officials sent the kids home. Whooping cough, a disease we thought we were rid of decades ago when a vaccination for it became mandatory for children. In 2010, 10 babies died of whooping cough in Marin County. More than 9,000 people caught the disease.
In some school districts in Marin County, around half of the parents choose not to vaccinate. Public health records show the number of parents opting out of vaccines has quadrupled since the late '90s.
(SOUNDBITE OF VIDEO)
UNIDENTIFIED GROUP: (Singing) We will sing and bless this place...
MCEVERS: This is a video that locals showed me from a playground dedication ceremony at the preschool with the whooping cough cases. We're not saying the name of the school because of the controversy. After the cases, some parents and school officials checked to see if the school could close its doors to children who haven't been vaccinated. What they found was a state legal system that's unclear on the subject. They didn't want to get sued, so they did nothing.
Now, the non-vaccinated kids are back at school, and officials are worried about offending the parents who don't vaccinate. With new measles outbreaks here in Southern California and in New York and British Columbia, it's our cover story today: Can we talk about vaccines?
(SOUNDBITE OF VIDEO)
UNIDENTIFIED GROUP: (Singing) We will celebrate God's grace as we sing and bless this place.
MCEVERS: Matt Willis is a public health officer for Marin County.
DR. MATT WILLIS: Welcome.
UNIDENTIFIED MAN: Hi.
MCEVERS: A few days ago, he sat down at a table with a PowerPoint presentation for a handful of local pediatricians.
WILLIS: So why are we doing this? Well, Marin County has some of the highest personal belief exemption rates in the state of California. You know, that's basically people opting out of some or all of required school vaccines.
MCEVERS: Personal belief exemptions, basically a form you fill out so you don't have to vaccinate your kids. Forty-eight states in the U.S. allow for some kind of exemption, except West Virginia and Mississippi. California now requires a doctor's signature on the form. But in Marin, parents are still able to find doctors who will sign the form. So Willis decided to do a survey. He and his colleagues asked moms and dads why they don't vaccinate their kids.
WILLIS: So these are some of the themes that came out of the survey. The preference for natural immunity over immunity conferred by vaccines, children perceived as low risk for some vaccine preventable diseases and lack of trust of the health care system and pharmaceutical industry.
MCEVERS: Willis thinks if pediatricians know why parents aren't vaccinating, then doctors can come up with responses to try to change their minds.
WILLIS: One reason parents cited for request of personal belief exemptions is that vaccines may contain unsafe toxins. Has that come up for you all? Yeah. How do you address that?
MCEVERS: Some doctors say they tried the soft approach. Michael Yamaguchi says he gives parents articles from scientific journals.
DR. MICHAEL YAMAGUCHI: I hand the article and I go, look, if you're going to kind of disbelieve this, you have to be saying these eight authors, the entire editorial board, are all in somehow collusion to create some sort of data that's untrue.
MCEVERS: Other doctors like Peter Simon and Lisa Leavitt say in some cases, showing parents the evidence is the last thing you want to do.
DR. PETER SIMON: It's hard to really come in thinking I'm going to change their position completely completely.
DR. LISA LEAVITT: Yeah, I agree. I think that there are those parents who come in with their mind made up and there is nothing that you can say that will sway them.
MCEVERS: It's a theory that was recently born out by a study at Dartmouth. Political scientists surveyed nearly 1,800 parents about the vaccine for measles, mumps and rubella. Turns out the more skeptical parents are about vaccines, the less likely they are to listen to public service ads or to their pediatricians.
So if traditional approaches don't work, how do you convince people to vaccinate? One pediatrician in Marin County, Nelson Branco, decided to do more than just talk.
DR. NELSON BRANCO: In 2012, we were very concerned about measles.
MCEVERS: The London Olympics were coming up.
BRANCO: And the European Cup in Eastern Europe...
MCEVERS: Lots of people would be traveling, picking up germs...
BRANCO: So we decided that we were going to choose one vaccine, the MMR vaccine, and that would be our line in the sand.
MCEVERS: In other words, Branco gave his patients an ultimatum: Vaccinate your toddler against measles, mumps and rubella by the time the kid is 2 or find a new pediatrician. And for some people, it worked.
BRANCO: There were many families that were on the fence about vaccines who chose to get the MMR vaccine and stayed in our practice. There were very few families that left our practice.
MCEVERS: Fewer than 20 families left, about 150 families chose to vaccinate. Branco says what people don't understand is if you don't vaccinate your child, your child could die from some of these diseases. But if you and your children are already vaccinated, why should you care?
MCEVERS: Well, first of all, trying to stop an outbreak is expensive. A 2008 measles outbreak in San Diego cost an estimated $10,000 per patient to contain, according to local public health officials.
MCEVERS: Seth Mnookin wrote a book on this stuff called "The Panic Virus." We got in touch with him for an interview. He says he asked one California epidemiologist which communities are most affected by these expensive outbreaks.
