2012 Star special report on vaccinations in Arizona

One in three Arizona schools last year had kindergarten classes with vaccination rates so low children were left vulnerable to infectious disease outbreaks such as measles, mumps or pertussis, an Arizona Daily Star investigation has found.

By far the worst offenders are charter and private schools, some with vaccination rates as low as 50 percent in Pima County and under 30 percent in Maricopa County. Rates need to be 80 percent to 95 percent, depending on the disease, to prevent the spread of infection.

The largest numbers of unimmunized children attend schools that fail to enforce state requirements that students either be immunized or have a personal-belief or medical exemption.

Schools are supposed to suspend students who aren't immunized, but other than sending letters, the state has taken no action. The health and education departments each said the other was responsible for enforcement, and the law doesn't spell out consequences for violators.

The more people in a group who are vaccinated, the better protection for the weaker among them. High vaccination rates help prevent the vulnerable from being exposed to infectious diseases.

Infants too young to be immunized face the biggest risk from an unvaccinated population because their small bodies can easily succumb to an aggressive bacterial disease like pertussis, also known as whooping cough.

High vaccination rates also protect people with conditions such as Down syndrome, whose weakened immune systems make them vulnerable despite vaccinations. Finally, high rates protect those whose vaccinations did not work, which for a disease like pertussis can be as high as 20 percent.

"It's a very real risk, choosing not to vaccinate," said Natalie Norton, whose newborn son died of pertussis in January 2010. "It's like playing Russian roulette with your own children, and with everybody else's."

• • •

Twenty-nine percent of schools in Pima County had levels of at least one vaccination fall below the threshold that curbs the spread of infectious diseases - what's called herd immunity - for the 2010-11 school year. That's the latest data available from the state. For the previous year, it was 31 percent.

The rates were worse in Maricopa County - more than one in three schools fell below safe rates in both school years for at least one of three major vaccinations. They are polio; DTaP, which prevents diphtheria, tetanus and pertussis; and MMR, which protects against measles, mumps and rubella.

Medical experts say safe herd immunity for DTaP is 90 percent, MMR is 95 percent and polio is 80 percent.

Dozens more schools have rates below safe levels, but the state is keeping their names secret. The Arizona Department of Health Services refused to release complete data for schools with fewer than 20 kindergarten students because it said parents could figure out how to identify unvaccinated children.

The state provided vaccination data from those schools, but redacted their names. Based on the data provided, it's clear the schools are highly vulnerable to disease outbreaks. More than half fall below safe vaccination levels.

The problem is growing because more kindergarten students are coming to school unvaccinated and staying that way, despite more outbreaks and deaths from vaccine-preventable diseases.

Measles in the U.S. reached a 15-year high in 2011, said the U.S. Centers for Disease Control and Prevention.

A Phoenix baby too young to be immunized died of whooping cough in late April.

A Gilbert school forced its unvaccinated children to stay home for a month in February after two students contracted mumps on a trip to Canada.

A 36-year-old Swiss tourist with measles led to an outbreak in 2008 that began at Northwest Medical Center and cost $800,000 to contain.

Desert Marigold, a Phoenix charter school, had a whopping cough outbreak in December with eight confirmed cases and many more suspected by Maricopa County health officials, who nearly shut down the school.

Desert Marigold had the second-worst vaccination rate in the state in 2010-11. Less than 30 percent of its kindergartners were vaccinated for MMR, polio and DTaP, which helps prevent pertussis.

Desert Marigold Administrator Charles Burkam said he didn't "necessarily see a tie" between the rock-bottom vaccination rates and the outbreak.

• • •

Natalie Norton will never escape the devastating consequences whooping cough had on her family.

Norton, a 30-year-old Phoenix photographer, says she and her husband, Richie, suffer each day.

In late 2009 the Nortons were living in Hawaii with their four boys. They decided to go to Utah for the holidays, and Natalie got the go-ahead from her newborn son's pediatrician to travel. Not quite eight weeks old, Gavin Norton was too young to be immunized against whooping cough.

He was scheduled to have his first shot when the family returned from vacation.

Infants are among the most vulnerable to whooping cough. Children and adults who aren't vaccinated might not get sick themselves, but they can pass the illness on to babies like Gavin.

Shortly after Christmas, Gavin began coughing.

"It was one cough here, another cough there. We decided to take him to the ER - he hadn't been eating well, and we were concerned about dehydration," Norton said. "I truly just believed they would give him some fluids, and they would send him home. When they decided to admit him I was very surprised."

Gavin was transferred to the pediatric intensive care unit, and his condition worsened.

"We got a positive test for pertussis, and from there it was a very quick decline," Norton said. "We sang to him, and we spent as much time right at his side as we possibly could."

