It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”. Herd immunity simply means that you have enough vaccination coverage to protect the entire community - including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective). Generally, herd immunity happens when a community has a vaccination rate above 95%.
A couple of months ago the ADHS released their latest school reporting data on vaccine exemption rates (medical, personal and religious). Here’s a 2-page summary of some of the results. This year’s report covers the 2017-2018 school year. The data show that:
Immunization rates have decreased across all age groups from 2012 to 2017;
Personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and
Overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.
Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity. Arizona does that through statutes labeled ARS-872 & ARS-873 - which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.
According to our current statute, parents can get a personal exemption if they “… sign a statement to the school administrator stating that (they) have received information about immunizations provided by the ADHS and understand the risks…” (as defined in R9-6-701-708). Despite numerous interventions to improve immunization rates among AZ school children- we continue to lose ground. In several parts of the state and among certain demographic groups (high income zip codes and some charter schools for example) we’ve lost herd immunity- which means we’re at real risk for outbreaks.
Arizona’s public health system has been doing some creative work to improve our immunization rates. One of my favorites is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process. The Maricopa County Department of Public Health worked with a University of Arizona medical student and the ADHS Immunizations Program to design and conduct the test pilot program. The new education course was piloted at 16 schools in Maricopa County (8 elementary, 5 middle or junior high and 3 high schools) last school year. The pilot objectives were to:
Learn how to best implement the immunization education module developed by ADHS in Maricopa County schools;
Get feedback from school staff regarding the use of the module to ensure a smooth rollout in the future; and
Identify whether parents learned new information about vaccine preventable diseases and vaccines using a brief anonymous pre-and post-knowledge assessment survey.
The pilot was small & wasn't designed as a formal study and therefore wasn't able to draw any conclusions about the effectiveness of the modules- but it’s a promising intervention that has a good chance of helping improve immunization rates.
There’s a lot of interest among a host of public health stakeholders in continuing to pursue this educational (informed consent) process as part of the personal exemption process. I’m optimistic that executive branch decision-makers will recognize the value that a more robust parent education policy can have in improving rates and that AZ will continue to develop and implement this innovative intervention.
Part of what makes me optimistic are comments that the Governor recently made during an interview with the Arizona Republic in which (about 25 minutes into the interview) he states that "This is a public-health issue, I’m a big believer in freedom and choice on a lot of issues, but… if your kid’s going to be in the public-school system in Arizona, they’re going to be vaccinated."
The bottom line is that despite our work to date, vaccination rates continue to decline and are below the herd immunity threshold in some parts of the state and among some demographic groups. Additional interventions are clearly needed. Perhaps the education modules will help. But it may be that the only real solution is to look to other states that have eliminated the personal exemption. California provides a promising case study.