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With the Vineyard having the lowest vaccination rate in the state, are some parents putting the Island at risk of an outbreak?

On June 28, 2015, Samantha VanLandingham’s eleven-month-old son Shepard developed a high fever. She called the doctor asking advice. Six days earlier, a bulletin had gone out to all the Island schools: an unvaccinated child had been evaluated and diagnosed with measles at the hospital. Over a period of nine days, the child had visited public locations in West Tisbury, Chilmark, Aquinnah, and Oak Bluffs. Officials feared the disease could soon spread to others who hadn’t been immunized.

It’s safe to say that doctors anywhere in America would be similarly worried. But here on the Vineyard there was more than the usual reason to be alarmed, because there are far more than the usual number of parents who, for reasons of their own, avoid having their children vaccinated. And it’s not just a few more: compared with the rest of Massachusetts, a child on the Vineyard is more than six times as likely to be unvaccinated, putting not just the unvaccinated child at risk, but heightening the potential for an outbreak to spread.

Shepard was too young to receive the measles vaccine, but the pediatrician told VanLandingham not to panic and to watch for a rash. If one didn’t develop within three days, they were in the clear. After three days without a fever or rash, Shepard seemed better, so he went back to day care. But when VanLandingham was buckling him into his car seat to take him home from daycare his shirt bunched up and she saw his belly was covered in a rash.

Mother and son were soon ushered into the hospital through the decontamination entrance and met by staff decked out in Hazmat suits. Shepard endured pokes and prods by people in full-body protective gear, a throat culture, and a nasal swab. But a blood test proved too much: he shed his first tear of the ordeal. That blood test came back positive, and Shepard was officially diagnosed with measles. He was to be quarantined at home for three weeks.

It wasn’t just Shepard, either. All over the Island, parents were told to keep infants and anyone with compromised immunity home for three weeks following the date of exposure, even if they showed no symptoms of measles, lest they come into contact with someone who had been infected. For some segments of the population, the Island was now on lockdown.

“Because measles is one of the most infectious diseases known to man, the worry is that, if you don’t react briskly at the outset and it really is the disease, the Island will very quickly have a large-scale outbreak because of the low vaccinated population,” said Dr. Jeffrey Zack, chief of emergency medicine at the Martha’s Vineyard Hospital.

Back at the VanLandingham house, friends and acquaintances started calling in quick succession, desperately seeking information. “It felt like hysteria,” VanLandingham said. And in a way, it was.

But, it turns out, it wasn’t the measles. Shepard and the first child were misdiagnosed, VanLandingham later learned. Their blood tests resulted in two false positives, which were not uncovered until more thorough urine test results came back weeks later. VanLandingham immediately took Shepard to a friend’s house to play. “Then we went grocery shopping,” she said. “And I went back to work. I was just thinking, ‘Yay! Life! We’re back!’”

She had good reason to celebrate. Measles, a highly infectious viral disease characterized by fever and severe rash, was eliminated in the United States in 2000, thanks to an effective vaccination program given in two doses, one at twelve to fifteen months and another at four to six years, as well as a strong public health response to outbreaks. Still, unvaccinated travellers bring new cases of measles to the U.S. every year. The disease can cause serious problems such as pneumonia and swelling of the brain, and in rare cases can lead to death.

Chris Burrell

So-called “herd immunity” is critical to stopping its spread. When a significant portion of a community is immunized from an infectious disease, most of the community is considered protected, even if they have not been vaccinated or have weakened immune systems, because there is little opportunity for the disease to spread to people at risk. But herd immunity on the Vineyard is lacking. According to state health records, the Island has the highest number of kindergarten-age children exempted from vaccinations in the state. A whopping 8.2 percent of kindergartners in Dukes County are not vaccinated, compared with the next highest exempted county, Hampshire, at 4.1 percent. The state average is 1.3 percent.

The percentage of people who need to be vaccinated before a community is considered protected via herd immunity varies depending on the disease. Because measles is so highly contagious, around 95 percent of the community would have to be vaccinated to prevent an outbreak, according to the Center for Disease Control. But on the Vineyard, that number  is closer to 85 percent, said Dr. Larry Madoff, director of the Division of Epidemiology and Immunization at the Massachusetts Department of Public Health. “The community is clearly at risk.”

