With nearly two dozen cases of whooping cough reported at schools in the community where he practices, Vail pediatrician Dr. Christopher Hickie fears the worst may be yet to come.

The father of four won’t treat patients whose parents have chosen not to vaccinate their children because of a personal belief. He has been kicked off a Facebook page for taking on an anti-vaccine parent.

And he has been relentlessly outspoken about his contention that Pima County is using a weak standard for figuring out what constitutes a whooping-cough outbreak, and that more unvaccinated children should be forced to stay home from school.

Whooping cough kills babies, regularly one or two per year in Arizona, Hickie points out. Typically they are infants too young to be fully vaccinated. A major outbreak in California in 2010 left 10 babies dead — all of them younger than three months.

Pima County officials say they are taking the local cases seriously and are maintaining public health without imposing unnecessary hardships on families and without compromising the privacy of infected children. Two outbreaks have been declared where three or more cases occurred in a 21-day period: at Empire High School and at Sycamore Elementary, both in Vail.

The latest case was in a faculty member at Sycamore Elementary, bringing that school’s number of probable and confirmed cases to seven since June.

Pima County Health Department Director Dr. Francisco Garcia has taken angry calls from people on both sides of the issue, including parents of unvaccinated athletes who had to miss important games and others who feel they are being punished for earnest religious and personal beliefs against vaccines.

Garcia is scheduled to talk at a Vail Unified School District parent meeting next week.

Deciding when and who to keep home from school depends on when an outbreak is declared. The Pima County Health Department uses the state standard, which is three or more cases in a 21-day period in a common setting. The “outbreak” standard is important because it’s the standard when health officials begin making decisions about keeping vulnerable children out of school. Unvaccinated children must stay at home for at least two weeks.

Hickie favors the U.S. Centers for Disease Control and Prevention guideline, which calls an outbreak two or more cases clustered in time — within 42 days of one another in a common setting.

Part of the reason the county does not use the federal guideline is that “we would be declaring outbreaks in a bunch of schools,” Garcia said.

“If there is not a benefit in terms of decreasing the morbidity and mortality of children, it’s not something we’re going to do. We do understand it imposes a hardship on parents. I’ve had calls from angry moms who say there’s no one to watch their kids while they stay home from school.

“I don’t want to see a kid in the ICU. I don’t want to see a kid die,” Garcia said. “That is why we keep kids at home. Not because we are trying to punish them. There are some kids allergic to the vaccine and they have to stay home. There are other kids who are incompletely vaccinated because it’s been tough on parents to get them to the doctor on time. It’s a combination and each kid is a little bit different.”

Had the county been using the federal guideline, it would have had to declare eight outbreaks in local schools since August, government reports indicate.

Deciding how to define an outbreak is difficult, said Jennifer Tinney, program director for the Arizona Partnership for Immunization, a statewide coalition.

“It’s always a tricky call. It’s difficult for the health officer because (whooping cough) is always circulating at low levels in the community,” Tinney said. “It’s just a CDC guideline. It’s case by case and a very difficult decision to make.”

Tinney’s organization promotes getting babies immunized as early as possible, and has ramped up promotion of a whooping cough booster shot for older kids and adults, in particular for pregnant women and health-care workers.

Anyone in close contact with a baby should be fully vaccinated, including a booster (called Tdap) for adults, she said. Surrounding babies with vaccinated siblings and adults is called “cocooning” and is the best way to protect them.

Hickie said he was alarmed to learn about the scope of pertussis cases in the fall, since he’d never seen one before in the 9½ years since he opened his practice.

He found himself making calls to the health department, school district and using social media to find out where the cases were occurring. He thinks the health department should be alerting the public about each case.

But Garcia said officials are careful about compromising privacy.

“In many cases, we’re talking about one kid in one school and we’ve already seen some backlash against parents,” Garcia explained. “Until we had more than one case we had been keeping those things under wraps. But we’re working really hard to communicate to the practitioners.”

There are no studies really showing that the exclusion of unvaccinated children is halting outbreaks, said Michael Acoba, epidemiology program manager for the Pima County Health Department.

“We have not had hospitalized children as far as we know,” he said.

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Acoba said Hickie is rightfully concerned about his patients.

“From our standpoint, looking at the entire county, we don’t want to make snap decisions based on emotion,” Acoba said. “We look at what the science is telling us and why recommendations are the way they are. The CDC can say what they want. Unfortunately the CDC is many steps removed from what is occurring locally and so really doesn’t have that ‘eye on the ground’ sort of viewpoint.”

Whooping cough ebbs and flows. Local pediatrician Dr. Eve Shapiro has regularly seen cases in the 30-plus years she’s been practicing. A statewide outbreak occurred in 2005, for example, and cases in Pima County numbered 302. The county total this year so far is 86, which is the highest level since that outbreak eight years ago.

Whooping cough is not just in the Vail Unified School District. Including the Vail cases, there have been 37 confirmed or probable cases in Tucson schools since June 7, health department officials say.

The cases include 34 students and three faculty members. In nine of the cases, the patient was either unvaccinated or under-vaccinated, county records show.

Local health officials say the situation with whooping cough, also called pertussis, is not solely one tied to children whose parents are choosing not to vaccinate because of personal beliefs. A change in pertussis vaccines in the 1990s gave patients fewer side effects but it also wears off more quickly than in the past.

As a result, adolescents, teenagers and adults are often infected because they have not received the booster shot known as Tdap, which is supposed to give extra protection. And even if they are fully immunized, the vaccine is not perfect, with an effectiveness of about 70 percent.

There has also been improved awareness of whooping cough and more doctors may be testing their patients for it.

As far as rates go, Arizona is at 17.2 cases per 100,000 people, which is higher than the national norm but not near the worst state in the country. In 2012, that distinction belonged to Wisconsin, where the rate was 120 per 100,000 people, the CDC says.

Hickie would like Arizona state law changed so that the only children allowed to skip vaccines and attend school are those who are considered medically exempt. His relentlessness has caused some friction on social-media sites where he shares his views. The backlash isn’t slowing him down.

“Too many people are electively not vaccinating,” Hickie said. “I don’t like the idea that people are accepting this as the new normal. It’s not right to wait for vaccination rates to drop and kids to die for parents to start vaccinating again.”