At the beginning of each school year, the school-nurse coordinator for the 3,000-student Ashland, Ore., district plans a “parents night” around the topic of vaccinations for the safety and health of children.
But that’s only the beginning of Belinda Brown’s contact with parents who are skeptical about the necessity of immunizations, a routine part of preventative care for most families.
While the vaccination-exemption rate for kindergarten students in Oregon is around 4 percent, in Ashland, about 28 percent of kindergarten students have exemptions on file, meaning they are missing one or more of the 10 vaccines required by the state for their grade. And so Ms. Brown starts every school year gently urging parents to consider all the risks to their child before forgoing inoculations. But most of all, she listens as they share their concerns.
“The key, I’ve found, is for people to feel heard, allowing them the time, providing the information. We’ve had success with that,” Ms. Brown said. “But it’s very, very time-consuming.”
As the United States prepares for a fall resurgence of H1N1, or swine-flu virus, the role of schools in the public-health effort to prevent illnesses is drawing more attention. A recent National School Boards Association survey of 485 districts found that about three-quarters said they would allow vaccinations to take place in school buildings.
“Parents trust their schools, and for good reason,” said Anne L. Bryant, the executive director of the Alexandria, Va.-based organization. Schools can serve both as locations for vaccination clinics and as a conduit for important information, she said.
Decisions for how and when to inoculate children against the swine flu will be made on a state-by-state basis.
Higher Contraction Rate
But research examining the role of the public education system in promoting public health goes far beyond merely being a convenient site for such clinics.
Public-health researchers say mandatory vaccination policies for school attendance have led to the eradication or control of diseases such as polio, diptheria, and measles. Nearly eliminating many formerly dreaded diseases from the population is considered a public-health triumph.
Even though vaccines are mandatory for public school attendance, all states permit medical exemptions, with 48 allowing them for religious reasons and 21 for personal beliefs. Each state decides how easy or difficult it will be for a parent to obtain an exemption to a vaccine.
But there can be consequences to those exemptions. A June study in Pediatrics, the publication of the American Academy of Pediatrics in Elk Grove, Ill., showed that parental refusal of the pertussis, or whooping cough, vaccine was associated with a greater risk of pertussis infections.
The study, which examined cases of pertussis in children enrolled in the Kaiser Permanente of Colorado health plan between 1996 and 2007, noted that vaccine refusers were 23 times as likely to contract the disease as unvaccinated children.
The report also showed that the “herd immunity” effect that should prevent a disease from gaining a foothold in a community that is widely immunized did not seem to be sufficient to protect the children whose parents decided to forgo shots for them. That may be because immunity wears off, and because people who are contagious don’t always have symptoms, the paper said.
“This study helps dispel one of the commonly held beliefs among vaccine-refusing parents: that their children are not at risk for vaccine-preventable diseases,” the study’s lead author, Jason M. Glanz, a senior scientist at Kaiser Permanente’s Institute for Health Research in Denver, said in a statement after the report was released.
A May article in The New England Journal of Medicine explored the evolution of immunization requirements in the United States, starting with a move in the 1800s to inoculate children against smallpox. The number of vaccines has grown since then, to the point where health officials now recommend vaccinations for 15 to 16 diseases for most children under 18. (The vaccine for the human papilloma virus is given only to girls and young women.)
Individual states may not require every one of those recommended immunizations for school attendance. But the sheer number of vaccines is a concern to some parents. Under the recommended schedule, children could receive as many as 25 vaccines by the time they are 2 years old. Depending on the timing, a child could receive up to nine vaccinations during one doctor visit.
People are also personally unfamiliar with many vaccine-preventable illnesses because so many have been immunized, say supporters of inoculation. Instead, attention has turned to the safety of vaccines themselves, with many parents expressing the belief that the number of vaccines, or ingredients in them, hurt children. Until more research is done, those parents say, those concerns are enough to prompt them to skip some vaccines, extend the vaccine schedule so that children are not getting as many at once, or allow the children to develop a natural immunity to some illnesses that are considered mild.
Autism Worries
“Is the atypical manipulation of the immune system, with more and more vaccines given in early life, setting some children up for chronic disease and disability? Is less better?” reads part of a brochure published by the Vienna, Va.-based National Vaccine Information Center, which describes itself as a vaccine-watchdog group.
There is an abundance of evidence showing vaccinations are not related to developmental disorders such as autism, says the U.S. Centers for Disease Control and Prevention, a part of the U.S. Department of Health and Human Services. Vaccines can provoke serious reactions in some children, according to the federal health agency, but those are extremely rare and are outweighed by the benefits of immunization. Not vaccinating children early leaves them susceptible to illness, experts say.
But the concerns persist. In a report published in the February issue of Wisconsin Medical Journal, researchers surveyed 780 parents of children who had nonmedical exemptions for school immunization requirements. Fifty-seven percent of parents who didn’t inoculate said they were concerned that the vaccine would cause harm. Thirty-eight percent said it’s better to get the natural disease than a vaccine, and 37 percent said their children were not at risk. The vaccines most often refused were those for chicken pox and for Hepatitis B, a virus which is transmitted through blood or sexual contact and can cause liver disease.
Dr. Daniel A. Salmon, a vaccine-safety specialist for the hhs’s National Vaccine Program Office, and the lead author of the Wisconsin report, noted that parents who choose to forgo vaccines report that they get more information from more sources beyond health care professionals and other medical and public health institutions, and tend to trust those alternative sources more than parents of children who have been fully vaccinated.
This is where the role of a school-based health professional could be important. In March 2005, a study in the American Journal of Public Health explored the school role in implementing school immunization requirements. That survey showed that a child attending a school with a school nurse was significantly less likely to have an exemption than a school where immunization information was handled by someone other than a nurse.
“Physicians are very involved in doing well-child checks, but after that, people mostly go to the doctor when they’re sick,” said Nichole K. Bobo, the nursing education director of the National Association of School Nurses in Silver Spring, Md. “There’s the importance of having another voice that’s trusted.”