Untangling the whys of low vaccine numbers on the Island can be a difficult task. Some cite fear of side effects; others would rather take a chance with diseases that do not seem threatening.

“I am not an across the board anti-vaxxer,” said Justen Ahren, a West Tisbury poet. “But my wife and I feel that you can just get immunity from certain things by exposure,” he said. His children are teenagers now and Ahren is open to them being immunized against certain diseases. They have had tetanus shots and he’s considering the polio vaccine before an upcoming trip to Mexico, but measles, chicken pox, and the flu don’t feel dangerous enough to vaccinate against. “They’re not deadly,” he said.
“I just don’t buy into the mass hysteria surrounding these things.”

Laura Hall of Edgartown was wary of vaccinating her now-teenaged children when they were young because it seemed like so many shots for such small beings, so she spaced them out and educated herself. “I’m not strongly opposed to vaccines,” she said, “but education is important on both sides.” Though her kids are mostly vaccinated now, she acknowledges, “Immunization is for the greater good, but it’s not always best for your kid.”

Regardless of the reasons for not vaccinating a child, religion – or at least the invocation of religion – comes into play in almost every case. Each child who attends public school in Massachusetts has to be immunized against communicable diseases, including hepatitis B, tetanus, polio, measles, mumps, rubella, and chicken pox. But as with all rules there are exceptions – or in the case of vaccinations, exemptions. Parents who do not vaccinate, or choose to vaccinate on a different schedule, have to obtain an official exemption based on religious belief or medical need.

Medical exemptions are issued for children with severe allergies to any component of a vaccine. In the case of some live vaccines, including measles, mumps, and rubella, children with any disease that affects the immune system cannot be immunized. A religious exemption, on the other hand, is intended to protect those whose religion prohibits the use of most medicine. Medical exemptions require the approval of a doctor and must be renewed every year; religious exemptions require only a one-time written statement by a parent or guardian.

Regulating religious exemptions can be difficult, if not impossible, which may explain why they are so often used. During the 2015-16 school year, medical exemptions accounted for only 0.5 percent of Dukes County’s vaccine exemptions; the rest fell under religious exemptions. Dr. Ronald Samuels, the associate director of Primary Care at Boston’s Children’s Hospital and an assistant professor of Pediatrics at Harvard Medical School, points out that no major religion officially prohibits vaccinating. Still, how do you argue with religious freedom?

Last summer, Vineyard Haven mother Anne Caldwell found herself in that tricky position, occasionally asking friends if their children were vaccinated before letting them near her nine-year-old daughter Samantha, who was battling brain cancer. Though Samantha had been vaccinated, the cancer treatments wiped out her immune system. “We’d had a really shitty winter,” said Caldwell, “and now we’re being quarantined.”

When Samantha did leave the house during the measles scare, she had to wear a protective mask. For her mother, the stigma and physical discomfort of the itchy face covering was a needless affront.“I just wanted to scream from the rooftop. ‘How about all of you who didn’t vaccinate wear the mask and not my poor kid!’” Caldwell knew of some children who were not vaccinated but were able to go to school because of the religious exemption. “These are not people who go to church,” she said.

Chris Burrell

Dr. Melanie Miller, an Island pediatrician, thinks a combination of factors contribute to a parent’s refusal to vaccinate. And the social aspect is not the least of them. “There are a lot of individualistic people here [on the Vineyard],” she said, “and people who are less trusting of the government. When they talk about vaccines they don’t have to look very far for someone to agree with them.

“These are real diseases and that we don’t have protection against them is a big deal,” she said. “The ultimate goal is to eradicate these diseases and maybe your grandchildren won’t need any of these vaccines.”

Ironically, some experts say the success of vaccines might have to do with the decline in their use. Many diseases are no longer being continually spread throughout the U.S., and therefore not always viewed as continuing threats. But the potential for harm still exists. Despite being declared “eliminated” from the country in 2000, 2014 saw 667 cases of measles in twenty-seven states. 

