Vaccination

CDC's Public Health Grand Rounds on Maternal Immunizations

Join CDC as they present their next Public Health Grand Rounds session on maternal immunizations on September 18. Pregnant women should routinely receive the Tdap (pertussis) vaccine and the influenza vaccine, as recommended by the Centers for Disease Control and Prevention (CDC). These vaccines have been shown to provide significant benefits to mother and baby. Watch live September 18 at 1:00pm ET on either of CDC's live streaming platforms.

AzDHS Immunization Action Plan:

Recommendations for Increasing Immunization Coverage Rates in Arizona

Immunization coverage rates in Arizona continue to fall. The ability for parents to opt their child out of vaccination is simple and is being done more frequently in Arizona. This has resulted in families and communities being at increased risk for vaccine preventable diseases. 

The ADHS recently led a stakeholder group that explored interventions and activities that could help to stop and reverse this negative trend and increase vaccine coverage rates across all Arizona communities. The group developed a report that included the following goals:

  1. Improve vaccine education to professionals who will interact with parents

  2. Implement public information campaigns to promote vaccination

  3. Evaluate the effectiveness of current vaccine education pilot in reducing exemptions

  4. Ensure private providers continue to provide childhood vaccination services

  5. Determine best practices for improving vaccination coverage

  6. Partner with the Department of Education to increase school vaccination rates and compliance

The team put together a 15-page report that includes recommendations to address each goal.  I couldn’t find a copy of the report on their website, but somebody sent me a copy. The recommendations are mostly educational or administrative- no major policy recommendations (like eliminating the personal exemption).  Take a look.  Sounds like we will be seeing more details about these goals and recommendations in the coming months.

Sign on to this Letter to Support Policies that Encourage Vaccination

We invite you to express your support for immunization requirements for public school attendance, vaccine education and informed use of appropriate vaccine exemptions by signing a letter of support to the Governor. The letter includes the Arizona Medical Association Resolution adopted in 2015. Practicing physicians, nurses and pharmacists from across the State of Arizona believe vaccine education is essential to the health of our children and our communities.

CLICK HERE and add your name to the growing list of Arizonans that believe that we must protect Arizona children against vaccine preventable diseases and protect community immunity that protects the most vulnerable among us.  Here’s a copy of the letter you’d be signing on to:

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.

Respectfully,

A.D. Jacobson, M.D.
Steering Committee Chair
The Arizona Partnership for Immunization

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk...  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They're recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you're interested in volunteering, please contact PHVolunteer@maricopa.gov.

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn't in the member’s health plan network. The list of covered vaccinations includes (but isn't necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak - and they also sets up a system that will be better able to prevent future outbreaks.

Using Public Health Policy to Boost Vaccine Coverage

Measles across the country have deteriorated to a level not seen in 30 years, and several states have recently taken direct action to implement policies to boost immunization coverage.

At the beginning of 2019, only California, Mississippi, and West Virginia had state laws that only allowed medical exemptions from their school attendance requirements. Now there are 3 more states like that.  This year Maine and New York passed laws that limit school vaccine exemptions to medical reasons.

 The Maine legislation (which will take effect on September 1, 2021) repeals the state’s religious and philosophical (personal belief) exemptions - but grandfathers in kids that have a non-medical exemption if the parents show that a healthcare provider was consulted about the benefits and risks of vaccinations.

The New York legislation (which took effect immediately) repealed their religious exemption (and has no grandfather clause). NY didn't have a persona exemption, so all they have now is a medical exemption for school attendance requirements.

Washington state removed their former philosophical exemption for the measles, mumps, and rubella vaccine.

I’ve heard through the grapevine that Arizona state government will be working on a “Breakthrough Project” in the coming year that will have a core goal of improving Arizona’s decreasing immunization rates. 

“Breakthrough Projects” are something in the "Arizona Management System" (a Governor's Office Initiative) that is also a state agency scorecard metric.  Breakthrough Projects are supposed to: 1) align with an agency performance measure; 2) result in a sustainable success that addresses a stakeholder concern; and 3) require “a substantial design or re-design of a work process documented with an A3 project plan”.

I’ll stay tuned to get more information about what the ADHS has planned for the Breakthrough Project and include it in a future Policy Update.

Terrific Op-Ed Regarding Vaccine Safety and Herd Immunity

Dr. Bob wrote a really good op-ed in the Daily News Sun this week.  I thought I’d include it in this week’s Policy Update because it’s so well written.

I’d like to try to offer some perspective in response to Diane Douglas’ May 24 commentary on vaccine safety.

“Herd immunity” is a medical miracle, preventing millions of cases of disease and many deaths every single year.  Yet it’s a pretty simple concept. 

No vaccine works perfectly.  But the more people are immunized, the less likely one person’s germs are to spread to the next person.  Depending on the disease, one sick person might infect several others, each of whom infect several more.  That’s an outbreak.  But if you keep the level of immunizations high enough that there is less than one new case of disease for each original sick person, then outbreaks simply don’t happen.  Your personal immunity from your own vaccine never gets put to the test, because you are never exposed in the first place.  This makes vaccines unlike any other health decision – because your action affects others.

