BY JULIE MACK AND ROSEMARY PARKER

A baby with whooping cough struggles for life while attached to a heart-lung bypass machine. A child on a ventilator suffers intractable seizures because of meningitis.

Drs. Ryan and Andrea Hadley, both physicians for University of Michigan Health System, know first-hand the devastation caused by vaccine-preventable diseases. They also know contagious diseases such as measles and whooping cough are making a comeback.

So when it comes to seeking day care for their own 1-year-old daughter, they're looking beyond cost and location. A top priority for them is finding a center where all or nearly all of the children are fully vaccinated.

That's no simple task in Michigan, where three-quarters of children in licensed day care attend a center with vaccination rates below federal guidelines, an MLive.com analysis shows.

Many of those centers are in the state's wealthiest, most densely populated counties, including Oakland, Washtenaw and Livingston, although virtually every county in Michigan has day cares with low vaccination rates.

Day cares house the very population most at risk of catching vaccine-preventable diseases. Infants and toddlers too young to receive many immunizations often play alongside older children with no sense of personal hygiene.

When they do get sick from vaccine-preventable diseases, very young children are more likely to develop complications.

"I have seen babies too young to be vaccinated near death in the ICU or who died from vaccine-preventable diseases that were passed to them from unvaccinated kids. It's terrible," Andrea Hadley said.

But while state law requires day cares to provide parents with detailed daily records of what their baby eats and drinks, of every diaper change and nap, there is a lax approach to the threat posed by vaccine-preventable disease.

MLive.com's investigation found:

* There are no consequences for day cares that enroll unvaccinated or undervaccinated children. In theory, the law requires children in day care to be vaccinated unless their parents sign a waiver. In reality, day-care providers are not penalized for enrolling unimmunized children. Their only responsibility is to document each child's immunization status, good or bad.

* A focus on record-keeping compliance over actual vaccination rates. The state sends out congratulatory letters to day cares with at least a 90 percent compliance rate, even if a center's actual vaccination rate is low. "They know what they have to do" to meet state regulations, which is to collect records on each child, said Wendy Trute, public health director of Grand Traverse County. "They haven't been focused on the bigger picture'' of the threat posed by a disease outbreak. Moreover, "no consequences exist for preschools or centers that do not reach a certain level of compliance," said Karen Manni, Washtenaw County's school immunization liaison.

* State law does not require day-care workers to be immunized. "That's completely crazy," Hadley said. "It's almost inexcusable."

* Publicly funded day cares can't exclude unvaccinated children. While private day cares can exclude unvaccinated children and staff, day cares that receive public dollars cannot. And parents may not even know whether their day care is receiving public money.

* The vaccination status of individual children and staff is confidential. A center is allowed to tell what percentage of staff and children are vaccinated, but cannot identify the individuals or provide additional information such as ages, which can make it hard for parents to assess the level of risk for their child.

Of the approximately 159,000 children in a licensed day care with at least five children, the MLive.com analysis of state data shows 119,000 are in centers where less than 95 percent of the children are fully vaccinated, the benchmark recommended by the federal Centers for Disease Control and Prevention.

Daycare vaccination-rates database

Use the text field to search a day care by name.

The average day-care vaccination rate of 87 percent is lower than the rate in Michigan's K-12 schools, which rank among the worst in the country.

MLive.com published in December an investigation of K-12 school vaccination rates in Michigan. Read the entire series here.

Even children who are up-to-date on immunizations are at risk when they have playmates or caretakers who are unvaccinated since no vaccine is 100 percent effective. Experts say the real safety net comes from "herd immunity," an environment where everybody who is medically able is vaccinated and contagious disease can't gain a foothold.

In 2013, about 400 Michigan children age 5 or under had a vaccine-preventable disease, including cases of whooping cough, chicken pox, measles, mumps, meningitis and Haemophilus influenza, also known as Hib, state data shows.

Yet, "I honestly think vaccinations are off most people's radar" as a public health concern, Trute said.

Grand Traverse County experienced outbreaks last winter of measles and pertussis, which is better known as whooping cough. Before those outbreaks, Trute said, "people thought everybody got vaccinations and there were only small pockets that didn't."

Traverse City learned the error of that thinking the hard way.

More than 20 schools and day cares got caught up in the region's pertussis outbreak last winter. Trute's office tallied 91 confirmed cases of pertussis and at least 142 probable cases, and that doesn't include cases not reported to health officials.

The youngest victim was 4 months old.

Some were hospitalized.

Around the same time, a nationwide outbreak of measles sickened a dozen babies at a KinderCare in a suburb of Chicago. Health officials in Oakland and Grand Traverse counties, where there also were cases of measles, say it was pure luck they dodged that bullet.

In Traverse City, measles were confined to a single family with young children because the children fell ill during the Thanksgiving holiday and were not in school exposing classmates, Trute said.

