Although no deaths have been reported so far this year, the state has declared an epidemic and public health officials say the numbers are staggering: 1,284 cases through early May, the most in at least three decades and 10 times last year’s total at this time, 128.  The response to the epidemic has been hampered by the recession, which has left state and local health departments on the front lines of defense weakened by years of sustained budget cuts.  Here in Skagit County, about an hour’s drive north of Seattle — the hardest-hit corner of the state, based on pertussis cases per capita — the local Public Health Department has half the staff it did in 2008. Preventive care programs, intended to keep people healthy, are mostly gone.  The county’s top medical officer, Dr. Howard Leibrand, who is also a full-time emergency room physician, said that in the crushing triage of a combined health crisis and budget crisis, he had gone so far as to urge local physicians to stop testing patients to confirm a whooping cough diagnosis.  If the signs are there, he said — especially a persistent, deep cough and indication of contact with a confirmed victim — doctors should simply treat patients with antibiotics. The pertussis test can cost up to $400 and delay treatment by days. About 14.6 percent of Skagit County residents have no health insurance, according to a state study conducted last year, up from 11.6 percent in 2008.  “There has been half a million dollars spent on testing in this county,” Dr. Leibrand said late last week. “Do you know how much vaccination you can buy for half a million dollars?” And testing, he added, benefits only the epidemiologists, not the patients. “It’s an outrageous way to spend your health care dollar.”  State health officials estimate that because of incomplete testing and the assumption that many people with mild cases are not seeking medical treatment, perhaps as few as one in five pertussis cases is being recorded and tracked, suggesting that the outbreak is far more widespread than the numbers indicate.  Pertussis was once a dreaded disease of childhood — killing 5,000 to 10,000 Americans a year from the 1920s through the 1940s — but is now a risk mostly to infants, to whom it is fatal in about 1 percent of cases. Most of the victims in Washington, as in previous outbreaks in other states, are between 8 and 12.  “It’s the largest epidemic I’ve ever seen,” said Becky Neff, the only registered nurse in the 3,700-student Burlington-Edison School District, in Skagit County. Ms. Neff said she had seen 142 suspected and confirmed cases, or about 3.8 percent of the student population from kindergarten through 12th grade.  But with only two nurses processing the disease reports she sends over to the county, down from five a few years ago, Ms. Neff said she had stopped even trying to ask for confirmation.  “They don’t have time to call and say who’s positive and who’s negative,” she said.  The pertussis vaccine is commonly given in childhood, and many states require it for children of school age. But Washington State, according to a federal study last year of kindergarten-age children, had the highest percentage of parents in the nation who voluntarily exempted their children from one or more vaccines, out of fear of side effects or for philosophical reasons.  So-called underimmunization — in which children do not get the full series of vaccinations — could also be a factor in compounding the outbreak, said Mary Selecky, Washington State’s secretary of health.  Last year, the Washington Legislature passed a law requiring parents to prove that they had consulted a physician before declining vaccinations for their children.  “We had the easiest opt-out law in the nation until last year, so what we also had was the highest percent of parents opting out,” Ms. Selecky said.  Officials at the federal Centers for Disease Control and Prevention, which sent three epidemiologist investigators to Washington last week, said the number of pertussis cases had been rising gradually nationwide for several decades, with periodic regional outbreaks. In 2010, California had its worst bout with pertussis in decades.  Dr. Thomas Clark, an epidemiologist at the C.D.C., said changes in the vaccine may be partly responsible. The formula was altered beginning in the early 1990s to reduce side effects, which means that its immunizing effects do not last as long, he said.  Most of the victims in the Washington outbreak and other recent ones received their early childhood vaccinations, Dr. Clark said. An early immunization, even if it does not keep a patient from getting the illness, generally produces a milder case, he said, since the victim would still have some residual resistance.  Ms. Selecky said immunizations were meant to protect not only individuals but also the broader population: the so-called herd immunity threshold. If a large enough segment of the population is unprotected from a disease — generally considered 5 percent to 15 percent, depending on the disease — even people with some degree of immunity through vaccination can have an elevated risk, she said.  Before the law was passed, Washington’s vaccination exemption rate was more than 6 percent.  But the drumbeat of publicity about the pertussis outbreak could be changing some minds.  Mary Ann Mercer, 74, a retired schoolteacher, went to Skagit County’s walk-in clinic on Thursday morning for a vaccination after hearing news reports. She never had whooping cough as a child, she said, and never thought of it much until recently.  “It’s just precautionary,” she said after receiving her shot.  Her husband, Roger Mercer, who ran a local Blue Cross insurance plan before his retirement, sat anchored to his chair in the waiting area.  “I’m a coward,” he said.
Efforts in Washington State to address a resurgent childhood ailment have been hobbled by years of recession-induced budget cuts that have hollowed out public health departments.