Vax Populi

Craig OuthierApril 1, 2015
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Vax Populi
Peer pressure, fear and inconvenience have bolstered Arizona’s vaccination rates in recent months.
Is legislative action still necessary?

For many years, Dr. Larissa Romero respectfully reserved judgment, and held her tongue, when friends and neighbors opined on the topic of vaccination refusal. After all, her prosperous Central Phoenix neighborhood is precisely the kind of place that tends to breed anti-vax sentiment – i.e. younger, college-educated parents, higher tax brackets, smaller families – so why stir up bad feelings?

But that was before the Disneyland measles outbreak in January, and an estimated 1,000 exposures to the virus in Arizona alone. Romero, the mother of a 2-year-old girl and an infant son, wasn’t prepared to take chances. Having dispatched an Evite for her daughter’s birthday party in early February, Romero – an obstetrician based in Phoenix – amended the invitation, asking families with unvaccinated children not to attend.

“It was to protect [my son], who was too young to get his MMR shot,” Romero explains, using the common acronym for the all-in-one vaccination that protects people against measles, mumps and rubella. “We were trying to limit our exposure to a harmful virus that could be life-threatening for an infant. We do care about people’s feelings, but when it comes to your kids’ health, like my husband said, you don’t really give a [crap].”

There was a pack-discipline side to Romero’s reasoning, too. “I think the [measles] outbreak was a wake-up call,” she says. “It brought back the larger voice of the pro-vaccine movement, if you will, which had kind of been drowned out for a long time.”

As one of 17 states that offer a so-called “personal” or “philosophical” vaccine exemption for schoolchildren in addition to near-universal medical and religious exemptions (see sidebar on page 70), Arizona is particularly susceptible to outbreak, which is why pro-vaccination parents like Romero have started to speak out, some resorting to public admonishment and peer pressure, and some urging schools to enforce quarantines of non-vaccinated children. The combined weight of the medical community and state regulatory agencies are behind them. Charged with implementing and monitoring the state’s vaccination program, the Arizona Department of Health Services recently bulked up the application process to make it more time-consuming for parents to attain exemptions – reams of paperwork as opposed to a simple consent. Call it tactical red tape.

Peer pressure and inconvenience: Those are the tools the pro-vaccination majority have at their disposal, but many are also railing for the Arizona state legislature to repeal the state’s “personal” vaccine exemption – a prospect the comparatively small but vociferous anti-vax camp decries as government overreach and an assault on their civil liberties. And since this is Arizona, where hands-off libertarianism is a deeply-entrenched political tradition, their complaints may not fall on deaf ears.

The motivations behind vaccination refusal are sometimes ambiguous, but the end result is not. When a population falls below the “herd immunity” threshold for a given disease – in the case of measles, generally estimated at 94 percent – an outbreak will almost inevitably follow. More than 140,000 people a year still die from the disease worldwide, according to the World Health Organization. Outbreaks are still common in developing countries, and the virus frequently catches a ride across the border, and through airport terminals.

According to Will Humble, former director of the Arizona Department of Health Services, the “troubling trend” of falling vaccination rates started in 2004 – sparked by an influential but since-discredited paper published in 1998 by British researcher Andrew Wakefield that drew a link between autism and MMR vaccines; the British General Medical Council later found Wakefield guilty of three dozen counts of fraud relating to the research and “the abuse of developmentally challenged children.” The trend accelerated when actress Jenny McCarthy publicly attributed her son’s autism to vaccines in 2008.

Vaccination refusal played a pivotal role in the recent Disneyland outbreak. During the 2013-2014 school year, the percentage of kindergarten students granted vaccination exemptions in Arizona was 6.1 percent, up from 4.7 in 2010-2011.

Ultimately, seven people in Arizona contracted measles during the outbreak. Hardly an epidemic, but Humble – who led the ADHS for six years before resigning in early March – says the state got lucky. The outbreak could have been much worse if not for a lucky twist of geography.

To wit: Humble notes that vaccine exemption rates are hardly uniform across Arizona. In fact, they follow a strong latitudinal bias: “As you go south to north, vaccination rates get worse. So Tucson and Nogales, they have the highest vaccination rates. Then you get into Coconino County and the rates get really low. Yavapai County has the lowest vaccination rate in the state.”