Shane Bies

In Oakland County, a mother with a child in day care called health officials immediately when she realized she could have measles, said Shane Bies, administrator of public health services for the Oakland County Health Department. The department ramped up an emergency response within hours, contacting more than 130 people who had potentially been exposed, and vaccinating adults and children over the weekend.

Luckily, the day care the woman's child attended had a high vaccination rate already and there were no additional cases of measles.

"That's how herd immunity works" -- a well-vaccinated community can stop an outbreak in its tracks, Bies said. "Had it popped up in a different center in this community, the outcome might have been far different."

It shows why parents should make it a priority to check vaccination rates when looking for day care, said Dr. Kelli Dodson Hunt, a Kalamazoo pediatrician and mother of a young son.

"When you have a newborn, you don't want anyone around - siblings, grandparents, cousins, friends - who haven't been vaccinated. You're taking a huge risk otherwise," she said.

That also includes children and staff at day care. "I have a lot of families where it doesn't cross their mind" to ask about day-care vaccination rates, she said. "But it's very important. .... Kids are very vulnerable."

'One of the worst'

The Michigan Department of Health and Human Services annually tracks vaccination records of children in public and private schools and licensed day-care centers. The data for licensed day-care centers with at least five children is public.

In October 2014, state records show, there were 3,629 licensed day cares with at least five children. Of those, 2,560 were below the federal recommended benchmark of having 95 percent of their children fully vaccinated.

Only eight of Michigan's 83 counties have average day-care vaccination rates above the 95 percent benchmark. As is true with K-12 vaccination rates, undervaccination among day cares is due in part to parents who shun vaccinations or who devise their own prolonged schedules for their children's shots.

Counties with the worst average day-care vaccination rates include Clare (70 percent), Leelanau (79 percent), Livingston (82 percent), and Oakland, Washtenaw and Grand Traverse (all 83 percent).

It is difficult to say where Michigan ranks nationally with day-care vaccination rates because the CDC does not track that information as it does in the case of kindergartners.

In 2013-14, Michigan had the fourth-highest rate of kindergarten vaccine opt-outs in the nation, behind only Oregon, Idaho and Vermont, according to the CDC.

Paul Offit

"Michigan is one of the worst states" for liberally granting waivers, an important contributing factor in low vaccination rates for children in day care as well as school aged-children, said Dr. Paul Offit, a leading authority on vaccinations in the United States and chief of the infectious diseases division at Children's Hospital of Philadelphia.

The state of Mississippi allows only medical waivers to vaccination for children entering kindergarten and also for those in day care. Mississippi's vaccination rate for children entering kindergarten is near 100 percent, according to CDC records.

Mississippi regulations for day-care centers require that any child attending a licensed center be up to date on vaccinations, said Liz Sharlot, director of communications for the Missisippi State Department of Health. The vaccination rates for day cares hover at around 95 percent, she said.

In addition, facilities are randomly selected quarterly and every third child in a selected site is sampled to assure children are, indeed, up to date on their shots, she said. Centers that fall short are subject to penalties if they do not improve their practices, she said.

While waivers can be a big issue in K-12 schools, an even bigger problem for day cares is posed by parents who have started vaccination, but have fallen behind. Some couldn't get to the doctor, or a shot couldn't be given on schedule because the child was sick or the doctor's office was out of the vaccine. In yet other cases, the parents worry about giving too many shots in rapid succession and plan to try a different schedule that increases the time between vaccinations, public heath experts say.

Statewide, only 87 percent of children in licensed day cares have received all the recommended vaccinations for their age, the most recent data shows.

Of the remainder:

* Six percent are classified as provisional, which means the child has received at least one round of the recommended vaccinations and is waiting for, but is not yet overdue on, another shot. These are the children who may have fallen behind because of scheduling issues, a parent's inability to get to an appointment, a child's illness with a cold or virus at the time the next shot is scheduled, or a variety of reasons.

* Four percent of children in day care are overdue for their required shots Those children are classified incomplete.

* Three percent have waivers, indicating their parents do not intend to vaccinate the children. If they adhere to the recommended schedule -- seven vaccines totaling 16 shots that immunize the child against 11 diseases -- children should be able to complete all of the preschool vaccines by age 18 months.

"It is more difficult to keep kids current because of the number of vaccines being administered at the young ages," said Bob Swanson, director of immunization for the Michigan Department of Health and Human Services.

But it's important.

Day-care vaccination rates in Michigan counties.

Research shows children who fall behind early on the immunization schedule are more likely to either not complete the vaccines or complete them late, Swanson said.

Public health officials note children with "provisional" status are not as fully protected as they could be for their ages -- and that increases a day-care center's vulnerability to outbreak of vaccine preventable diseases.

"The vaccine-preventable disease doesn't know 'provisional,'" said Jane Nickert, director of Nursing for the Washtenaw County Health Department. "The disease does not know your good intentions."

