Vaccination

More Bad about AZ's Immunization Rates

School Vaccination Rates Drop Again this School Year

At the core – vaccines are really about community protection.  Our public health system depends on a solid network of providers that are available to vaccinate kids for all the nasty infectious diseases that have plagued humanity for millenia.  Vaccinating yourself and your kids is more about community protection than personal protection. It’s a social contract that we have with each other to keep all of us healthy.

We need just about everybody to participate in our shared social contract to vaccinate in order to get the herd immunity.  When communities have herd immunity, those who can’t be vaccinated and folks with weakened immune systems will still be protected because the viruses can’t circulate.  Measles needs a 95% community vaccination rate to achieve herd immunity.

As a means to maintaining herd immunity, Arizona law (ARS-872 & ARS-873) requires that all children attending school or child care have certain vaccines unless they're exempted by a doctor for medical reasons or by a parent for personal reasons.  

Each year, schools (6th grade, kindergarten, and child care/preschool) are supposed to turn in data about the vaccine exemptions in their school to the ADHS.  

There's bad news again in this year's report- continuing a multi-year trend toward higher exemption rates (worse vaccination rates). For the current school year:

  • 6th grade exemption rates went from 5.4% last year to 6.1% this year

  • Kindergarten exemption rates went from 5.4% to 5.9% 

  • Child care exemption rates increased from 4.3% percent to 4.5%

This year's results can be found on the ADHS' Immunization Coverage Level page.  You can check out individual school exemption rates on the Arizona School Vaccine Exemption Spreadsheet.

There are some pretty discouraging results in this year's results. For example, only 27% of Yavapai County schools (12/44) have herd immunity among 6th graders. Coconino County is only at 33% on the same measure (6/18). As in previous years, charter schools tend to have higher exemption rates than public schools. Lots of data to dive into in the spreadsheet. 

Arizona School Vaccine Exemption Spreadsheet

Sadly, several bills that would have improved rates weren't even heard in committee this year like HB 2162 which would have removed the personal exemption and HB 2352 which would have required schools to post on their school's immunization rates.

However, several bills were heard that would have eroded immunization rates even further including SB 1115, HB 2471, HB  2472, SB 1116, and HB 2470.  Fortunately those bills appear to be dead for this year- but may very well return.

Enough with the California Bashing

California had also been struggling to maintain herd immunity vaccination rates (just like us).  After trying a variety of interventions- and following a measles outbreak associated with Disneyland- the California Assembly passed & Governor Brown signed Senate Bill 277 (in 2015) which abolished personal exemptions in California.

The intervention worked. In the following years, CA had sharp increases in vaccination rates among kindergarteners entering school. During the 2014–2015 school year the statewide kindergarten full-vaccination rate was only 90.4%. After implementing the new law, the kindergarten full-vaccination rate rose to >95% and has stayed there.

Just saying.

Measles & Mumps Cases in AZ

Arizona Has Lost Community Immunity in Many Places

In the last 2 weeks AZ public health officials have identified and confirmed cases of measles and mumps.  The mumps cases (2) were found in the SE valley and are under investigation by Maricopa County Public Health folks. Another mumps case has been confirmed in Cochise County.  The measles case was found in Tucson in a 12 month old- and appears to have been acquired after travelling to Asia. That case is being investigated by Pima County public health epidemiologists.

The basic detective work will include looking for susceptible contacts and conducting interventions to control the spread. Kids don't get the MMR vaccine until their first birthday, so infants are at high risk of getting the disease if they're exposed... so that group along with unvaccinated contacts (whether for medical or choice reasons) will be among the high priority contacts to identify.  You can see the investigation and control measures for both illnesses in Arizona's communicable disease rules (Pages 34-39).

Measles is more contagious than mumps- but both are easily spread (direct contact isn't needed to spread the virus).  Both are vaccine preventable diseases.  For measles (the most contagious disease), 95% of children need to be vaccinated to prevent spread.  

