Arizona schools’ measles risk is even worse than it appears

For a third year in a row, the share of Arizona parents exempting their children from school-required vaccines has increased, but the situation is even more perilous as schools have allowed unvaccinated students to attend without the required exemption.

An Arizona Republic analysis of the state’s immunization data, which was released April 12, found more than half of the state’s kindergartens have immunization rates below the level required to fend off an outbreak.

This year, more than 555 cases of measles have sprouted in 20 states, including Arizona, according to the Centers for Disease Control and Prevention.

Arizona law says children attending school and child care must obtain certain vaccines, unless they are exempted by a doctor for medical reasons, or by a parent for personal or religious reasons.

Non-medical “personal belief” exemptions for Arizona kindergarten students have more than quadrupled since 2000, and they’ve jumped sixfold for sixth-graders, according to state Department of Health Services numbers for the 2018-19 academic year.

The Arizona Republic found two large groups of unimmunized students attending schools:

• Those with the required exemptions. That group includes nearly 4,000 kindergartners.

• Those that schools allow to attend even though they don’t have an exemption or immunization record on file with their school. Almost 900 kindergartners — enough to fill 12 average-size kindergartens — have neither a vaccination record nor an exemption on file with their schools.

The Republic found that overall, compliance with state law is better at Arizona district schools than charter schools.

Exemptions for medical reasons, which must be signed by a health-care provider, are consistently low, with rates well below 1%, state officials found.

The growth has been in the exemptions for personal belief reasons, reflecting an increasing “vaccine hesitancy” among families that the World Health Organization identified as a top threat to global health.

“The state law is very clear that a student either needs to have evidence of immunity to these illnesses or documentation that they were vaccinated according to the law, or an exemption on file,” said Dr. Rebecca Sunenshine, medical director for disease control at Maricopa County Public Health.

School nurses help enforce vaccine law

Private schools and charter schools had disproportionately high rates of personal belief exemptions and low rates of vaccination coverage compared with district schools.

The Republic’s analysis found that seven of the 10 schools with the lowest measles immunization rates for kindergarten, for example, were either charter or private schools. Charter and private schools seldom have a school nurse, The Republic’s analysis found.

“Charter schools in particular tend to have fewer resources,” Sunenshine said. “We do know that school nurses play a large role in educating students and parents about immunizations.”

School nurses explain to parents the importance of immunization, yet they “are often the first victims of budget cuts,” Arizona Department of Education spokesman Stefan Swiat said.

Nearly 85% of kindergarten students at Cottonwood Elementary in Colorado City have exemptions for the measles vaccine and are unvaccinated, the worst rate in the state. 

Carol Timpson, the school’s principal, said “community values” in the town dominated by members of the Fundamentalist Church of Jesus Christ of Latter Day Saints have kept the immunization rate low despite awareness campaigns and free vaccines. The school has a nurse.

“I’m an immunization ninja,” Timpson said. “The more you can do to protect your kids the better off you are.”

Timpson said she “dreads” the day an outbreak occurs because unvaccinated children wouldn’t be allowed to come to school, and it would likely shut down temporarily. The school has looked at offering online classes were it to happen, she said.

At least three schools with extremely low vaccination rates disputed the state data, which the schools themselves reported to state officials in November.

Paul Bummer, principal of the Tucson charter school La Paloma Academy South, disputed the state data, which places his school as the second-worst in the state for measles vaccination coverage.

State records show just 23% of his school’s kindergartners are vaccinated against measles, and that none of the unvaccinated students has a vaccine exemption. But Bummer said the school is in full compliance with state law, and all the kindergarten students are now fully vaccinated.

Bummer acknowledged that the state’s data is what his school submitted in November when it was due. The school does not have a nurse, but that “really has nothing to do” with its vaccine data issue, Bummer wrote in an email.

The state does not audit schools’ reporting, but relies on schools to report the information they collect from parents and guardians. Counties do not audit schools’ reporting either, Maricopa County’s Sunenshine said.

Falling below ‘community immunity’

According to the state data, more than half of kindergartens in Arizona are at risk for a measles outbreak at a time when the U.S. is experiencing a measles outbreak that as of April 11 had infected 555 people.

The U.S. declared measles eliminated in 2000, but outbreaks have periodically occurred since then.

“Anybody can get a vaccine from a health department. It’s not a matter of finances, it’s a matter of refusal,” said Dr. Mary Ellen Rimsza, a pediatrician who is chair of the Arizona Child Fatality Review Program.

“It’s a very, very serious problem. Unfortunately, there’s so much misinformation. The risk of the vaccines are infinitesimal compared with the risks of the diseases.”

In a review of the Arizona Child Fatality data for the last 10 years, Rimsza said she has not found a single child who has died from a vaccine. Yet at least 60 children have died of vaccine-preventable illnesses, including pertussis (whooping cough), flu and meningitis, she said.

Public health officials say the “community immunity” level for measles is 95%, meaning in a classroom, 95% of the students need to be fully immunized against measles in order to protect vulnerable students in the event of an outbreak.

“Measles is incredibly contagious because you are contagious before you have the rash and you are contagious for a few days after you have the rash,” Rimsza said. “Most people who are exposed and aren’t vaccinated will get the disease — over 80 percent.”

Measles is not just a rash, either. A measles infection can cause multiple health problems, including weakening the immune system and placing the child at higher risk for other illnesses. It can also cause brain damage and death, Rimsza said.

The measles vaccine is about 98% effective. When more people are immunized, the entire “herd,” whether it’s a kindergarten class, a family or a school, is protected.

Community immunity, sometimes called herd immunity, protects children with health problems who can’t be vaccinated, including those with compromised immune systems who may have undergone an organ transplant or who are in treatment for cancer. Infants who are too young to be immunized are protected by the herd, too.

Virtually all major public health organizations worldwide, including the American Academy of Pediatrics, World Health Organization and U.S. Centers for Disease Control and Prevention, say school-required vaccines are far safer than the diseases they prevent.

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