This 2006 photograph showed a nurse in the process of administering an intramuscular vaccination to an adolescent girl whose sister, mother, and grandmother watched from the background.
This 2006 photograph showed a nurse in the process of administering an intramuscular vaccination to an adolescent girl whose sister, mother, and grandmother watched from the background. CDC/ Judy Schmidt

By Sarah Ovaska-Few

Some pediatric practices around the state are sending a strong message to parents and guardians hesitant to vaccinate – immunize or find another doctor.

That’s the tactic that Scott St. Clair and his colleagues at Boone’s Blue Ridge Pediatric & Adolescent Medicine took in early 2015 when announcing the practice would no longer treat patients whose parents and guardians choose not to vaccinate for non-medical reasons.

The decision came after doctors at the Blue Ridge practice treated seven cases of pertussis, or whooping cough, the prior fall. They were concerned that having these sick patients in their waiting rooms put other children, unable to be vaccinated because of age or medical reasons, at great risk, St. Clair said.

Whooping cough, with an effective vaccine against it widely available since the 1940s, can be dangerous or even fatal for newborns who typically don’t get their first dose of immunization until two months of age.

“We felt like we were putting other families at risk,” St. Clair said.

The N.C. Pediatric Society doesn’t keep track of how many practices have adopted policies like that of the Boone clinic. But doctors around the state are looking for ways to make clear the life-saving importance of childhood immunizations, including policies that decline to treat unvaccinated children, said Elizabeth Hudgins, the N.C. Pediatric Society’s executive director.

“Vaccines are one of the greatest accomplishments of modern medicine,” Hudgins said.  “High immunization rates are how we protect communities.”

More skipping the shots

The numbers of unvaccinated or partially vaccinated children appear to be rising in the state, with data from the Centers for Disease Control and Prevention showing a concerning drop in overall vaccination rates for very young children.

More than 80 percent of North Carolina’s toddlers were up to date in 2014 on a series of seven vaccines recommended by the CDC and the American Academy of Pediatrics, a rate that exceeded national numbers by nine percentage points.

But North Carolina’s coverage rate dropped to 70.9 percent just three years later in 2017, according to the most recent data collected for the CDC’s annual National Immunization Survey of toddlers 19 to 35 months old. The survey is conducted by telephone, with researchers later confirming reports about immunizations with medical providers.

In the past, North Carolina has done better than the rest of the nation in getting kids fully vaccinated, but more recently, that advantage has dissipated. NCHN graphic.  

North Carolina is now just slightly above the national average (70.9 percent of North Carolina toddlers versus 70.4 percent nationwide) for the combined seven-series of immunizations. The series of seven vaccines includes protections against diphtheria, tetanus and acellular pertussis (DTaP); polio; measles, mumps and rubella (MMR); hepatitis B; Hib (Haemophilus influenza B, which can cause bacterial meningitis); varicella (commonly known as chickenpox); and pneumococcal diseases (PSV).

The number of children without any vaccines is still small – 1.3 percent of U.S. toddlers born in 2015 – but much higher than it was in 2001, when only 0.3 percent of surveyed children reporting having no vaccines, according to a 2018 report from the CDC.

Zack Moore, N.C. Department of Health and Human Services’ state epidemiologist and a pediatrician by training, emphasized that the overall numbers of vaccination are high in North Carolina —a sign the majority of children are protected from preventable disease. But he also is concerned about the drop over the last three years.

Statewide numbers can mask a larger problem, he said, with pockets through the state with high numbers of unvaccinated children especially susceptible to outbreaks.

“People don’t get sick statewide, they get sick in their own individual communities,” Moore said.

That’s what happened last fall in Buncombe County, when an outbreak of chickenpox, or varicella, connected to a private school in Asheville received national attention. Nearly three-quarters of the Waldorf School’s students were unvaccinated against the disease at the time of the outbreak, according to a report in the Asheville Citizen-Times.

It’s also what’s happening nationally, where small communities of unvaccinated people, largely children, have led to the worst measles outbreak in decades.

There have been a total of 764 confirmed cases of measles in 22 states, the CDC reported Monday.  North Carolina has not yet been affected.

Click on a county to find out the vaccination rate for kindergarteners in 2017-18.

Most of those sickened – 503 people – were unvaccinated children and adults, according to CDC information. The U.S. outbreaks stemmed from travelers from countries such as Israel, Ukraine and the Philippines where there have been large outbreaks, according to the CDC.

Measles is an extremely contagious disease and can be transmitted through droplets in the air up to two hours after an infected person coughs or sneezes. Oftentimes, infected people may not know they’re sick until the tell-tale spotted rash appears, which can be four days after a person is first contagious.

The outbreak has returned attention to the controversy over vaccinations, as many of those who have fallen ill have been in clusters of people with low vaccination rates including several large Orthodox Jewish communities in New York. To try and stem the still uncontained outbreak, a New York county tried to ban unvaccinated children from being in public places, while university students in California face a quarantine if they don’t have proof of immunization against measles.