Richie Norton put his hand on his son's chest and felt for the last beats of Gavin's heart.

"And within moments, he was gone," Norton said. "We left the hospital with empty arms. We had to leave him there and go back to the reality that we were not whole."

Norton now advocates for childhood immunizations against pertussis and urges adults to make sure they are up to date, too.

"I never thought this would happen to my family," she said, "and yet, here I am, two years later, still trying to pick up the pieces of my broken life."

Cases of whooping cough have increased in Arizona and nationwide. There were no pertussis deaths in Arizona between 1991 and 2002. But since 2003, there have been six. There were 11 times as many cases of pertussis in 2011 as in 1991.

Deaths are up elsewhere, too. Ten infants died of whooping cough in California in 2010 alone.

Children who have weakened immune systems - those with cancer or Down syndrome, those who are organ transplant recipients or take intensive medicine like steroids - are also vulnerable. Older kids who aren't vaccinated can bring home diseases like whooping cough to their younger, more susceptible siblings.

"You are vaccinating your kids so that you protect your community. It's a community responsibility - it's a social contract," said Will Humble, director of the Arizona Department of Health Services.

Humble said some children, like his son Luke, who has Down syndrome, have fewer antibodies to fight off disease. That's why Luke, 18, came down with chickenpox even though he'd been vaccinated against it, Humble said.

"He's the kind of person that we need to vaccinate everybody for," Humble said. "It's about community protection, not personal protection."

• • •

By far the worst offenders with unsafe vaccination rates - in Pima County and statewide - were charter and private schools, the Star's investigation found.

The cause is not parents signing waivers to opt out of vaccinations. Rather, it's schools letting kids come to class unvaccinated.

In other words, schools are not following the state law that requires immunizations or a waiver.

Eight of the 10 worst schools in Pima County for vaccinations in 2010-11 were charter or private schools. The Academy of Tucson Elementary and the Academy of Math and Science on Prince Road had the worst vaccination rates in Pima County last school year, with less than 60 percent immunized for multiple vaccines.

The state's data showed some Pima County public schools in lower-income areas below safe levels in 2010-11 - but still much higher than many charter schools. Those public schools said they got their rates above 95 percent over the next few months through a combination of parent education and diligent enforcement.

Charter schools, by contrast, did not report similar improvements or raise rates to safe levels.

The Star found the key to higher vaccination rates is for schools to require parents to show proof upon enrollment and then to follow up with noncomplying students. A school nurse helps, but what schools really need is a commitment to vaccinate.

Deborah Bryson is the principal at Desert Willow Elementary in the Vail School District, which has one of the best vaccination rates in Pima County. She said the school won't let children register without meeting state requirements. There is a grace period, but the staff gets more aggressive with each follow-up, requiring the date of the doctor's appointment and then finally telling kids they cannot attend school. Bryson said she's never had to exclude a child, however.

The Academy of Tucson, questioned by the Star about its low vaccination rates, said it will adopt many of these procedures next year.

But at Khalsa Montessori School, which had low vaccination rates for both years the Star examined, the philosophy is that vaccines are "a parent's choice," said Director Nirvair Khalsa.

"The school's job is to collect the data and report it," Khalsa said.

At the Academy of Math and Science, front office manager JoAnn Belvedere said it's difficult to get some parents even to just sign the waiver. "Some of them get very indignant. ... There's not much you can do when your parents don't comply," she said.

Belvedere said all she needs to do is get the rates above 75 percent. She's wrong - that's below herd immunity for all diseases.

Dr. Bob England, director of the Maricopa County Department of Public Health, said charter schools are low for two reasons: They usually don't have a school nurse, and they have a higher percentage of alternative-minded parents who believe in natural medicine. Desert Willow Principal Bryson noted that charter schools face enrollment pressures that could contribute to lower rates because they don't want to lose students who fail to comply.

England almost sent home 70 percent of Desert Marigold's students during the pertussis outbreak in December because they were unvaccinated. Unlike most schools with low rates, Desert Marigold makes its parents sign a waiver and has only a small percentage of students who don't comply with state law.

Burkam, the Desert Marigold administrator, said low rates could be because it is a Waldorf school. Waldorf parents spend quite a bit of time informing themselves and don't just take the word of authority, he said.

"They make up their own minds."

• • •

Schools that fail to comply with the vaccination law don't face any consequence.

No one is enforcing the law. The two state departments responsible for vaccinations - Health Services and Education - point at each other while children go unvaccinated.

State law says students cannot attend school without full immunizations or a waiver. Students without either are supposed to be suspended.

"There is absolutely no consequence to a school if they report or don't report at all," said Dr. Michelle McDonald, chief medical officer for the Pima County Health Department. "You have no idea how much work this is, to go to all these schools and get this data. ... To not have any consequences for that work is kind of galling."