Whether these cases transition to an outbreak or epidemic will depend on where the index cases were prior to diagnosis, who was potentially exposed and the vaccination status of the contacts.  If the index cases were isolated or if they were in communities (or medical facilities) with vaccination rates above 95% it's unlikely that measles will spread beyond the first case. If they were among communities with lower vaccination levels, there's a good chance there will be more cases. Another wildcard will be whether there were potential infant contacts in doctors offices or clinics if potential exposures happened there.

Many parts of Arizona have vaccination levels lower than "herd immunity" levels, meaning that in many parts of the state we've lost community immunity.  Fortunately, Pima County has among the highest vaccination rates in the state, meaning there's a better chance of containing the disease.  Had the index case been from one of the many communities in AZ with much lower vaccination rates the risk would be higher. Of course- there are pockets of under vaccinated areas in every county- so many communities are at risk these days.  

Arizona is one of eighteen states that allows parents to opt out of vaccinating their child with a non-medical exemption Click this link to view the full report.  In fact, Maricopa County leads the nation in the highest number of non-medical exemptions.  

There are 30 Legislative Districts in AZ. You can click here to find out what District you live in so you can communicate with your elected officials about the importance of community immunity and ensuring they understand you support public policies that encourage immunizations.

BTW: there are science-based resources available to help parents make informative decisions about vaccines such as the CDC, Children’s Hospital of Philadelphia and TAPI.

Are School Attendance Vaccination Requirements Constitutional?

There was a lot of contentious debate in both the Arizona Senate and House this week regarding bills that have proposed that would add a religious exemption for school attendance vaccination requirements.

Much of the testimony from parents centered around their belief that public school vaccination requirements are unconstitutional, so I thought I’d take a deeper dive into that subject this week before I get to this week’s bill summary.

There are a couple flagship US Supreme Court cases that address school vaccine requirements.  The first case (from 1905) is called Jacobson v. Massachusetts, in which a guy named Henning Jacobson challenged Massachusetts law that required everybody to be vaccinated against Smallpox or face fine or imprisonment. 

Justice Marshall Harlan delivered the decision for a 7-2 majority, holding that the freedom of the individual must sometimes be subordinated to the common welfare.  The majority opinion rejected Jacobson's claim that the 14th Amendment gave him the right to refuse vaccination.  However, the court held that there needs to be exceptions for people with medical contra-indications. 

A later Supreme Court case (in 1922) called Zucht v. King directly addressed the constitutionality of school attendance vaccination requirements.  In that case, the Court held that a school system could refuse admission to a student who failed to receive a required vaccination.

In that case, San Antonio the family of Rosalyn Zucht challenged San Antonio’s ordinance requiring that students present a certificate of vaccination for smallpox before attending school (public or private).  Rosalyn’s parents were unwilling to vaccinate her, so she was excluded from both public and private schools in San Antonio.

The family argued that since smallpox wasn’t present in town at the time, there was no emergency requiring vaccination, and that she was deprived of liberty without due process of law by effectively making vaccination compulsory. The Texas state courts denied her claims, and the family appealed to the United States Supreme Court.

The Court found no reason to question the fairness with which the city ordinance was applied and found that the ordinance reflected the broad discretion needed by authorities to protect the public health.

Measles Outbreaks, Personal Exemptions, Parent Education & School Exclusions:

Interventions to Protect Kids & Stop the Spread of Disease

The Social Contract & Herd Immunity

At the core – vaccines are really about community protection.  Our public health system depends on a solid network of providers that are available to vaccinate kids for all the nasty infectious diseases that have plagued humanity for millenia.  Vaccinating yourself and your kids is more about community protection than personal protection. It’s a social contract that we have with each other to keep all of us healthy.

We need just about everybody to participate in our shared social contract to vaccinate in order to get the herd immunity.  When communities have herd immunity, those who can’t be vaccinated and folks with weakened immune systems will still be protected because the viruses can’t circulate.  Measles needs a 95% community vaccination rate to achieve herd immunity.

 

School Enrollment Requirements & Exemptions

To achieve herd immunity and prevent the spread of measles and other communicable diseases, every state including Arizona requires kids in public school to be vaccinated against a series of diseases, including measles.

