Caitlin McGlade, The Republic | azcentral.com10:14 a.m. MST February 4, 2015

At least one in every three kindergartners in Arizona who enrolled last year without measles vaccinations were missing exemption forms required by state law

Nearly one in every three kindergartners in Arizona who enrolled last year without measles vaccinations were missing exemption forms required by state law, according to Arizona Department of Health Services data analyzed by The Arizona Republic. The law calls on schools to suspend students who are unvaccinated and do not have exemptions. Schools use those exemptions to track unvaccinated students so they can send them home when a student contracts measles. Neither the county health department nor the DHS tracks whether schools suspend students who are missing exemptions or vaccinations regularly, but the county does ensure that those students are pulled out of school if a case of measles occurs. The waiver, mandated for other preventable diseases as well, requires parents who choose not to vaccinate their kids to sign that they understand the risks. The state added descriptions last year of the diseases in attempts to make parents think more deeply about their decision. But records reviewed by The Republic show that hundreds of schools didn't require some parents to turn in the exemption forms. ADHS Director Will Humble has urged parents to vaccinate their kids, calling immunization a social contract to protect the community. He has stepped up his call recently as up to 1,000 people in Arizona have possibly been exposed to the measles. State, county not enforcing law But ADHS has not enforced the state law requiring vaccine exemptions for all students who enroll without vaccinations. ADHS and the Department of Education said the statute does not lay out penalties for schools that don't comply. Humble said county health departments and state staff check in on schools' missing exemptions, but said that it isn't done enough. "That's something we need to work on for sure," he said. "I think it's different for each county. For a county with resources, it's a matter of prioritizing, for the rural counties, it's a matter of financial ability ... or you have a much smaller pool of candidates (to operate health departments)." In Maricopa County, it's a resource problem, said Rebecca Sunenshine, medical director for Maricopa County Public Health's disease control division. The staff conducts education outreach so all schools understand vaccination rules, Sunenshine said. But with more than 1,000 schools to monitor, she said staff could not check every school's records. The staff instead relies on the schools to ensure that they have what is required. "If there are schools that are not in compliance, we would not be aware," she said. Some schools contacted said they had reported errors and did in fact have the proper records on file. Rep. Heather Carter, chair of the House of Representatives Health Committee, said the statute has "no teeth." The lax enforcement renders the reporting requirement somewhat moot, she said. "That's a huge problem if we're going to have the schools do a report," said Carter, R-Cave Creek. "They have to be accurate, they have to be timely and they have to serve a purpose." Schools that don't have parents sign the waivers are "missing that opportunity for either the school health aide or the teacher or even the parent for this issue to pop into their brains and say, 'Gosh, do I really want to do this,' and may do a little bit of homework," said Francisco Garcia, chief medical officer of the Pima County Health Department. The state has known about schools lacking vaccine exemptions for unvaccinated students since 2012, when the Arizona Daily Star in Tucson reported on it. The released data includes schools with kindergartens with more than 20 students, as the state would not release smaller schools' data, citing privacy concerns. Low vaccination rates The data reviewed by The Republic shows about two of every five kindergarten classes in Arizona have such low vaccination rates that measles could spread rampantly among students and even to the community. Those schools reported that less than 95 percent of their kindergartners last year were vaccinated against the measles — placing them below herd immunity rate. Herd immunity is achieved when enough people in a population are vaccinated that the disease cannot spread effectively, Sunenshine said. It works like this: One person in a room is sick with the measles, but he is surrounded by many people who are vaccinated and cannot contract the disease. That protects others, who are unable to get vaccinated, from catching the measles from that one person. But vaccination rates at kindergartens in Arizona last year were as low as 30 percent. In Maricopa County, the lowest measles vaccination rate was 53 percent vaccinated at Desert Marigold School in south Phoenix. The principal did not return calls for comment. "A school like that can be ground zero for an outbreak which would significantly affect Arizona," said Sean Elliott, medical director of University of Arizona Infection Prevention. In 2008, one of the country's largest measles outbreaks since the 1980s struck Arizona when an unvaccinated Swiss tourist was treated at a Tucson emergency room. There were 363 suspected, 8 probable and 14 confirmed cases in Tucson from February through July of that year. All 14 of the individuals confirmed to have the measles were unvaccinated. The outbreak cost about $800,000 in containment efforts, according to Science Daily, a science-focused news website. Many parents who opt not to vaccinate their children believe vaccines are harmful. It can be difficult to persuade them otherwise. These tend to be parents who place a high value on personal choice and distrust what the government mandates, Elliott said. At Frank Borman Elementary School, where 88 percent of kindergartners were reported vaccinated last year, nurses and teachers are commonly up against a cultural and linguistic barrier, said Rebecca Osuna, assistant superintendent of administrative services at the Cartwright School District. Some parents were not raised in the