FARGO—Plenty of parents happily oblige their pediatrician or family physician's recommendation for their children to receive vaccinations to stay healthy. After all, having the shots or showing proof of some kind of exemption from them is the law in every state.
The majority of those immunizations go just fine, with children bouncing back quickly after being fussy or feverish for a day or two.
But Dawn Herrmann's experience with her youngest son 15 years ago was quite different. The rural Dent, Minn., mother said her four other children had no trouble being vaccinated, so she wasn't overly concerned about getting then-toddler Wyatt caught up on his immunizations. But she was leery about the "five or seven" vaccines he received that day.
"Within a few days thereafter, we had the projectile vomiting and it was like, the light in his eyes just went," Herrmann said. "He wouldn't make eye contact anymore and then, slowly, he would just sit in rooms and stare off into space."
Wyatt was later diagnosed with autism. Herrmann said his case is severe; her son, who doesn't talk, can get aggressive and become "almost violent" at times.
Though medical studies have not shown a causal link between vaccines and autism, Herrmann is convinced, and experiences like hers account for some of the hesitancy that's driven down child vaccination rates. They may not, however, tell the whole story.
Barriers to vaccination
Dr. Paul Carson, professor of public health at North Dakota State University and director of infection prevention and control at Sanford Health in Fargo, said North Dakota is coming off a decade-long slide in vaccination rates.
In 2000, 95 percent of the state's kindergartners were fully immunized. In 2014-2015, the number was 89 percent.
"That put us amongst the five lowest states in the U.S.," Carson said.
The state Department of Health asked NDSU's Center for Immunization Research and Education to consider all of the reasons why, and provide some answers in getting rates to swing back the other direction.
One reason for the lower number of fully vaccinated children can be attributed to an influx of people moving into the state. Nearly 7 percent of kindergartners were "unaccounted for" in the school immunization survey data during the last school year.
Lead researcher Kylie Hall said those children may have all, some or none of their vaccinations, but there's no record on file at their school.
"Part of the oil boom, you have a lot of kids coming in from out of state, and it's really hard for those parents to get their records from out of state," Hall said. "Immunizations fall to the bottom of their priority list."
A smaller but growing area of concern to public health officials is the number of parents filing vaccination exemptions. In 2000, only 0.5 percent of kindergartners had an exemption on file. During the last school year, that number was 3 percent.
All states allow a medical exemption for children with compromised immune systems or allergies to vaccine ingredients. Most states allow for religious exemption, and 18 states—including North Dakota and Minnesota—allow parents to opt out for personal belief.
Carson said North Dakota makes it too easy to get those philosophic or moral exemptions.
In Minnesota, parents need a notarized statement, saying they have a conscientiously held belief not to vaccinate. In North Dakota, a parent or guardian simply signs a form. Carson said sometimes it's done out of convenience.
"That should not be easier than getting your child fully immunized," he said.
Another hurdle revealed in the study, through interviews with stakeholders, was "misleading information" about vaccinations being disseminated by some chiropractors in the state,
It states "One chiropractor was holding seminars to 'inform' people about vaccinations."
Brittany Ness, director of nursing at the Steele County Public Health Department, said most of the chiropractors in her area fall into that category.
"There are a lot of naturalistic people out there who are anti-vaccinators, promoting not to vaccinate," Ness said.
The NDSU researchers sent a survey to chiropractors to gauge their beliefs and received 15 responses. They said that while the surveys showed a broad range of opinions on immunization practice and policy, the number of responses was too low to have any statistical significance.
The Forum reached out to numerous chiropractors, who declined comment, and to the North Dakota Chiropractors Association regarding the assertion that some chiropractors are spreading misinformation about vaccines, but president Jacob Holkup also declined comment.
"The NDCA does not have an official statement concerning procedures that fall outside our scope of practice, including vaccination," Holkup said in an email.
Schools a key link
There are school districts in the area that have some of the lowest vaccination rates in North Dakota and Minnesota.