Fortunately, the family that unwittingly brought measles to Arizona – ultimately identified as the Yslas-Roach family of Kearny, where five of the state’s seven measles infections took place – did not live in one of Arizona’s anti-vax hot zones. “We’re really lucky that those initial cases were in Kearny,” Humble says of the Pinal County town. “Their rate is 99 percent. If you told me people were coming back from Disneyland with measles and where do you want to put them? I’d say Kearny. I wouldn’t say Sedona or Chino Valley.”

And why are vaccination rates in Arizona so Balkanized? Humble – who commissioned the University of Arizona to study Arizona vaccination trends five years ago –  says researchers discovered a “really distinct pattern in which people opposed to vaccinations tend to be upper-income parents with college degrees and upper-end ZIP codes,” consistent with affluent pockets of anti-vaxxers in California’s Silicon Valley and Washington’s Redmond area, where vaccination rates among kindergarteners sometimes dip into the 60 percent range.

Humble says his agency learned to get strategic after commissioning the U of A study. As a mechanism of the state, the ADHS administers Title 15, the provision that provides for Arizona’s personal exemption. But the agency is also obliged to protect public health and properly educate people about their healthcare choices.

“As administers, we tried to tackle the vaccination issue not through lawmaking but in the way we go about exemptions,” he says. “The [study] allowed us to build an evidence base, and an action plan in which we implemented our message to parents. For example, the old exemption form was simple and easy to sign. In the new one, we go through each vaccine, make sure the parent reads a statement on measles, understands it, and signs it.”

The point was not to inconvenience anti-vaxxers, but to weed out the ambivalent. “The idea is to have a moment when a questioning parent has the opportunity to know more before they sign,” Humble says. “There are two categories of [vaccine-denying] parents, only one of which is our target; there’s the questioning parent who might have read something or heard something at a party from an anti-vaccination person, and there’s the true, hardcore anti-vaccine activist. They’re the 2 percenter, we’ll never change their mind… but the other four percent are the low-hanging fruit.”

Dr. Jack Wolfson is demonstrably not the low-hanger to which Humble refers. A one-time mainstream cardiologist who experienced a born-again holistic-medicine reboot a decade ago, Wolfson enjoyed notoriety as the de facto national spokesperson of the anti-vax movement during the January outbreak. Speaking to the Washington Post, he derided “bad mother[s]” for not asking “about the chemicals” in vaccines. Later, he characterized the measles as “benign” and told the Arizona Republic “we should be getting measles, mumps, rubella, chicken pox… these are the rights of our children to get it.”

In lieu of vaccines and antibiotics, Wolfson – a peer-selected PHOENIX magazine Top Doc in 2011 – recommends “Paleo nutrition” and ample sleep and exercise. “That’s the best way to protect,” he told the Republic.

Though savaged by fellow physicians and public health experts, Wolfson’s apocalyptic view of vaccines struck a chord with people in the anti-vax community. Following appearances on CNN and local TV news, Wolfson amassed more than 30,000 Facebook likes – presumably from snakebitten anti-vaxxers delighted to see one of their own make the media rounds.

Certainly, Wolfson has taken his licks, too. He was called “the latest driver of the anti-vaccine clown car” by TIME magazine, and is the subject of a complaint currently being investigated by the Arizona Osteopathic Medical Board stemming from his anti-vax crusade. But he’s unbowed.

“Well, the reality is, as a physician, as a parent, as a human being, I have the right to question anything,” he says. “And in the U.S.A., it’s our constitutional right to speak what we want. If we didn’t question authority, we’d be carrying a British flag right now. So we have to to able to question. If we don’t, [authority] will bully right over us.”

A newfangled granola conservative who resides in that unlikely intersection of anti-authoritarian paranoia and chemical-free “natural” living – for more on this, visit, where you can pick up both organic hand soap and a birther “news” item in one fell swoop – Wolfson views state-mandated vaccinations as an unfair intrusion on his rights as a parent. Offered the example of Annie Jacks, the 3-year-old leukemia patient who was exposed to the measles virus at Phoenix Children’s Hospital by a member of the Yslas-Roach family, and whose medical condition prevents her from being immunized herself, Wolfson says this: “What you’re asking me to do, and asking parents to do, is asking me to put my child at risk of a vaccine injury to possibly prevent a child somewhere else who is immunocompromised from getting one of these infections. And I don’t think that’s a fair thing to do to parents.”

Citing “thousands and thousands of reports of adverse vaccine reactions,” Wolfson sees mandatory vaccine scheduling, which now includes 72 vaccines over a child’s lifetime, as a slippery slope with no end. “[The government] has 200 other vaccines in the pipeline, and there will [come] a time when nobody has a say in it,” he predicts. “It will be the law of the land. And the pharmaceutical companies will have won.”