Health Services collects immunization data from counties, but department officials said enforcement is up to Education. State law doesn't say that.

Health Services sends a letter to schools with vaccination rates below 80 percent, but it does not say what will happen if the school doesn't raise the rates.

Neither department can remember a school being sanctioned over vaccinations. Education spokesman Ryan Ducharme said the law is silent on what to do if schools don't suspend students, meaning there is no teeth to it.

McDonald said county health departments are powerless.

"The county Health Department has no authority to tell a school to do anything," she said. "We can educate until we are blue in the face, and that's really all we can do."

• • •

Tucson naturopathic physician Tevna Tayler doesn't vaccinate her two children, and said she does not worry about them contracting vaccine-preventable diseases.

"I felt like the potential risks outweighed the benefits," she said. "You can die from anything, but I'd rather naturally boost the immune system. In what natural world do you get injected with a strange concoction?"

She is one of a growing number of parents who fear health repercussions from immunizations. Some say there are too many vaccinations. Others believe vaccinations cause autism, although that link has been discredited by leading medical journals, the mainstream medical community and the U.S. government.

Dr. Sean Elliott, a pediatrician who specializes in infectious diseases at the University of Arizona Medical Center, said vaccinations are in some ways a victim of their own success. People have forgotten the viciousness of the diseases they prevent.

"People forget what real measles looks like, and the fact that it can be fatal. They forget what mumps looks like and the fact that it can cause sterility in men and be fatal," he said.

The last six cases of pertussis Elliott treated were all infants below 2 months old, too young to be vaccinated. Infants typically have prolonged intensive care stays. Some are hooked up to an external lung. Elliott has watched babies die.

"It is horribly tragic," he said.

McDonald said a school with only 75 percent of its students immunized is not much better than having only 25 percent vaccinated.

Schools and classrooms are "microuniverses," which is where many outbreaks occur, said Dr. Karen Lewis, medical director for the state's immunization program.

"What really protects you isn't so much the vaccine you get: It's the vaccines the people around you get," Maricopa County's England said. "It's crucial in a school to keep the herd immunity high."

Live chat on StarNet

Chat with Star reporters Rob O'Dell and Stephanie Innes about this series at noon MST Tuesday. They will also welcome your ideas and questions for future stories about why so many Arizona parents are not vaccinating their kids.

Find the chat at live.azstarnet.com

Deficient rates by county

Percentage of Arizona schools with vaccination rates below safe levels for at least one of three major vaccines

* State health department withheld data for Greenlee County

10 worst Pima County schools for vaccination rates

Figures reflect percentage of students vaccinated in the 2010-11 school year. Percentages in parentheses under the vaccines are considered safe levels.

 *Ranking based on school's percentage below safe levels on at least one of three major vaccines

• Students from the University of Arizona College of Medicine will be holding free Tot Shot clinics this summer at the Community Food Bank, 3003 S. Country Club Road. The clinics are scheduled for 9 a.m. to noon on July 28 and Aug. 18.

• The Pima County Health Department holds regular immunization clinics throughout the year. The department also holds back-to-school clinics in July and August. For a complete schedule of clinics, go to www.pimahealth.org/ The Health Department's administration fee is $15 for a single shot, $25 for two to five vaccines, and $35 for more than five vaccines. Fees can be waived for an inability to pay. Adults are charged the price of the vaccine plus an administration fee.

• Regular county clinics plus hours. The clinics are walk-in except where appointments are specified: • Ajo Office, by appointment, 1-520-387-7206. • Catalina Community Clinic, 3535 E. Hawser, by appointment, 825-9299 or 243-2850. • East Office, 6920 E. Broadway, 1-4 p.m. Mondays and 9 a.m.-noon on the third Saturday of month, 298-3888. • Green Valley Office, 601 N. La Cañada Drive, 1-4 p.m. Wednesdays by appointment, 648-1626. • North Office, 3550 N. First Ave., 1-7 p.m. Thursdays, 243-2850. • South Office, 175 W. Irvington Road, 1-4 p.m. Tuesdays and 1-6 p.m. on the fourth Tuesday of the month, 889-9543.

What about adults?

Before 2005, the only booster available contained protection against tetanus and diphtheria (called TD), and was recommended for teens and adults every 10 years. Today there is a booster for preteens, teens and adults that contains protection against tetanus, diphtheria and pertussis (Tdap). Adults should get vaccinated with Tdap at least two weeks before coming into close contact with an infant. This is especially important for families and caregivers of new infants.

The current recommendation is one DTaP, then back to the 10-year TD schedule. It remains to be seen whether there is a need to reboost the pertussis immunity with DTaP 10 years after the first dose.