United States, Osuna said, and are not aware of vaccination requirements. But they are seldom opposed to the vaccinations when advised of them. About 67 percent of charter school kindergartners in Arizona were under herd immunity last year, compared with 34 percent of public school kindergartens and 43 percent of private schools. Elliott said charters may be less likely to pressure parents to vaccinate their kids or file exemption papers because they want to show parents that they respect their right to choose, a move to keep enrollment numbers and recruit more. Keven Barker, principal and director at Ridgeline Academy near Anthem, said his charter school encourages parents to vaccinate their children and is not worried about enrollment. Barker said charter schools do attract the type of parents who are skeptical of participating in government mandates. "You're looking at the people that choose charter schools, they're looking at something non-traditional. They're not somebody that's looking for the normal education offered by the state, so they're probably also not looking at what's normal for their family," he said. Missing exemptions State health officials use vaccination data to determine where vaccination rates need improvement. ADHS sends a notification to schools and child-care centers with coverage rates between 90 and 94 percent and contacts those with less than 90 percent to discuss the rates. Staff also calls schools and child care facilities that report unsual numbers and those that did not submit data, according to ADHS. A spokeswoman said the Department of Education does not receive immunization reports. The data isn't perfect. Schools must send reports by November, so students missing vaccines or exemption forms may have turned them in after the deadline or moved, said Cara Christ, chief medical officer at the ADHS. Humble said that staff sometimes finds that schools offer parents exemption forms even if their kids are vaccinated because it may be more convenient than asking parents to obtain records from doctors. Or, in the case of Ridgeline Academy, the office collected all documents but didn't report that it had, principal Barker said. The former staffer who compiled the report may have ditched accuracy in exchange for meeting the deadline, he said. The charter school reported that just 71 percent of kids were vaccinated, with nearly all of its students missing exemption forms — placing it among the most non-compliant schools in the state. Barker said he had no idea the numbers reflected that until The Arizona Republic called him. He expressed surprise that the state did not ask him why his school appeared sorely out of compliance with the law. Barker said he received a letter at the beginning of this school year indicating that his school had not fully complied with state law the year prior. But that was a year after 20 kindergartners would have attended school unvaccinated and unexempted if the data were accurate. "There's no penalty," Barker said. "It's like, OK, submit the report. We don't know the importance of it. We were not reached out to .. they didn't talk to us about it." Osuna gave a similar reason for missing 16 exemptions at the Frank Borman Elementary School in Phoenix. The school, like Ridgeline, appeared among the most non-compliant schools in the state based on ADHS data. Osuna said the Cartwright District lost six nurses prior to last year. The remaining nurses and teachers were unable to collect and file all exemption and vaccination records by the reporting deadline, but eventually collected all documentation. But Osuna said the school was not contacted about its numbers. When a child is missing vaccination or exemption records, school nurses and teachers will call and send letters to the parents until they receive the proper documents. Ultimately, they threaten to suspend the kids, which usually generates a quick response, she said. The principal of another school in the Valley with a high number of non-compliant students told The Republic he was unaware of the numbers on file with the state. Happy Valley School East Campus, a charter school in San Tan Valley, reported last year having only 68 percent of kindergartners vaccinated against the measles, with less than 14 percent exempt. "Our policy is that we don't enroll students without vaccine records or exemptions," said Principal Jared Palmer. Palmer declined to comment further about the school's compliance record. California enacted a law this year that made it more difficult for parents to opt out of vaccines. Rep. Carter said she supports legislation like that, but similar bills have failed in the Arizona state legislature. Even given the current measles scare, Carter said she had little hope that such a bill could get through. Rep. John Kavanagh, R-Fountain Hills, chairman of the House Appropriations Committee, said the state ought to send the auditor general out to schools that are not in compliance — and withhold funding for each student that is missing exemptions or vaccines. "I don't want to send immunization police to peoples' homes, but the schools should say, make the change and until you make the change, your enrollment is not complete," he said. Contact the reporter at cmcglade@arizonarepublic.com or 602-444-8290. Varying rates Vaccination rates at kindergartens across the state varied last year from 100 percent to 30 percent. These are the schools that reported the lowest measles immunity rates in the state: —Tucson Waldorf School, Tucson, Pima County: 30 percent —Skyview School, Prescott, Yavapai County: 43 percent —Pine Forest Charter School, Flagstaff, Coconino County: 45 percent —Ajo Elementary School, Ajo, Pima County: 46 percent —Masada Charter School, Colorado City, Mohave County 46 percent —Primary School: Tuba City, Coconino County: 51 percent —Desert Marigold School, Phoenix, Maricopa County: 53 percent —Grand Canyon Unified School District Grand Canyon, Coconino County: 61 percent —Prescott Valley Charter School, Prescott Valley, Yavapai County: 61 percent *This includes only schools with kindergartens with more than 20 students. Source: Hundreds of Arizona schools skirting vaccination rule