“If I told a parent that there was a 100 percent chance that their child would get measles, develop inflammation of the brain, and become severely incapacitated for the rest of their lives, but could keep that from happening with this amazing magical vaccine given a few times, I don’t know a parent that wouldn’t push their way up to the front of the line,” said Dr. Zack. But because of the effectiveness of the vaccinations, many parents never encounter a measles scare – and even if they do, it’s not always a worst-case scenario, which leads many to believe that the risk of not vaccinating their child is one they’re willing to take.

“This is not about science. It is about belief. You aren’t going to fix this with data, because the data is overwhelming,” said Dr. Samuels of Boston Children’s Hospital. Samuels lists time, language barriers, and complicated science as challenges to communicating the importance of vaccines to parents, and believes that being concise, firm, and persistent is the most effective way to educate leery parents. “One of the most important factors that influence a patient’s decision to be vaccinated is a clear and unequivocal recommendation of the vaccine from the provider.” In lectures, he encourages providers to listen to parent concerns, keep the message simple, and emphasize the importance of vaccines with anecdotal evidence rather than empirical data.

To that point, involvement with the Island’s measles scare, even only anecdotally, may have had an impact on those who had not yet vaccinated their children. Following the apparent outbreak in the summer of 2015, the staff at the Martha’s Vineyard Hospital sprung into action informing the public and setting up immunization clinics. In the letter sent to all Island schools, Dr. Zack pleaded with the Island community to make sure children were up to date with all vaccinations. “Ensure you and your family are vaccinated,” the letter read. “It is the only reliable way to protect yourself and your family from the disease during an outbreak.”

In all, nearly 200 people were vaccinated at two hospital vaccine clinics, which Dr. Zack deemed a success. While the number isn’t large, it decreased the number of people  who could someday be exposed. And it may have gone a long way toward reducing the number of school exemptions. While the Island’s 8.2 percent exemption rate remains the highest in the state, the percentage dropped precipitously from the 2014–15 school year, when vaccination exemptions totaled 13.8 percent.

“Vaccines are like insurance,” said Dr. Zack. “With auto insurance, while you hope you never need it, you are sure glad to have it when you do. The difference is that you never know if you used the insurance with vaccines.” Such is the miracle of science. Or as Dr. Zack said, “Human nature is great at reaction, but not so much at planning ahead.”

As for sharing her own evidence of the importance of herd immunity, Caldwell would like to say that her family’s ordeal had changed someone’s mind about vaccination. “But at the very least,” she said, “maybe someone will think twice about vaccines as a general courtesy.” If not – if the Vineyard’s exemption rates continue to soar – the Island could be poised for a real outbreak, leaving its most vulnerable citizens at risk.

(Note: this article has been edited slightly since it's appearance in the print version of Martha's Vineyard Magazine.)

Comments (2)

Anne Caldwell
I know vaccines are a hot topic and debate... we personally spaced out our daughters' shots vs follow the typical schedule. The only thing I would like to clarify from this article was how upset my daughter was about having to stay home at the start of summer after a winter of massive snow & trips to Boston for treatments. With cancer taking its toll on her body, about the only thing that gave Samantha any happiness & peace was swimming. The measles scare was serious for us because that vaccine is a "live virus" and her oncologist told us she could catch measles simply by being near anybody newly vaccinated. So Erin's quote should have said "I wanted to scream from the rooftops: how about everybody who just ran in [to the clinics] for their vaccine wear a mask for three days until they don't pose a threat to those with compromised immune systems". My daughter was not the only person at risk of course, but if she contracted the disease it could have been deadly for her and at that time we had no idea if her cancer treatments were working to cure her, so our heartache was doubled.
September 7, 2016 - 11:13am
Ruth Campbell
West Tisbury
I would like to see the Island public schools including the Charter School, preschools, day cares, Doctors offices, And most anywhere that children gather post vaccination appeals and info. Please home school your children, and let mine grow up without the risks you feel are worth taking. And further, I would like to see manditory vaccinations for school admissions, as California is considering.
September 16, 2016 - 9:41pm