If enough people are vaccinated, an isolated case of infectious disease will not morph into a full-blown outbreak.

This is called "herd immunity" - the unvaccinated are more protected because they aren't exposed to the disease. To achieve it, vaccination rates need to be 80 percent to 95 percent, depending on the illness.

Herd immunity relies on the effectiveness of the vaccine and how easily transmissible the disease is, said William McKinney, associate dean for research at the School of Public Health at the University of Louisville.

On the low end, herd immunity for polio is about 80 percent, McKinney said, while measles is at the high end at about 95 percent. The Star used those standards as safe levels for polio and measles vaccines.

Measles is highly infectious because it is spread through airborne droplets that remain active on surfaces for up to two hours. Polio is less infectious because it is spread through the "fecal-oral" route, where one person's contaminated feces are ingested by another person due to poor hand washing or unsanitary conditions.

Other vaccine-preventable diseases fall between the herd immunity of polio and measles, McKinney said.

For DTaP, which protects against pertussis, tetanus and diphtheria, the Star - after consulting with public-health experts - used 90 percent as a safe level. Pertussis and diphtheria are infectious because they are spread through the air by coughing and sneezing. In addition, the pertussis vaccination is effective in only about 80 percent of those who receive it, said Maricopa County Public Health Director Dr. Bob England. That calls for high herd immunity.

England said the unvaccinated serve as potential vectors for the disease, which can keep an outbreak going - a reason unvaccinated children are often removed from schools if there is an outbreak, such as a February wave of mumps in a Gilbert school, he said.

McKinney said a good metaphor for herd immunity is a herd of cattle that puts its weaker members on the inside of the group, protected by the stronger individuals on the outside. This shields the vulnerable against attack by predators such as wolves.

For people, the weaker members at the center of the herd are babies, those with weakened immune systems or whose vaccines didn't work. "Those folks are insulated from those diseases by the healthy people," McKinney said.

What exactly constitutes a herd? Basically, a group of people who regularly share the same space and circulate together, McKinney said.

For younger children - like the kindergarten classes the Star analyzed - "their classroom is pretty much the herd," McKinney said. For high schoolers, who switch classes regularly, the herd is at least as large as the grade level, and could be the entire school.

The state requires schools to report vaccine data in kindergarten, sixth grade and 10th grade. The Star chose to examine kindergarten data because those small classes most resemble a herd for disease purposes.

The Arizona Daily Star first requested vaccination data broken down by schools from the Arizona Department of Health Services on Jan. 4.

After several follow-ups and rounds of back and forth, the state turned over immunization rates of kindergarten students in the 2010-2011 school year on Feb. 10.

Data from 216 schools with fewer than 20 children enrolled in kindergarten were missing. The state refused to release the data, "to ensure the privacy of children and families." State officials said the information could be used to identify unvaccinated students on the campuses, which represent 17 percent of Arizona schools.

The Star requested follow-up data on immunization rates of kindergarten students in the 2009-2010 school year, and threatened to sue to obtain data on the missing schools. We argued there's no obvious way to know who has been vaccinated or not unless parents choose to reveal that information.

We also pointed out that the data isn't from the current school year. The kids in second grade probably are not the same group that was in kindergarten two years ago, making identification of individuals even more unlikely.

The state provided the requested 2009-10 immunization data, but again left out schools with fewer than 20 kindergartners enrolled. The state stood by its privacy position and said it was prepared to defend it in court if the Star sued to obtain the school names.

In April, after more back and forth, the state agreed to provide data from all but one of the 216 schools with the name and address of the schools redacted, grouped by county. State officials contended they still couldn't release Greenlee County because it only had one school in the group, so it would be easy to identify the unvaccinated students.

The state would also not release any exemption or enrollment data for those 215 schools, when it provided the redacted data on May 1.

Star reporters organized, cleaned and simplified the data, found additional information on schools and queried the data to determine which schools fell below safe vaccination levels.

Finally, the Star created searchable databases for all schools statewide. They can be found at www.azstarnet.com/databases

Public service is an important part of the Arizona Daily Star's mission.

The newspaper's public-service projects in recent years have exposed the gaps in Arizona's mental-health system, explained the dangers of childhood obesity and revealed weak government oversight of nursing homes.

Today we begin an examination of low vaccination rates in Pima County and Arizona. The first installment investigates low rates for kindergartners and reveals that a state law requiring children to be immunized is not being enforced.

Next month, we analyze the latest in the perceived link between autism and vaccinations, and how that belief, discredited by professionals, contributes to low vaccination rates.

Send your thoughts or ideas to reporters Stephanie Innes at sinnes@azstarnet.com or Rob O'Dell at rodell@azstarnet.com.