PUBLIC HEALTH UPDATE: Vaccines, Policy and Dialogue in Marin

Matt Willis, MD, MPH

At the end of my first day as a primary care physician in Marin in 2011, I remember being impressed by two common challenges with my new panel of patients. First, I was surprised by expectations of prescription medications as a first-line remedy for ill-defined pain, and second, many of my patients refused the vaccinations I recommended.

I realized my work was cut out for me as a communicator, navigating decisions with patients seeking potentially harmful agents with unproven effectiveness on the one hand, while refusing safe preventive measures on the other.

As public health officer, I see how the challenges experienced in the exam room are manifested on a community-wide scale. Prescription drug abuse and low vaccination rates are two of the most pressing public health challenges facing our community. Fortunately, since 2011, significant progress has been made in both areas. I have focused on prescription drug abuse in prior updates in Marin Medicine, and will continue to address the issue as we work to control this epidemic. Less visible, but equally important, has been our progress in vaccinations.

Under longstanding California law, children enrolling in schools are required to have certain vaccinations. However, the public health benefit of this law has been significantly undermined by an exemption offered to parents opposed to vaccination on the basis of personal beliefs. Marin County had the Bay Area’s highest rate of personal belief exemptions (PBEs) to required childhood vaccinations. Of greatest concern is that we have several communities with clusters of unvaccinated school children. In some of these communities, astonishingly, vaccination rates are far below those of some developing countries.

Thanks to a new California law, all Marin communities will be better protected against disease outbreaks. Senate Bill 277, co-sponsored by our pediatrician senator, Dr. Richard Pan of Sacramento, eliminates personal belief exemptions from California law. Starting this year, no incoming kindergarteners will be exempt from required vaccinations without a medical contraindication.

Marin County has been the subject of national media attention regarding vaccinations and vaccine decision-making among affluent, well-educated residents. On national TV, Jimmy Kimmel accused Marin of being “more afraid of gluten than smallpox,” and John Stewart said that our PBE rates were the result of “mindful stupidity.” Those of us practicing in Marin know the picture is more nuanced than this. In order to help our community adapt to the new law eliminating PBEs and predict its effects locally, it is necessary to understand baseline community beliefs and existing trends.

In 2013, to better understand local vaccination beliefs, Marin County Public Health partnered with the Marin County Office of Education to survey parents of kindergartners from 40 schools. Of the almost 500 parents who responded, 15% had children who were not current on required vaccinations.

We learned from the survey that most families with PBEs actually chose some, but not all, required vaccinations. Some delayed due to concerns about too many vaccines, or believed that the risks of disease are low. Those who categorically refused all vaccinations were a small minority. This is important, because it suggests wide understanding of the value of vaccination even among parents with PBEs. I trust that these Marin parents can react thoughtfully to the new policy and will choose to expand the protection they already offer their children to the full range of vaccine-preventable diseases.

We also found limited understanding of the communitywide implications of vaccine decision-making. The term “personal belief exemption” is misleading because the effects of opting out of vaccinations are not only personal—they can carry profound consequences for our friends, neighbors and children’s classmates. Many parents did not understand that babies younger than 12 months and people who are medically fragile cannot be vaccinated. We learned that we needed to offer stronger messaging about vaccinations as a community responsibility, as something we do not only for our own children, but also for their friends, classmates and neighbors.

Additionally, SB 277 arrived during a trend of increasing vaccination uptake. Perhaps because of a growing understanding of the community benefits of vaccination, or fueled by the 2014 measles outbreak, Marin County vaccination rates began improving even before the new legislation. The PBE rate in Marin has been declining since its peak in 2012. In fall 2015, 6.0% of kindergarteners entering school had a PBE, down from 7.8% in 2012. The last time this many Marin kindergarteners were fully vaccinated was 2007. Still, our opt-out rates remain well over twice as high as the statewide average of 2.3 percent.

While the new law promises to increase vaccination rates among children attending school, it’s important to keep in mind that those children who entered school unvaccinated under a PBE in the past can remain in school unvaccinated. It will take several years, as new fully vaccinated cohorts of kindergarteners enter and advance through the grades, before any school—any community—will enjoy the full protection this law is meant to ensure. For this reason, we must remain vigilant for the possibility of preventable outbreaks of childhood diseases.

Before joining the Marin County Health Department, I worked for the CDC, helping control disease outbreaks in the developing world. We failed to control an outbreak of diphtheria in Haiti’s tent camps after the devastating 2010 earthquake. In that setting, the spread of disease was a sign of the total disintegration of the local health system and a historical lack of access to safe and effective vaccines. As Public Health Officer, I’m concerned that Marin could end up with similar outbreaks, but for very different reasons. In our case, an outbreak of preventable disease would be the result of choice, through vaccine refusal. Our risk is diminishing significantly thanks to SB 277 and recent increases in vaccine acceptance, but we remain divided—and the risk is still with us.

The so-called “vaccination debate” risks polarizing our community. We want to understand and help address any concerns in the context of three principles: preventable diseases are a real and growing risk; vaccines offer safe, effective protection; and vaccination is a matter of both personal and community responsibility. We unequivocally advocate vaccination as the best, safest way to keep our community free of preventable diseases and want to promote respectful dialogue to this end.

SB 277 is a very positive step. It shows that our community’s vaccine decisions are coming into line with Marin’s well-established values of prioritizing health. I hope that after being highlighted nationally for low levels of vaccination, Marin can serve as a national model for collective response as we come together to close a gap in our community’s health.

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Dr. Willis is Marin County’s public health officer.
Email: mwillis@marincounty.org