Colorado allows three kinds of vaccine exemptions -- religious, medical, and those related to personal beliefs. 

(Photo: CPR/Megan Verlee)
If you’ve ever heard a child take the gasping, desperate breaths that characterize whooping cough, you’ll understand why the disease has become the poster child in the debate over childhood vaccines in Colorado.
 
The Centers for Disease Control (CDC) recommends five doses of the vaccine for pertussis, also knowns as whooping cough, for children under six with booster shots throughout life.  But, for the second year in a row, the disease has reached epidemic levels in Colorado, with more than 1,000 cases reported in 2013.  
 
At Cherry Creek Pediatrics in Denver, Dr. Steve Perry sees cases of whooping cough regularly. Dr. Perry also regularly encounters parents worried about the potential side effects of vaccinating their young children against pertussis and other diseases.
 
“Nowadays the hesitancy is more around the number of vaccines and the timing of the vaccines,”  Perry says, as opposed to an outright refusal to vaccinate.
 
Perry tries, with some success, to talk patients into sticking with the CDC-recommended schedule for vaccinations.  
 
It’s a conversation more vaccine-wary parents may end up having with their doctors in the coming years. That's if policy-makers decide to follow the recommendations of a new report commissioned by the state health department.

Exemption rates raise concerns

Two years ago, the CDC listed Colorado as having the second-highest rate of vaccine exemptions in the country.  For some, that ranking was a wake-up call.  
 
“We started receiving a bit more attention from stakeholders and a variety of groups,” Dr. Rachel Herlihy, Deputy Director of the state’s Disease Control Division, says.  “They were asking the Department of Health what we were thinking about the personal belief exemption and was there something we needed to do to examine the way [it] works in Colorado?”
 
Colorado allows three kinds of vaccine exemptions: religious, medical and those tied to personal beliefs.  
 
Last year, the personal belief exemption, which only requires a parent’s signature, made up 93 percent of the estimated 2,869 opt-outs granted to Colorado kindergarteners. 
 
High exemption rates are a concern for public health officials because the greater the unvaccinated population, the higher the likelihood that preventable diseases will be able to spread and possibly find their way to newborns and people with compromised immune systems, where the results could be fatal.  
 
In response to the inquiries, Herlihy’s office commissioned a year-long investigation into the attitudes and opinions of people in the state involved in the vaccination issue, from parents groups to health care professionals and public health workers.
 
Those stakeholders agreed unanimously that Colorado needs to do a better job collecting and sharing data about childhood immunizations. And a majority of them wanted to go further, recommending the state require parents talk with a health care professional before they can take a personal belief exemption, and that they be required to renew that exemption annually.
 
“There have been a number of states that have implemented required education and counseling prior to claiming a personal belief exemption,” says Herlihy.
 
Herlihy cited Oregon, which recently implemented an online training that parents must take, but Washington state and California have also adopted similar policies.
 
Stephanie Wasserman of the Colorado Children’s Immunization Coalition points to nationwide data that shows exemptions decline in states that require parental education.
 
“Really, only about 2 percent of parents are 'hard core refusers,'" Wasserman says.  “But I think the data range [is] between 10 and 25 percent of parents who have questions about vaccines.”

‘Hostile’ climate for parents who want to refuse?

For many parents who decide not to vaccinate their children, the idea that they’re making an uneducated choice can stir tension.  
 
“I think it’s a bit arrogant, actually, to say, ‘for those of you who don’t agree with the public health agenda and who seek exemption, we’re going require that you get extra education, because obviously you’re missing the boat here,’ ” Theresa Wrangham, Executive Director of the National Vaccine Information Center, a nonprofit concerned about the potential side effects of vaccines, says.
 
Wrangham lives in Louisville and believes Colorado’s policy is working just fine without any extra layers, pointing out that the number of exemptions actually fell last year. Wrangham also questions the number of children whose parents filed exemptions are actually unvaccinated.
 
People on both sides of the vaccine debate agree that personal belief exemptions are often used by parents who find it easier to sign the form than to dig out their children’s immunization records. 
 
Requiring those parents to talk with a doctor won’t change anything, Wrangham argues. Instead, Wrangham believes any new policies would only be used to unfairly pressure families who really do oppose vaccination.
 
“What you’re really trying to do is make it harder for them to exercise their right to say no, or their right to delay,” says Wrangham.
 
Wrangham doesn't like that anti-vaccine parents are under pressure from both the medical establishment and an increasing number of state governments.
 
“From a legislative level, it’s getting increasingly hostile," Wrangham says.  "We’re seeing a big push to restrict choice.”

A new voice joins the debate

If Colorado’s legislature does move to make it harder to obtain a personal belief exemption, Wrangham and others concerned about vaccines are likely to form a vocal opposition. They’ll be met on the other side by a relatively new group, Voices for Vaccines, an organization that encourages parents who do vaccinate to speak up about their decision.
 
“The parent voice has, until recently, always been an anti-vaccine voice,” Sundari Kraft, a member of Voices for Vaccines parental advisory board, says. “Most parents vaccinate their kids, but that voice is not being heard.”
 
Kraft, who lives in northwest Denver, says the group will make sure lawmakers get an earful from parents who favor widespread vaccination.
 
Kraft also says parents who find themselves in a situation like hers is to be direct and talk openly about the decisions with their kids.  She suggests that parents can help lower the number of exemptions by talking openly about the decisions they’ve made with their own kids.
 
“We can just never underestimate the value of moms talking to other moms,” Kraft says. “If you’re the mom next to them in play group or at breastfeeding class or at mommy-and-me yoga, it’s really important to be willing to speak up about what you do for your family and why you think it’s important.”
 
It's not clear whether or not there will be a debate in the statehouse this session. Both lawmakers involved in the health department’s stakeholder process -- Democratic Sen. Jeanne Nicholson and Republican Rep. Lois Landgraf -- have said they’re not ready to push for toughening the personal exemption standard at this point.  
 
First, Nicholson and Landgraf want the state to gather more accurate information about how many children aren’t being vaccinated as opposed to focusing so much on those whose families use the exemption for convenience.  
 
Other legislators may be ready to push for a tougher exemption policy and, if they do, it’s likely to be one of the more controversial bills of the session.
 

Correction: An earlier version of this article incorrectly spelled Theresa Wrangham's name and the current version of this article reflects the change.