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State law and school outreach both levers for boosting immunization rates

This vial contains the DTaP vaccine, which prevents whooping cough.
This vial contains the DTaP vaccine, which prevents whooping cough.

Kathy Hill is a health clerk at Central Elementary School in Longmont. With a few clicks of her mouse, she can find out which of the school’s 340 kindergarten through fifth-grade students are up to date on their immunizations and which ones have “personal belief exemptions” because their parents have opted them out of some or all of their shots.

On a recent day, she did just that using the Infinite Campus data system. Her search revealed that 14 students, or about 4.1 percent, have no immunizations due to personal belief exemptions and 27 students have exemptions for certain immunizations, often Hepatitis B or chicken pox, but are up to date on others.

Hill’s data queries, which she efficiently sandwiched between helping a student with an itchy patch of skin and another who came in with a headache, provide exactly the sort of data that schools will be required to disclose by law beginning next year with the passage of House Bill 14-1288 last Friday. Originally, the bill also contained a provision to make it harder for parents to obtain personal belief exemptions, but a Senate committee stripped the bill of that measure last month.

In addition to requiring schools to disclose vaccination and exemption rates upon request, the bill requires the Colorado Department of Public Health and Environment to create a website with immunization information and to help schools analyze student immunization data. Also, it requires the State Board of Health to establish rules on the frequency with which parents have to submit exemption forms to schools or child care centers.

While some public health advocates are disappointed that a parent’s signature will continue to be all that’s required to get a personal belief exemption, they hope that requiring schools to disclose vaccination and exemption rates will bring more transparency to a historically murky area.

They say such information will arm parents, especially those with children who can’t get vaccinated for medical reasons, with valuable information that could figure into school choice decisions. In addition, the information might also nudge schools to improve their rates.

“We think it could be almost like a consumer-driven force rather than a mandate,” said Stephanie Wasserman, executive director of the Colorado Children’s Immunization Coalition.

The idea is that parents with concerns about vaccine-preventable illness–perhaps those with infants or immunosuppressed children or family members–will actively seek out school immunization information and could send their child to the local school where rates are highest and therefore herd immunity strongest. In turn, schools with low immunization rates might make extra efforts to push their rates up so they are on par with the competition.

“Schools are playing such an important role in enforcing immunization policy,” said Wasserman.

Mary Beth Rensberger, director of health services in Aurora Public Schools, said her staff can pull up vaccination data within five minutes, but she’s never heard of a parent request for such information.

“Once that hits the headlines that might be happening more.”

Unimpressive immunization rates

Colorado, which is one of 18 states to offer parents the option of a personal belief exemption, lags behind most other states when it comes to childhood immunization rates. While many have rates in the 90-95 percent range for three common kindergarten vaccinations, Colorado and Arkansas bring up the rear with rates in the low to mid-80s.

These low rates are a concern for public health experts, particularly because of outbreaks of whooping cough in recent years. The highly contagious disease, also known as pertussis, can be deadly for babies and young children.

The problem is most people don’t know whether the vaccination rates in their schools and communities are high enough to offer herd immunity, which usually requires immunization rates of 90-95 percent. Statewide immunization numbers don’t help much because they are based on surveys with relatively small sample sizes so they don’t reveal much about risk in individual communities. That’s where school immunization data may help.

“Theoretically, every school is supposed to have this information on hand,” said Wasserman. “It’s just that it’s not collected in a uniform way.”

State officials say district’s like St. Vrain Valley, where Hill works, are exemplars when it comes to immunization policy, but many districts lag behind. Part of the problem is that schools vary widely in how they collect, confirm and store immunization information. Results can depend on a health clerk’s or nurse’s hours, the type of student data system used, whether districts are signed up to access the state’s immunization registry, and how deeply principals care about the issue.

Other immunization levers

School staff members like Hill are on the front lines when it comes to improving immunization rates. Not only are they charged with tracking down missing or incomplete immunization records, they’re often the ones to remind and encourage parents to get their children up to date on shots. Sometimes, they also help families address financial or logistical barriers.

It may not be glamorous work, but there is evidence it makes a difference. The Boulder County Public Health department worked with the St. Vrain Valley and Boulder Valley school districts to study the impact of school outreach to families during the 2012-13 school year. At the time, there were a number of whooping cough cases among school-aged children and Boulder health officials secured a state grant to look DTaP vaccination, which protects children from the disease.

Specifically, the project examined changes in DTaP vaccination rates after school staff contacted parents whose kindergarteners had received most but not all of the shots in the five-dose series. In the Boulder Valley district, 289 kindergarteners started school that year with four of the five shots and in St. Vrain, it was 137.

Soon, health clerks, nurses and sometimes even principals were e-mailing, calling and sending out letters to remind parents to get their children up to date on shots. In some cases, staff gave out vouchers for free immunizations or helped working parents figure out which providers had evening clinics. While such outreach efforts are routine in the two districts as well as many others, the DTaP project marked one of the rare occasions the results have been measured.

At the end of the project, the proportion of Boulder Valley kindergartners fully immunized against whooping cough rose from 75.4 percent to 86.2 percent, and in St. Vrain Valley, the numbers rose from 86.9 to 88.4 percent. In addition, both districts saw increases in the number of schools with DTaP vaccination rates of at least 90 percent, a guideline for herd immunity. In Boulder Valley, where there are 34 elementary schools, the number rose from 2 to 14. In St. Vrain Valley, where there 32 elementary schools, the number rose from 11 to 18.

Sophia Yager, immunization program coordinator at Boulder County Public Health, said, “The bottom line is we did see improvement.”

Plus, she added, “We were able to stomp the myth out that Boulder people don’t vaccinate.”

Hurdles for parents and schools

For harried parents, getting their kids up to date on shots can mean inconvenient appointments, confusing insurance coverage, and the hassle of submitting one more school form. And although students are required by Colorado law to have vaccinations or signed exemptions to attend school, those without the required documentation are rarely turned away.

“There’s not really any sanction or teeth in that law,” said Rensberger. “Sometimes, it just really, really tedious to have parents see the need to get their healthy kids in there.”

For that reason, some parents will simply sign a personal belief exemption even if they’ve already gotten their child partially vaccinated and have no philosophical objection to vaccines.

Hill said, “Unfortunately, when they sign their exemption, they’re like, ‘Oh well.'”

She said the timing of kindergarten registration is also a factor in parent follow-through. With some registration events now held in December, it’s easy for parents to forget about immunization forms over the next eight months.

“It’s much more difficult for some families to keep it together,” she said.

In Aurora, district staff try to make it easy for parents to get their kids vaccinated on-site. The district’s school-based health clinics vaccinate elementary children with parental consent and the district’s annual “Welcome Back” event in August often features a walk-in vaccination clinic operated in conjunction with the local health department. In previous years, up to 400 students have gotten shots at the clinic.

While a certain percentage of parents don’t follow through with vaccinations no matter how many reminders they get, others are amenable to getting their kids caught up. The problem is that over-taxed school staff don’t always have the time to contact those parents until the school year is almost over.

In Aurora, Rensberger said some schools weren’t reaching out to “non-compliant” families—those without required vaccinations or signed exemptions– until March. This year, she set an early November deadline for that work.

Susan Rowley, director of health services for the Boulder Valley district, said in schools where health clerks work a full day, the job gets done during the first semester. In schools where they’re on duty for just three or four hours a day, it takes longer.

“This is what the unfortunate economic downturn did,” she said.

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