As is the case statewide, Washtenaw County health officials face challenges of delayed vaccination schedules and parents or guardians who are opposed to vaccination, relying on information that is not credible, said Karen Manni, the public health nurse who serves as the county's school immunization liaison.

In addition, until requirements were made more stringent in January 2015, some parents sought waivers out of convenience, because it was easier to opt out than to get their kids in for shots, she said.

"If we're making it easier to sign a waiver than to get the vaccines, that's a problem," Trute said.

Who should parents ask?

While the vaccination rates for day cares with five children or more is public information, deciphering the data can be confusing -- even for day-care operators.

Day cares and preschools report their immunization records once a year, in October. While the status of fully vaccinated children 18 months or older will not likely change over the course of the year, that is not the case for infants who are just beginning their shots, or those whose parents delayed their vaccinations or followed a schedule not recommended by the CDC. Their provisional status may fluctuate during the year as they get caught up with more shots -- or fail to keep up.

When MLive.com contacted a sampling of day cares with the lowest vaccination rates in the state, day-care officials questioned the accuracy or currency of the data -- which the centers themselves report.

Day cares may view their "provisional" children as "up-to-date" on their shots because they are not overdue on their next series, even though they are behind where they should be for their ages.

For instance, state records shows that Gretchen's House day-care facility on Stadium Boulevard in Ann Arbor has a compliance rate of 95 percent, which means the state has paperwork on 41 of 43 children. It's a task they take seriously, said Heidi McFadden, director of Gretchen's House.

"Each center has a system for regular review of the immunization and health records throughout the year, and as children transition to new programs, such as moving from an infant room to toddler, or to preschool within our centers," McFadden said via email. "The penalty for not having appropriate documentation (no medical waiver or approved philosophical waiver) would be that a child cannot be enrolled. We comply with the State requirements on such matters."

But only 21 of those children - 49 percent - are fully vaccinated, state records show. Another 20 are provisional and two were incomplete.

At Karnak Creative Infant Center in Wayne County, where state records show only 11 percent of the children were fully vaccinated in October 2014, the records show there are no waivers on file. But only three of the 28 children listed as enrolled at the time the records were collected were listed as fully vaccinated. Another 24 were provisional and one was incomplete.The center's website says it accepts infants from birth to 18 months.

Jennifer Skeens, director of the center, declined to comment except to insist that every student is "100 percent completely up to date, all are current on their shots," a fact she said she had confirmed with her local health officials.

However, Nickert and Bies said a provisional designation is not the same as being fully vaccinated. They said parents can contact local health departments with questions they have about a particular day care's vaccination rates.

More transparency

Recent outbreaks of measles and pertussis have served as a wake-up call for some parents and day-care centers.

KinderCares across the country now require all staff working in infant rooms to be vaccinated against measles. The day-care chain also is "also limiting access to our infant classrooms to immunized teachers and center management staff and to those dropping off or picking up a child," a spokeswoman said. KinderCare has 22 centers in Michigan.

After the whooping cough outbreak this past winter in Grand Traverse County, The Children's House -- a private Montessori school in Traverse City -- implemented a rule that new students must be fully immunized as a requirement for admission. Only medical waivers will be allowed.

Trute said her office is encouraging other day cares in Grand Traverse County to follow that example. "They set what we consider as a kind of a gold standard," she said. "In fact, we nominated them for a community hero award."

Beth Olosky runs a day care out of her home in the Traverse City area. When whooping cough surfaced in her oldest son's high school last winter, she was concerned about the possibility her son might bring it home and infect his younger siblings, as well the children she cares for. Vaccination rates were not something she thought much about "until the outbreak hit home."

Now she says her parents are asking about the immunization status of the other children, and she is thinking she would decline to care for a child whose parents refuse to vaccinate.

"It was absolutely an eye-opener," she said about the outbreak in Traverse City. "It was a scary time for a while."

Dr. Sarah Clark

A recent national survey conducted by the University of Michigan suggests that parents want increased transparency and more stringent requirements when it comes to day-care vaccination policies. The survey questioned 614 parents with children under age 6. The poll found two-thirds of parents think they should be informed of the number of children in a day care who are undervaccinated, and 41 percent support a policy to exclude under-vaccinated kids from day care until they become current.

Sarah J. Clark, a U-M researcher involved in the survey, said the takeaway message is parents shouldn't be shy about asking questions. "It's perfectly legitimate for parents to ask questions of their day-care provider about the number of children who aren't fully vaccinated," she said, "and then to make choices about which day care their child will attend.

Julie Mack and Rosemary Parker are reporters for MLive.com. Reach them at jmack1@mlive.com and rparker3@mlive.com.

MORE:

* Why delayed vaccination schedules are a bad idea

* For child with cancer, vaccinations in day care can mean life and death

* 7 things to know about day-care vaccinations

* Day-care vaccination rates in Michigan's 30 largest counties