All states allow an exemption from the required vaccines when it’s medically necessary.  Seventeen states (including Arizona) allow parents to exempt their kids from the requirements because of personal or philosophical beliefs (called personal belief exemptions).  BTW: HB 2162 would change that by removing Arizona’s personal belief exemption (it hasn’t been scheduled for a hearing).  States with a personal exemption option usually have lower vaccination rates than states without that option.

States also have authority to exclude kids that are unvaccinated from school during a vaccine preventable disease outbreak. In Arizona, ARS § 15-873(C) states that students “… who lack documentary proof of immunization shall not attend school during outbreak periods of communicable immunization-preventable diseases”.  The decision to exclude kids during an outbreak rests with the directors of the county health departments and school administrators and is prescribed in Arizona’s Communicable Disease Rules.

 

Immunization Rates Among AZ Schools

Arizona has many pockets in which our vaccination rates are below 95%, mostly in high income areas and among certain charter schools. One of our best sources of vaccine coverage data comes from schools and childcare centers- which are required to report their vaccination coverage and exemption rates for 19-35 month old’s, kindergartners, and 6th graders.

Public health agencies aren’t the only group of folks interested in school exemption rates. Many parents are interested in finding out whether their child’s school is has a high vaccination rate.  For the last several years, the ADHS has been posting the vaccination rates of schools across the state.

Last year exemption rates increased across all age categories. Exemptions rose from 3.9% to 4.3% for child care, from 4.9% to 5.4% for kindergarten and from 5.1% to 5.4% for 6th grade.  As is always the case, exemption rates were much higher in charter schools. Data for exemption rates and vaccine coverage rates by county and school are available on the ADHS website.  Note: updated exemption rates will be available in a couple of months.

 

Educating Parents

Arizona’s public health system has been doing some creative work to improve our immunization rates. One is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process.  

Last year a pilot project was conducted recently at a dozen or so schools in Maricopa County to learn how to best implement an immunization education module, get feedback from school staff, and identify whether parents learned new information about vaccines using a pre-and post-knowledge assessment survey.

A new more robust pilot is planned for the 2019-2020 school year. The county health departments and the ADHS are partnering in the project.  At participating schools (hopefully as many as 125 schools), parents who want to exempt their kids from the school enrollment vaccination requirements will be asked to complete the Immunization Education Course first.  Upon completion, they’ll be able to download their school’s exemption form.

The online course is designed only for the use of Personal Beliefs Exemptions in grades K-12 at pilot program schools. It doesn’t change the process to request and obtain a Medical Exemption form or the Religious Beliefs Exemption form.

Hopefully the project will demonstrate positive results and will include an academic partner so the eventual results can be published and other states can learn from this important work.

We don’t have much time, though.  Vaccination rates are already below herd immunity levels for measles in many parts of the state, and all it'll take right now is a sentinel measles case in the right place at the right time and we’ll have a measles outbreak- maybe one as bad as the one happening right now in Washington state and across much of Western Europe.

CA Eliminated Personal Exemptions & Vaccination Rates Improved A Lot

California had also been struggling to maintain herd immunity vaccination rates- especially in higher income areas (just like us).  After trying a variety of interventions- and following a measles outbreak associated with Disneyland- the California Assembly passed & Governor Brown signed Senate Bill 277 (in 2015) which abolished personal exemptions in California.

The intervention worked.  In the following years, CA had sharp increases in vaccination rates among kindergarteners entering school. During the 2014–2015 school year the statewide kindergarten full-vaccination rate was only 90.4%. After implementing the new law, the kindergarten full-vaccination rate rose to >95% and has stayed there. 

By the way- a few months ago the Second District Court of Appeal in Los Angeles found that the CA law didn’t violate freedom of religion or the right to an education.

The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.  Just saying.

Support School Attendance Vaccination Requirements

Please express your support for immunization requirements for public school attendance and informed use of appropriate vaccine exemptions by signing on to this letter of support to the Governor.

