By Del Stover
7/22/03 -- If someone comes down with the measles in Ashland, Ore., it won't be a small matter for the local schools. As many as one-quarter of the students in some schools are not immunized against the disease.
This doesn't just pose a health risk for children, says county Health Director Hank Collins. It also raises the possibility of an educational nightmare if scores of children are barred from school for weeks or months until the outbreak ends.
"That would cost the school board a tremendous amount of [state aid]," he adds. "And it would really throw parents' lives into total havoc."
That's not to say such a scenario is inevitable. But it could happen. And the risk is not limited to this one Oregon community. Public health officials say that, despite state vaccination laws, students without proper vaccinations are a largely overlooked problem in schools across the nation.
It's an issue that made front-page news this month in Texas, where the medical community has raised strong objections to a new state law that provides parents with an exemption to vaccination requirements if they have a "conscientious objection" to vaccinating their children.
"Vaccination is one of the greatest public health accomplishments of the 20th century," Dr. Michael Foulds, president of the Texas Pediatric Society, says. "Expanding exemptions will only increase the outbreak of deadly infectious diseases."
So how could Texas lawmakers make such a decision?
According to political observers, the new legislation wasn't a shift in policy. The reality is that a lawmaker slipped the provision into a massive state reorganization bill at the last minute -- a concession to a small but vocal group of parents who question the safety of children's vaccinations. Already, there are calls for the legislature to review passage of the law.
That opponents to state vaccination policies exist might strike some as a surprise. At the beginning of the 20th century, infectious disease -- diphtheria, measles, polio, and tetanus, to name a few -- was the leading cause of death among children. That ended with the nearly universal immunization of children.
Parents fear side effects
Yet, today, there are parents who express fears about what they describe as traumatic side effects to some vaccines, despite repeated studies that indicate serious side effects are rare. What's more, the Internet is filled with Web sites warning of the dangers of modern-day vaccines.
Parents' fears have sparked an increasing advocacy effort. In Minnesota, some citizens unsuccessfully opposed state plans to inoculate children against chickenpox and a bacterial infection that can lead to meningitis or pneumonia.
In Arkansas, an anti-vaccination group is working to stop mandatory vaccinations and to reverse a court-ordered end to exemptions for those with religious beliefs that oppose immunizations.
Such advocacy in the state legislature and in the courts is largely beyond the scope of school officials. But how state immunization exemptions are written ultimately does have a potential impact on local schools.
In Oregon, "the exemption law is big enough to drive a Mack truck through," Collins says, noting that parents need only claim a "philosophical objection" to avoid vaccinating their children.
Elsewhere, anti-vaccine groups have set up online "churches" that parents can join. These churches provide documentation stating that one's beliefs oppose immunizing children, which parents can use to seek a religious objection.
But school officials share some blame in the misuse of exemptions by parents, suggests Jan Pelosi, director of the Texas Immunization Program. For years, she's heard stories of schools that grant a provisional enrollment for new students, whose health records have not yet been transferred to the schools.
Where problems arise is when school officials never confirm that the immunization records arrived -- or they refuse to back school nurses who seek to confront parents with the law's requirements.
"The information school nurses relate to us, and this is just anecdotal information, is their school boards don't support them," Pelosi says. "They often don't get support from school personnel -- up to the school board -- to exclude the child."
Risk of outbreaks
Health officials say some communities are simply resistant to vaccinations. In Vashon Island, Wash., and Ashland, Ore., there is a sizable "counter-culture" segment of the population who favor non-traditional medical therapies. On Vashon Island, when an infant died two weeks after his first immunization, some were quick to blame the vaccine.
Other communities with high poverty rates or a large proportion of immigrants also are more likely to have large numbers of under-immunized children, experts say.
These areas are what some in the medical community call "hot spots," where the risk of a serious outbreak of infectious disease is all too real.
And the risk is very real: In the early 1990s, a measles epidemic broke out in California, killing 44 children and hospitalizing 2,000 others. A 1993 outbreak of whooping cough, which can cause brain damage and death, struck 600 statewide.
Smaller outbreaks occur all the time. In Burnet County, Texas, 172 cases of whooping cough were diagnosed after a high school student came down with the disease last year.
Collins recalls a measles outbreak in 1988 -- and he worries about the potential impact for Ashland's under-immunized student population. Just recently, a nearby community reported 35 cases of whooping cough.
"It would have huge implications," he says, adding that he's working with local physicians to "chip away at the problem."
At the school level, Deborah L. Wexler, executive director of the Immunization Network Coalition, says school officials can do their part to tackle this issue by ensuring immunization records are up to date.
In St. Paul, Minn., she says, computerized records allow school nurses to quickly check the immunization records of transferring children -- and keep children without proper vaccinations from falling through the cracks.
School policies needed
Wexler also recommends that school officials have clear procedures regarding the acceptance of exemptions to state vaccination laws. And, if possible, school nurses should be enlisted to educate parents.
"I think it's important school boards understand the complexities of these issues," she says. "This should never be about a signature on a piece of paper that lets parents opt out. I really believe that if parents are to be allowed to opt out, they must be educated."
Daniel Salmon, associate director for policy and behavioral research at Johns Hopkins' Institute for Vaccine Safety, agrees. "Often parents who request exemptions are not being given proper information about the risks of not immunizing children. It won't take you long to find there is a ton of poor information on the Internet."
School boards also need to take this seriously because of the risk to the increasing population of children who legitimately cannot be vaccinated for medical reasons -- children on chemotherapy, infected with HIV, or suffering from a weakened immune system, says Marilyn Kinne, nursing projects coordinator with the National Association of School Nurses.
Noting that "immunizations aren't 100 percent effective," she says "there may be up to 10 percent of your students not fully [protected]." School boards can minimize the risk by trying to keep student immunization rates high.
Salmon is working on a study that surveyed 1,000 schools to see how school policies and the attitudes of school personnel affect parent attitudes about vaccinations, the frequency of vaccine exemptions, and the enforcement of immunization laws.
Although unwilling to share the results until the report is published, Salmon says the study will show that "clearly schools have a role here."
Schools Need to Educate Parents
School leaders, as well as state lawmakers and public health officials, need to play an active role in school vaccination policies, says Superintendent Mimi Walker of Vashon Island, Wash.
In her district, anywhere from 9 to 12 percent of students aren't properly immunized. A measles case last year in a nearby community brought home the potential health risks her students face.
"We are more sensitive to the situation," Walker says. "The school nurse and I last spring brought this matter to the attention of our school board, and it was covered in the local newspaper."
Since then, school officials have attempted to educate parents about the importance of vaccinations, she says. They've also enlisted local physicians to aggressively encourage parents to get children immunized.
School officials sent home a letter telling parents that if a student were diagnosed with measles or another infectious disease, students without the appropriate vaccinations would be barred from school until several weeks after the last reported case.
The importance of proper immunization records in the schools also has been emphasized, Walker says. In the past, parents of transferring students didn't always have the proper records, and school secretaries didn't feel comfortable insisting on the documentation
Now, parents are given a letter that basically says, "If you truly have a religious reason for an exemption, we respect that," Walker says. "But if you're doing it so you can get your kid into class the next day, we have a problem with that. Let's do the registration properly."
Walker was surprised to find out that she -- not the county health department -- is responsible during a disease outbreak for closing school or sending home students without proper vaccination records.