SETH MNOOKIN: And he said, sure, we just take out a map and put a pushpin everywhere there's a Whole Foods and draw a circle around that area. He was speaking slightly in jest, but what he was referring to is the fact that you do see a number of well-educated politically liberal people who self identify as being environmentally conscious like Marin County in California, like Boulder, Colorado. But you also see some people with a very libertarian bent coming at this from a different angle.
MCEVERS: Mnookin says one reason these communities aren't vaccinating is because of a sense of exceptionalism, a sense that it can't happen here. But it can happen. We should all care about non-vaccinators, Mnookin says. And here's why. It's all about herd immunity. Put simply, the idea that enough people in the community have to be vaccinated to protect those for whom vaccines might not work.
In many communities like Marin County, we no longer have herd immunity to stuff like measles. That's why we're seeing the recent outbreaks. For some families, this is dangerous. Like Sonia and Holden Green, who live outside Chicago. They went to a studio to tell us their story.
HOLDEN GREEN: Hi.
MCEVERS: Is this the first time you've ever been in a radio studio?
MCEVERS: How does it feel?
GREEN: It's fun.
MCEVERS: Holden is in fifth grade. He goes to school, plays soccer, but Holden and two of his brothers have an immune disorder called XLA. Sonia recently blogged about it.
SONIA GREEN: Basically, Holden and two of his brothers are walking around with half their immune system missing. And so Holden was exposed to something last spring, which for another kid might not have been so bad, but for Holden, it actually caused a pseudomonas infection in his skin, which required him to be in the hospital. And those are the things that we worry about.
MCEVERS: How long were you in the hospital, Holden?
GREEN: For about a week.
MCEVERS: Yeah. How'd it feel?
GREEN: It was a little bit scary. And also, they had to put, like, three IVs in every day. So they had just one place that they put it in. But they would put one in at, like, 11 in the morning, about, like, 3, and then one at, like, 1 a.m.
MCEVERS: Yeah. Sonia, can your boys, can they be vaccinated?
GREEN: They can't. Or rather they can. Best-case scenario it would do no good. But the worst-case scenario is that they simply wouldn't mount the immune response that you have to to the vaccine and that it would actually make them sick.
MCEVERS: So then you have to rely on other parents to vaccinate their kids.
MCEVERS: Do you talk to parents about this?
GREEN: I do a lot, to anybody who'll listen. Yes. Yes.
MCEVERS: Where? How?
GREEN: So if people are having a conversation about medical issues or, you know, sometimes even if they're not, I'll just mention, hey, my kids have this. And when people say, you know, oh, but your boys look so healthy, you'd never know if there was anything wrong with them, I tell them very honestly that part of what keeps them healthy is the medicine they take. But a big part of it is the fact that we live in a community where most people are vaccinated.
MCEVERS: So has that happened? You personally have convinced people to vaccinate their kids after telling them your story?
GREEN: Yes. There have been a couple of families, and it wasn't an instant reaction. It wasn't, OK. Well, now, I'm convinced. With one family that I talked to in person, I got an email from them a little bit later saying, you know, we were on the fence. We thought about what you said, and we've decided to vaccinate, which was fantastic.
Another family emailed me after reading my blog post, and they're a family that we know. And they said, you know, I didn't know this about your family, but I was hesitant to vaccinate. And now that I know why it's important to people in my community, I'm going to choose to vaccinate. So that was - it was great.
MCEVERS: Anybody you talk to who hardened their position even further?
GREEN: No one has told me that to my face. But certainly in Facebook exchanges, email exchanges, responses to blog posts, I've gotten into some discussions with people who do become more entrenched. When I try to make it personal about my kids, I can see how they flip it. And they say, well, to me, it's personal about my kids. But I think part of it is they just become more entrenched in their position because they kind of feel like they're coming under attack. And I understand that.
MCEVERS: Yeah. I mean, do you feel like this is going to have to get to a point where it's like, you know, people drawing the line in the sand saying like, look, this preschool, this play date, this playground, this classroom, you know, everybody here is vaccinated?
GREEN: Absolutely. And I, you know, I don't know if it needs to come through legislation or if it just needs to come through more public pressure. Certainly as a parent, I can say that, you know, I'm ready to pull my kids from a situation where if I know that most people around them aren't vaccinated, they're not going to that party. Or if it were a school, they're not attending that school. To me, it's - they're gambling with my kids' lives when they don't vaccinate their kids.
MCEVERS: Well, Sonia Green and Holden Green, thank you guys so much.
GREEN: Of course.
MCEVERS: Thanks, Holden.
GREEN: You're welcome.
MCEVERS: Take care.
GREEN: You too.
MCEVERS: This is NPR News Transcript provided by NPR, Copyright NPR.
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