Health experts at the CDC also suggest people immunized between 1963 and 1967 reach out to health providers to see if they need a booster shot – the inactive (killed) virus used for many immunizations then has been found to be ineffective.

Misinformation, access to healthcare keep kids from shots

Vaccination skeptics and opponents have hinged their arguments against childhood immunization for years on largely refuted claims the vaccines themselves can lead to chronic health issues like autism. But public health experts say those concerns are overblown, and that the risks vaccines pose are minuscule compared to the dangers the diseases themselves pose.

It’s not entirely clear what is behind the recent drop in immunizations in North Carolina, Moore said, although he suspects the continued spread of misinformation or exaggerated claims about vaccine dangers have contributed to the drop.

Skepticism of vaccines isn’t new, Moore said, but the way false or misleading information can spread and take equal footing with scientifically-backed evidence about vaccine effectiveness is.

“It’s much easier for these inflated risk concerns and untested science to spread rapidly,” he said.

A study conducted last year by CDC researchers also found young children are likely to be under-vaccinated due to limited family resources and lack of access to health care.

“Consistent access to health insurance is another important element of the immunization safety net,” the 2018 report about vaccination coverage stated.

The CDC analysis of 2017 national immunization data found full vaccination coverage lowest among uninsured children and those dependent upon Medicaid or living in rural areas. That comes despite a national program, Vaccines for Children, intended to cover the cost of immunizations if a child’s family cannot afford it.

“Vaccination coverage differences by insurance status are concerning, given that children insured by Medicaid and uninsured children are eligible for the VFC program, which was designed to remove financial barriers by providing free vaccines to program participants,” the report’s authors wrote.

But not enough people or providers may know about the federal program, or parents might face other barriers to ensure their child is up-to-date on their shots.

Stricter vaccine policies changed some minds

The doctors at Sandhills Pediatrics, a large pediatric practice with three locations in Moore and Hoke counties, also limits itself to seeing patients who are vaccinated.

Christoph Diasio, one of the clinic’s pediatricians, talks with parents who may have questions about the side effects of vaccines or are worried their small child’s immune system can’t handle the shots and immunizations. Diasio tells them that he vaccinated his own children according to recommended schedules and strongly believes in them as a safe way to prevent diseases that can otherwise be deadly.

Parents can make their own choices, but the doctors at his practice have concluded they won’t be a good fit for families that elect not to vaccinate their children.

“We cannot be complicit in a decision that is dangerous for the life of a child,” Diasio said.

Having it put in those stark terms ended up convincing many of his more hesitant families to vaccinate, he said.

“That pushed a lot of fence sitters to realize this is not a reasonable choice,” Diasio said. “This is not the same thing as what brand of baby bottle will make a child burp less.”

Not everyone believes that turning away unvaccinated patients is a good model.

Robert Jacobson, the medical doctor of the Mayo Clinic’s population health science program said the renowned medical center in Rochester, Minn. will treat unvaccinated children at pediatric clinics.

Doctors and health workers there continue to urge their vaccine-hesitant parents and guardians to read about the science behind vaccination policies, in hopes that they will change their minds as they hear more from their children’s pediatrician about the importance of vaccination.

Having a scenario where a parent feels coerced to vaccinate in order to stay in a medical practice undermines the larger goal of having parents understand and believe in the need for vaccination against preventable diseases, he maintained.

“I don’t want them to do it (vaccinate) because they’re forced to do it,” Jacobson said.

In Boone, the goal of the Blue Ridge Pediatric & Adolescent Medicine’s policy on vaccines also wasn’t to shame families who disagreed with the doctors’ advice, St. Clair said. It was instead to emphasize how critical the doctors there believe vaccination is and to keep other patients safe.

It’s a real issue for St. Clair, who practices in Watauga County, where 4.7 percent of the county’s kindergartners in public or private school reported skipping required school-age vaccines during the 2017-18 school year because of religious exemptions, according to annual data collected by the N.C. Department of Health and Human Services. Only Buncombe County, where 5.7 percent of kindergartners were unvaccinated for religious reasons, had higher numbers in the state.

Office and medical staff at the Boone practice worked closely with families who weren’t up to date on their vaccines, giving them a year to get caught up on shots and also helping families find other providers if they declined to vaccinate.

While a few families left the practice over the new policy, several families that St. Clair described as vaccine-hesitant ended up staying and immunizing their children. Others thanked him for implementing the policy.

Overall, the shift has been a good one for the Boone practice, he said.

“I feel better about having it in place,” St. Clair said. “It’s a way to have a really respectful conversation.”

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Sarah Ovaska

Sarah Ovaska is a freelance writer based in Orange County, who has called North Carolina home for well over a decade. She’s reported on criminal justice, education, health and government issues at publications...