Despite criticism of his position, and the scorn of his ex-colleagues in the mainstream medical world, Wolfson says he wouldn’t walk back any of his recent comments. He adds: “When I maneuver in the natural world, and I’m friends with naturopaths, chiropractors and homeopaths… those professionals, pretty much to a person, are on board with either an anti-vaccine stance in general, or a freedom to choose.”

However, some professionals in alternative medicine have shifted their attitudes about vaccines, however modestly, in the wake of the outbreak. Scottsdale naturopath Jonathan Psenka is one of them. “I do think vaccines can save a lot of lives, and most [people] will handle them without adverse effects,” he says. “But I have a hard time giving parents who are educated [about vaccines] a hard time… An allergic reaction is always a possibility with any medication.”

Psenka thinks it’s reasonable for autism-concerned parents to “space out” vaccinations. He acknowledges that no evidence has conclusively linked autism to vaccines – or proven the efficacy of spacing out vaccinations – but “most people are concerned about some kind of cognitive deterioration after drugs are put in their bodies, so it’s a smart idea.”

Schools in Arizona reacted swiftly and decisively to the outbreak. Some public schools enacted the Title 15 override, which allows administrators to exclude non-vaccinated students from schools for two incubation periods in the event of an outbreak. Even many private and charter schools – which present historically higher rates of vax exemptions than public schools, according to Humble – assumed a defensive posture. At Natural Choice Academy, a sustainability-focused preschool in Phoenix that maintains its own organic food garden, administrators banned unvaccinated children from campus for 21 days following the last measles infection.

Coupled with social media chatter and concerns about immediate child safety, these official actions served to immediately drive vaccination rates upward in Arizona. The vaccination rate for measles, mumps and rubella jumped 30 percent in January, according to the Arizona State Immunization Information System. Pediatricians and general practitioners dispensed 12,855 MMR vaccinations in January, compared with 9,888 during the same month last year.

Humble believes the renewed ardor for vaccinations is a direct result of the outbreak. “This is not a coincidence,” he told the Arizona Republic. “I have no data to suggest that it was exactly from the outbreak, but I can’t imagine it was something else. We certainly have not had a 30 percent increase in births.”

Whether the spike in vaccinations represents a sea change in Arizona’s vax-consciousness – which is to say, a permanent upward shift in vaccination rates– Humble is less certain. He believes it more likely the outbreak simply motivated like-minded parents to bring their children up to date on their vaccination schedules. Did it also reprogram scores of anti-vaxxers? Unlikely.

Which invites the original question: Does Arizona need a new vaccination law? Arizona State Representative Juan Jose Mendez thinks so – a position he presciently embraced weeks before the January outbreak. In December, Mendez authored HB 2466, which would oblige public schools to post student body immunization rates, along with a notice alerting the public whether each school employs a nurse. Think of it as school-shaming.

“But for me, it’s more,” Mendez says. “In terms of public health and well-being, I’m ultimately trying to create an environment where we can get rid of the vaccination waiver and how they’re misused. These people are putting everybody at risk when they don’t vaccinate their children. People think it’s fringe, but it’s huge, and we need to get the info out.”

Mendez, a Democrat whose District 26 encompasses parts of north Tempe, northwest Mesa, south Phoenix and the Salt River Pima Maricopa Indian Community, admits the bill is a long shot. At press time, HB 2466 – lacking a bipartisan sponsor – had missed the deadline to entertain House bills in committee, leaving Mendez scrambling to reshape it as an amendment to a healthier bill.  

Most likely, HB 2466 will have to wait until the next legislative session. If, by then, a Republican lawmaker were to seek to steal Mendez’s thunder and recapitulate the bill – or author a bill to eliminate the personal vaccine exemption altogether – the lawmaker would be fully behind it. “I would be OK with that,” Mendez says. “I believe much more in the bill than getting credit. I’d turn it over to them, then work on something else. But we need to do something. Last [month], [the virus] went up and down the coast from Ontario to Mexico.

“People are afraid to broach the issue,” he continues. “They interpret Arizona as a place of independent free choices and they don’t want to encumber that. And that’s fine, but we need to transcend individualistic attitudes.”

In Mendez’s view of the social contract, your right to swing your arm ends where his right not to get hit in the nose begins. Ironically, hardcore anti-vaxxers like Wolfson probably feel the same way. The question: Is the swinging arm an unvaccinated child, or a syringe?

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