As the mother of a special needs child and a four-month-old, Meagan Riggs is the last person who would take a cavalier approach to her children’s health.
So when she got a letter in mid-January from West End Elementary that students there may have been exposed to pertussis, Riggs went on high alert. Her oldest son is a student there.
“The kids were sick and we just thought it was a cold, and I had already brought them to the doctor once and was told it was just a cold,” she said.
Another visit to the family’s primary care doctor got her the same response, and the office didn’t perform pertussis testing. Riggs called the health department, and secured a test at FirstHealth Moore Regional Hospital.
“I was just outraged that it took so long to get testing and not for any lack of trying,” she said. “I have an infant and a medically complicated child; I know how awful it is to be exposed to something, and I don’t think it’s being taken seriously.”
The Moore County Health Department this past week recorded five pertussis, or whooping cough, cases in Moore County Schools: three at West End, one at Pinecrest and one at Southern Pines Primary. The county recorded just two cases in January and February of 2018.
With six so far this year, Moore County is on track to have the highest number of whooping cough cases since 2014. That year, there were 35 cases, Moore County had the fifth highest incidence rate in the state.
The news this past week has put parents of school-age children on alert, with many of them asking how diseases virtually wiped out by years of vaccination can be re-emerging.
The answer is that loopholes exist that allow unvaccinated children in schools. And it only takes one unvaccinated child’s illness to affect others.
In the case of whooping cough, it doesn’t take a large scale anti-vaccination movement to lead to an outbreak of the disease. According to Dr. Christoph Diasio of Sandhills Pediatrics, the vaccine for it “just isn’t that great.”
“In truth there’s always a small degree of pertussis moving through any community,” said Diasio.
“We wish we had a perfect whooping cough vaccine. I think the true story is that this is probably just waning immunity, which is normal and to be expected.”
Vaccinations are most effective when administered on a schedule as provided by a physician, but there are loopholes that allow unvaccinated or under-vaccinated children in schools. And it only takes one unvaccinated child’s illness to affect others.
A Requirement — but Exceptions
Whooping cough is one of several diseases included in a battery of childhood vaccinations. Diseases like mumps, measles and chickenpox — once a common complexity of childhood — have largely been eliminated, and for good reason.
In the case of whooping cough, the vaccination has brought the number of deaths in the United States from 8,000 per year to less than 20. The disease is most dangerous in infants under two months of age; violent coughing associated with pertussis can cause them to stop breathing.
But protections are not infallible and don’t last forever. Kids routinely receive booster shots as a result. Riggs said her four-year-old son tested positive for pertussis despite her children being up-to-date on immunizations.
By law, students attending any public or private school in North Carolina must be fully inoculated against diphtheria, tetanus, whooping cough, measles, rubella, and polio. Moore County Board of Education policy is consistent with state laws requiring schools to suspend admission of children who have not had the requisite immunizations within 30 days of enrolling.
But Moore County — like the state — makes exceptions, and the loopholes can be broad enough to undermine the mandate. Students can remain in school without their immunizations if a parent provides a medical exemption or expresses a religious opposition.
Small but Present Group
So how many undervaccinated children are in public and private schools? The total number is hard to track. The N.C. Department of Health and Human Services only collects data for kindergarten and seventh grade students, and that’s based on students’ status 30 calendar days from the start of school. A student could be in school a month, get their vaccinations, and be in compliance.
In the first part of each school year, principals submit health and immunization reports to the state — recording the number of students with completed immunization records, as well as the number of students with medical and religious exemptions on file.
Current-year data is not yet available because the state extended the reporting deadline after Hurricane Florence. But for the 2017-18 school year, Moore County Schools reported one percent of 1,200 kindergarteners with vaccination exemptions on file. Just one of those was a medical exemption.
The rate 30 days into the school year of kindergarten students who had not obtained the required vaccinations, though, was higher at 4.4 percent overall. That’s consistent with the statewide rate. Of the census of 120,000 kindergarteners in 2017, 4.6 percent were behind on immunizations at that same point in the school year.
“They have to have either the certificate of immunization, a medical exemption certification, or there is something in writing from the parent,” said Phyllis Magnuson, Moore County Schools’ health programs manager.
“They cannot just go without having that on file in North Carolina public schools.”
“Medical exemptions” can apply to students with compromised immune systems or who have had a severe, documented reaction to a past vaccination.
“It’s not easy to come by and it has to be completely documented by a physician,” she said.
Some states allow for “philosophical” exemptions. North Carolina isn’t one of them, but does allow for the medical and religious exceptions. Obtaining a religious objection is easy enough. Some families print documents online, but a written note to the effect that the family’s religion prohibits vaccinations will do.
“They can hand write that, it has to be signed by the parent, but it can be a very simple statement,” said Magnuson.
“We don’t have that many religious exemptions in the county,” Magnuson said. “Our providers are so good at explaining to the parents to begin with, if they have questions or they’re nervous, about why this is so incredibly important.”
Private School Impact
The non-vaccination issue is more pronounced within the ranks of Moore County’s private schools, according to state data. They had some of the highest rates of under-immunization — and not just because of their small student counts.
At The O’Neal School, a private K-12 school on Airport Road, nearly half of the 30-student kindergarten class had yet to receive any or all of the required vaccinations by the 30th day of the 2017-18 school year, according to data supplied by O’Neal to the state. O’Neal started school that year on Aug. 15.
The report asks for the number of students — at the 30th day mark — with either no immunization record, missing records or children not yet fully up-to-date as required by law. O’Neal reported that number as 14.