Herd immunity results in remarkable protection.  Diseases that were once nearly universal can be practically wiped out.  In the example of smallpox, a disease that killed perhaps half a billion people in the 20th century alone, we were able to eliminate the disease entirely.  There’s no biological reason that we couldn’t do the same with some other diseases – we’ve come close to eliminating polio, for example.

You are, right now, being protected not just from the vaccines you got, but from all the vaccines that everyone around you got.  And what you do by immunizing yourself or your kids doesn’t just benefit your own family – it helps to protect everyone else, notably all those who, for medical reasons, can’t be vaccinated themselves.  Similarly, choosing not to be vaccinated, yet living among others, lowers that level of herd immunity and puts others at risk.  Exactly what that threshold of herd immunity is varies by disease (how infectious it is), by the vaccine (how effective it is), and by the setting (how congested and interactive people are).  Among the worst settings for spreading disease are schools and childcare centers. 

That concept of pitching in to benefit each other is a thoroughly American idea, from the early colonists creating a commons in nearly every town, to compulsory quarantine in the 1600s, to requiring vaccination for school attendance beginning in 1855, to early and repeated court decisions that have upheld various vaccination laws and regulations since at least 1905.  This is not new, and since it has been in place for all our entire lives, it is obviously not a “slippery slope” that has led to any sort of draconian consequences.

Vaccines must meet the same safety and efficacy standards that other pharmaceutical products must reach before being licensed for use in the U.S.  The benefits to an individual and to society of vaccines far outweighs the small risk, for example, of an allergic reaction.  Yet recognizing the societal value of immunizations, the nation established the National Vaccine Injury Compensation Program, which requires a far lower burden of proof and a simpler process than a lawsuit, to assure that anyone who legitimately might have been harmed by vaccines is compensated.  Even with these looser standards, which mean that some people are compensated even though it may be unlikely that the vaccine caused the injury, approximately one person is compensated for every 1 million doses of vaccine given in this country.

In her commentary, Ms. Douglas invoked appeals to individual liberty.  All of us can relate to that.  America guarantees many liberties, but we establish limits when others might be harmed.  Any one of us is free to use public streets, but we don’t get to drive however fast we want, because that would put others at risk.  Similarly, any one of us is free to send our kids to public schools, but we should not be allowed to deliberately put other people’s children at risk by ignoring vaccine requirements. 

Bob England, MD, MPH

Former Director (2006-2018) of the Maricopa County Department of Public Health

Measles-response Toolkit Offered to Health Departments

State and local health department are tasked with the difficult job of leading the response to measles outbreaks when they occur in their communities. To assist in the effort, CDC has developed this one-stop-shop digital toolkit with products that can be used to reach a variety of audiences during measles outbreaks.

The products include accurate, science-based evidence that can help to counter misinformation in communities about measles and MMR vaccine. The kit includes answers to frequently asked questions; a place to direct additional public inquiries to CDC; a measles microsite that you can syndicate on your own website; graphics to post on your websites; and modifiable letter templates (to school principals, parents, etc.) to quickly reach key stakeholders during measles outbreaks.

Washington State Eliminates the Personal Exemption for MMR

Washington’s Governor also signed a new law this week that will eliminate the “personal exemption” that parents can sign to exempt their kids from school and pre-school vaccination attendance requirements. 

Interestingly, the new law just eliminates the personal exemption for the MMR (measles, mumps, rubella) vaccine.  The personal exemption option will still be available for the other school-required vaccines.  The new law will be effective before the start of this year’s school season.

Washington lawmakers overcame strong lobbying by anti-vaccine groups who mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, and turned out in large numbers for the hearings.

As is often the case, a protracted outbreak created the political will to pass the measure.  Earlier this year Washington declared a  state of emergency after officials reported 25 measles cases. The cases continued to climb – and so far 78 measles cases have been confirmed in Washington and neighboring Oregon.

As is the case in AZ, Washington has seen a consistent increase in the number of kids whose parents have exempted them from vaccination school enrollment requirements.  In fact, Washington’s exemption rate for Kindergarteners is 4.7%.  Arizona’s exemption rate is even worse than Washington’s- as the exemption rates for Kindergarten went up this year to 5.9%.

It’s only a matter of time before Arizona has a Washington/Oregon style outbreak.  Most likely it’ll be in a place like Yavapai County- which has the state’s lowest immunization rates.  There’s a good chance it’ll start when an unvaccinated Arizonan returns from Europe with measles and spreads it within their community.

Measles Communication Resources Site

With the rising number of measles cases in the US and globally- and no end in sight for the erosion of immunization rates in Arizona and elsewhere- it’s more important than ever for our public health system to have resources at their fingertips for how to prepare for and to rapidly and effectively respond to vaccine preventable diseases- measles in particular.  Sadly, this is our new reality.

I found a good resource this week that was developed by the National Public Health Information Center- which is basically a Measles Resources website. The site has a Resource Library with fact sheets, infographics, social media tools, a sample op-ed for you to use once a case is identified.  There’s also an Outbreak Communication Guide for actions you can take before, during and after an outbreak, and the CDC's measles microsite.

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.