For instance, in the Dilworth-Glyndon-Felton school district, only 64 percent of kindergartners at the elementary school in Glyndon-Felton and 72 percent of them at the elementary school in Dilworth were fully immunized last year, state data shows.
The overall kindergarten vaccination rate in Clay County is around 88 percent, down from 93 percent five years ago.
Clay County Public Health has a contract with some schools, including the D-G-F district.
Director of nursing Jamie Hennen said the numbers in D-G-F aren't low because of medical contraindications or conscientious objectors.
She said it's more a matter of making parents aware that their children are missing doses.
"It will be our plan to improve," Hennen said, adding "that's what our focus will be for spring."
D-G-F superintendent Bryan Thygeson said the school board's recent approval of additional nursing staff will help, given an enrollment increase of 270 students over the past six years.
"In the past, followup letters to parents were done sporadically at best," Thygeson said. "I believe that will not be the case in the future."
In North Dakota's Steele County, while immunization appear low, Ness said that's somewhat misleading.
There are only 8 kindergarteners in all of Steele County and, if one has an exemption, the rates drop dramatically, she said.
At the Finley-Sharon school, there is one child each in kindergarten, first and second grades whose parents have filed an exemption, or three out of 22 students, giving them an 86 to 87 percent vaccination rate. The statewide rate is currently around 90 percent.
Ness said she meets with parents requesting exemptions so she can explain the risks and school exclusions, should a disease outbreak occur. She said one dad signed the form, despite not having a true reason.
"His girlfriend was pretty insistent that his child not have any vaccinations," Ness said. "He couldn't tell me why."
Hall said some schools are enforcing immunization requirements, telling parents they will exclude children who don't have their paperwork in, and some are not.
She said some schools decided to change their enforcement practices in the middle of the 2015-2016 school year, after superintendents attended a school law conference. There, it was reiterated that schools not enforcing the requirements could be held liable if an outbreak should occur.
In those districts that changed, "rates rose to 97 percent," Hall said.
'Crunch the numbers'
Many parents are still convinced of a link between vaccines and autism, even though medical science has shown otherwise.
In 1989, British physician Andrew Wakefield published a small study of just a dozen children claiming a link between MMR vaccine and autism.
It has since been widely discredited, after it was determined he acted "dishonestly and irresponsibly" and eventually lost his medical license. Wakefield recently directed the documentary "Vaxxed: From Cover-Up to Catastrophe."
Carson said multiple studies of 14 million children in different countries since have shown no association at all between vaccines and autism.
"This is far, far more powerful data, but to try to scrub out that false association is extremely difficult," Carson said. "What happens is—and this is one of the most frustrating things we face in public health—is that anecdotes will trump true data."
Sanford Health pediatrician, Dr. Rebecca Bakke, who has four children of her own ages 6 and under, said she often fields questions from skeptical parents.
"What I have to always remind myself is, this is what I do," Bakke said. "I've looked at these studies, I've read these studies, I've been thinking about vaccines for a long time in my medical training and my practice."
She said nothing she does is more important than vaccinating kids
"The thing I do that has the most impact is vaccines, really," Bakke added.
Carson said nothing in medicine is more studied or scrutinized for safety than vaccinations. The Vaccine Adverse Events Reporting System, or VAERS, is monitored by the U.S. Centers for Disease Control and Food and Drug Administration, but anyone, from doctors, parents and attorneys can report adverse reactions. The federal agencies keep an eye out for any trends, and can issue recalls or advisories if necessary.
But you won't convince the Herrman family about the safety of vaccines.
Wyatt Herrmann has been through many alternative therapies for his autism, including homeopathy, essential oils, and applied behavior analysis. While they've helped some, the effects haven't stuck.
Wyatt is a freshman at Detroit Lakes public schools, where he's integrated into a regular classroom. The family hopes to continue having him live at home, but that will depend on whether his behaviors can be held in check.
In the meantime, his father would like to see a third party do more studies of vaccines and autism.
"Crunch the numbers and look at the facts. Take it back to the universities, where they can sit and do it from a totally unbiased situation, and that's when you 're going to find out what the reality is," Eric Herrmann said.
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