By simply clicking here you can add your name to the growing list of Arizonans that believe that it’s important to protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us. Here’s the letter:

Dear Governor Ducey,

We, the undersigned, want to express our full support for this resolution adopted by the Arizona Medical Association (ArMA):

“ArMA supports adopting requirements that parents (or guardians) who do not wish to have their children vaccinated receive public health-approved counseling that provides scientifically accurate information about the childhood diseases, the available vaccines, the potential adverse outcomes from catching diseases, the risks unvaccinated children pose to children who cannot be vaccinated for medical reasons, the risks of vaccine side effects, and the procedures that are implemented to exclude unvaccinated children if an outbreak of disease occurs in the area administered by the local or state public health agency.

ArMA also supports adopting requirements that parents annually sign an affirmative statement that acknowledges the risks they are accepting for their own children and the children of others by claiming a personal exemption from mandatory vaccination requirements.”

As residents of Arizona, we actively support and encourage you to work with the Arizona Department of Health Services (ADHS), all County Health Departments, and longstanding partners of The Arizona Partnership for Immunization (TAPI) to maintain high levels of immunization coverage rates in our schools and our communities…to keep your constituents safer and healthier.

 

Research Published about Vaccine Exemption Policies

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).

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.

Arizona’s immunizations rates continue to decline: 1) immunization rates have decreased across all age groups from 2012 to 2017; 2) personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 3) 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.

Of course- when looking toward interventions to stem the tide it’s important to look to the scientific literature to see what’s going on in other states.  A very informative article about personal vaccine exemptions was published recently entitled The state of the antivaccine movement in the US: A focused examination of nonmedical exemptions in states and counties.

The researchers conducted a detailed analysis of personal exemptions within each of the 18 states that allow nonmedical exemptions to their school vaccine requirements. Here’s a map of which states allow non-medical school exemptions.

The researchers found that several counties, especially those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics.  Since 2009, personal exemptions have risen in 12 of the 18 states that currently allow philosophical-belief exemptions.  On average, states that allow non-medical exemptions have 2.5 times higher exemption rates.

The also dove into the data and found that there is a direct correlation between higher personal exemption rates and lower vaccination rates.  That might be intuitive- but it’s important because it shows that personal exemption rates for school requirements is a good measure of real immunization rates.

The discussion portion of the article discusses the efficacy of interventions in various states, and basically found that more aggressive approaches – like eliminating personal exemptions entirely- are more effective at long term improvements in vaccination rates than softer approaches.

Definitely worth a read.

Educating Parents to Improve Vaccination Rates

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.

CA Eliminates Personal Exemption & Vaccination Rates Improve

California has also been struggling to maintain herd immunity vaccination rates- especially in higher income areas.  After trying a variety of interventions- and following a measles outbreak associated with Disneyland, CA passed Senate Bill 277 (SB277) in 2015 which abolished all nonmedical exemptions in California.

Their intervention worked.  In the following years, CA had sharp increases in vaccination rates among kindergarteners entering school. During the 2014–2015 school year the statewide kindergarten full-vaccination rate was only 90.4%. After implementing the new law, the kindergarten full-vaccination rate rose to >95% and has stayed there. 

By the way- a few months ago the Second District Court of Appeal in Los Angeles found that the CA law didn’t violate freedom of religion or the right to an education. The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.

AZ Vaccination Exemptions Continue to Increase

Despite numerous interventions in the last year designed to improve immunization rates among AZ school children- we continue to lose ground.  Last week 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 was submitted by the schools to the Department in the Fall of ’17). The data show that:

  • Immunization rates have decreased across age groups from 2012 to 2017;

  • Non-medical exemption rates continue to be highest in public charter schools, followed by private and public schools in 2017; and 

  • Non-medical (e.g. personal and religious) exemption rates have increased from 2016: 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.

The Arizona Public Health System has done a remarkable job turning the data reported by schools into actionable information.  My favorite is the Personal Belief Exemptions Map.  Parents can also look up the exemption rates in individual schools.  But there are also data for: Arizona Reporting Schools Coverage; County Kindergarten Coverage; County 6th Grade Coverage; County Child Care Coverage; Whooping Cough Immunization Coverage Map; and a Measles Immunization Coverage Map.