Another question on the report asks just for the number of students with no immunization record on file as of the 30th day of school. O’Neal’s report to the state lists that number as seven.
A single member of the class had a religious exemption on file, according to the report.
A school representative said that those seven students with no immunization records had gotten up to date by Oct. 1, when the state forms were due.
According to O’Neal school nurse Sue Gibbons, the school had a high number of incoming students facing delays due to private or military insurance authorizing vaccinations based on children’s dates of birth.
“The issue tends to be that insurance companies won’t let them get it done before a certain date,” said Gibbons. “Otherwise, we have families who are not able to get immunizations until the latter part of October. Especially in the military.”
O’Neal typically has a completed immunization record for each student — two families in the school currently have religious exemptions on file — by early November, but the state’s reporting mechanisms don’t reflect that.
This year, six incoming students were behind on vaccines as of the first day of school, and all had gotten up to date by the 30-day deadline. Gibbons also pointed out that she now has access to the state’s immunization registry, so she can view students’ status online at any point.
“I continue to work with these families to make sure that they furnish the information,” Gibbons said. “Being able to have access to NCIR made my job tremendously easier.”
None of the six kindergarteners at Solid Rock Christian in Aberdeen, which reported no exemptions, were up-to-date.
In the public school district, 15 of 914 kindergarteners — or about 1.6 percent — were behind on their immunizations. Most of those did not have an exemption on file.
Some anomalies exist: Southern Pines Primary reported a student with a religious exemption, but a 100 percent immunization rate, and West Pine Elementary had only one exemption on file, yet 10 percent of the kindergarten class was behind on vaccinations. But that still left about 10 students without either an exemption or a certified immunization record.
According to Magnuson, school nurses begin notifying families of their impending suspension date about two weeks before that 30-day point.
“There’s a great deal of communication going on before that last date; we start sending letters and start making phone calls,” she said. “We’re not forcing their hand, we’re calling to ask them how we can help them get this because it’s their requirement to get it to the school.”
And money is no obstacle to vaccination. The district has a “Kids in Crisis” fund for families struggling with finances, and students can be inoculated at the Moore County Health Department with fees on a sliding scale based on the family’s income.
At 30 days into the school year, the district sends home letters of exclusion, effectively suspending students who don’t at least have appointments, verified by the school’s nurse, to receive needed immunizations. Most years, less than five of those letters go out.
In some cases, families aren’t spurred to follow up on their children’s vaccinations until expulsion is looming, so they end up falling into compliance further into the school year than ideal.
This past year, with the delayed deadlines after the storm, there were two such cases. According to Catherine Murphy, the district’s public information officer, both of those students’ families had their vaccinations done and brought them back to school within the week.
Tighten the Rules?
For the most part, diseases like measles and diphtheria have become a distant memory for the families of today’s school-aged children.
“In a way, vaccines are a victim of their own success because people stop thinking of the disease as dangerous,” Diasio said.
So in some cases, schools’ requirements that families keep their children’s vaccinations up to date really are a more compelling factor than fear of infection.
“It’s a very small percentage of people who are trying to slide through the gaps in the system,” said Diasio. “The school requirement has actually been shown in multiple places to be very effective as a broad public health policy. But, as we’re seeing these outbreaks and people having a disease and being put in the hospital and in some cases dying, it raises the question: Do you need to tighten the rules?”
Particularly in middle school, when schools report on seventh grade students’ booster status, families can find themselves scrambling to get their children’s vaccines up-to-date in the first few weeks of school, but find physicians’ offices slammed.
As long as progress is being made, the state’s regulations provide for students to be able to remain in school. But the state doesn’t check back with schools in later in the year for updated figures.
“That is not recorded and the state really doesn’t ask for that information or if it’s ever resolved,” said Magnuson.
And that ends up with a small number of under-immunized students in schools.
When a highly communicable disease arises in a school, Moore County Schools defers to the health department to manage the situation — and make the call whether or not to send unprotected students home.
“Say there is a child with a religious exemption, the first thing we do is pick up the phone and call the health department and ask them what to do with these children, whether or not to exclude them from school,” said Magnuson. “They’re the ones who are legally required to control the situation.”
Protecting the Public’s Health
While schools are vigilant when it comes to vaccination records, there are gaps elsewhere. The homeschooled population isn’t taken into account in the state’s data. In Moore County, that was about 1,600 children last year.
But exemption statistics indicate far lower numbers of undervaccinated children than in some areas of Washington state. The governor there declared a state of emergency after a measles outbreak affected more than 30 people.
North Carolina experienced such an outbreak over two months in 2013 when an unvaccinated Stokes County resident infected another 22 people after picking up the disease in India.
Though immunizations are concentrated in the childhood and teen years, the issue goes beyond their health as individuals. The wider community remains vulnerable.
“We have a lot of older folks here and folks with potentially weakened immune systems, cancer patients. We are all part of the community,” Diasio said.
“The bottom line is that we’re incredibly lucky and blessed to have access to these amazing vaccines to protect our children and our population. Parents in lesser developed parts of the world walk with their kids for three days across the desert to get vaccines.”
Schools do have some power to compel parents to get on top of their children’s immunizations. But ultimately it only goes so far, much to the consternation of parents like Meagan Riggs, who has a houseful of children on preventive antibiotics while watching her four-year-old son suffer through a severe case of whooping cough.
“My first was initially vaccinated and then had a lot of medical complications, so we delayed the rest of his vaccinations. With my subsequent children everybody has been up to date on their vaccinations,” she said.
“You do it because you want to protect your kids … but now I have the kid that is exposed to this even though we’ve done the right things, because I guess not everybody feels the same way about preventive health care.”