 

Interventions to Reduce Vaccine Exemptions

The ADHS has significantly overhauled their vaccine exemption form to better inform parents about the risks that they are taking for their child and for their child’s classmates and the community by choosing not to vaccinate their kid. Other interventions (by the Arizona Partnership for Immunizations) have included working with school administrators to help parents overcome any barriers that might be preventing them from getting their children vaccinated and by reducing “convenience exemptions,” in which parents sign a waiver because they can’t get their children immunized in time to meet school requirements.

I’ve also heard that there is an Immunization Education Course under development by the ADHS that’s designed to serve in lieu of a new exemptions form has been built and piloted at some schools in Maricopa County.

During the 2015 legislative session, Representative Mendez sponsored HB 2466 which would have required all public schools (including charter schools) to maintain a website to post the rates of their pupils’ immunizations against vaccine preventable diseases.  It never even received a committee hearing.  Back in 2012 a Bill that would have required a doctor’s signature to get a personal exemption failed. 

A couple of years ago California eliminated personal exemptions entirely.  While the rate for personal exemptions rose after the personal exemption was eliminated, a study In study in JAMA back in 2017 found that the rate of medical exemptions for immunizations for incoming kindergartners rose the year after California eliminated the personal-belief exemption, but vaccination rates did improve substantially - especially in high income enclaves that had the highest personal exemption rates. 

By the way- last week the Second District Court of Appeal in Los Angeles found that California didn’t violate freedom of religion or the right to an education when it eliminated most exemptions.  The court said that… “Compulsory immunization has long been recognized as the gold standard for preventing the spread of contagious diseases”.  The court said the new law was not discriminatory and was a valid measure to protect public health.

AzPHA Letter to ADHS on Proposed Immunization Rulemaking for School Vaccination Requirements

March 15, 2018

 

Cara M. Christ MD

Director,

Arizona Department of Health Services

150 N 18th Avenue

Phoenix, AZ  85007


 

RE: Vaccination Rulemaking

Dear Director Christ:

I write on behalf of the Arizona Public Health Association (AzPHA) – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities.  An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

The AzPHA has examined the Arizona Department of Health Services (ADHS) proposed Rulemaking to revise the rules in 9 A.A.C. 6, Article 7, Required Immunizations for Child Care or School Entry.  We are generally supportive of the rule package as it appears to clarify and improve the requirements for personal, medical and religious exemptions, makes the rules more consistent with standard medical practices, and better allows for electronic records and record-keeping.

However, we believe that the Department is missing an opportunity to update the child care and school vaccine requirements so that they are consistent with the CDC’s Advisory Committee for Immunization Practices (ACIP) recommendations.  As you know, rulemaking packages are resource intensive and time consuming, and this may be the only opportunity for many years to update the Department’s vaccine requirements.

We urge the ADHS to update the requirements so that they (over time) are consistent with ACIP recommendations by adding a 2nd Varicella vaccine, the PCV 13 series, Rotavirus, and 2 Hepatitis A doses to the child care requirements.  We also urge you to add a 2nd Meningococcal vaccine, and the Meningococcal B at 16 years old to the school requirements.  We recognize that ARS 36-672 (C) prevents you from being able to add the Human Papilloma Virus Vaccine to the vaccine requirements.

We understand that the requirements may need to be phased in so that pediatricians and families have the time needed to become compliant with the new requirements. 

For example, the ADHS could write the final Rule such that the vaccines with the highest current coverage levels (as reported in ASIIS) are phased in over the next 18 months.  Vaccines with lower current coverage levels could be phased in at later dates. 

This approach would allow the Department to responsibly phase the vaccine requirements using coverage projections while being a good steward of future Department Rulemaking resources and at the same time secure a healthier future for Arizona children and families.

Sincerely,

Will Humble, MPH

Executive Director,

Arizona Public Health Association