Incomplete vaccination records leave schools guessing

Meghan Hoyer | USA TODAY

As the measles outbreak spreads across the country, tens of thousands of children remain in a paperwork limbo — unsure whether they are fully vaccinated, a big unknown in assessing the risk at many schools.

A USA TODAY analysis of school vaccination records found that at more than 2,200 public and private schools in 12 states, at least a tenth of kindergarten students had either incomplete vaccination records or had fallen behind schedule in receiving their shots.

In some cases, schools dismiss that as a documentation problem, pointing out that many students have had at least one shot.

Not knowing can exacerbate a crisis.

"You have to have all that information before you can start the work of controlling the outbreak," says Shoana Anderson, director of communicable disease and emergency preparedness for Nashville's Department of Public Health. "The amount of staff time and work that it takes to gather that is incredible. And with diseases, you don't often have awhile."

As an epidemiologist, she spent three months in 2008 trying to contain a measles outbreak in Tuscon.

In that outbreak, which centered around two hospitals and entered at least one school, half the 14 confirmed cases were in people with unknown immunization status.

Hundreds of hospital workers and a handful of schoolchildren who may have had contact with the patients couldn't provide proof of immunization — meaning workers had to be sent home and students kept out of school for as long as 18 days. The outbreak cost the hospitals nearly $800,000 and 15,000 lost hours of work, mostly because of furloughs, a report from the Centers for Disease Control and Prevention found. Among those who weren't sure of their vaccination status, about 10% were found to have no immunity.

"Most of the time, it doesn't impact you — these cases are so rare that you might never face the situation," Anderson says. "But when it does happen, it has a pretty big impact."

Students arrive at school without their shots for lots of reasons. In low-income neighborhoods, access to doctors has long been an issue. Newly arrived immigrants often appear without proof of immunization or with a spotty history of vaccinations. In some cases, parents scared of their children receiving more shots have decided to slow or stop the vaccination schedule. Anderson said lost or missing records can be a huge problem if parents change doctors or move.

Nearly 270 of the schools with the highest incomplete record rates were in Los Angeles' Unified School District. At a handful of schools with the most extreme cases, as many as nine out of every 10 children begin kindergarten under the state's conditional entry program for students missing some vaccines or their immunization paperwork.

"I know that sounds alarming," says Tonya Ross, the district's director of nursing, but she points out that conditional students in most cases have received at least some of their immunizations and that even if students receive one measles shot — instead of the recommended two — they still have 95% immunity.

Despite an outbreak of measles that began at nearby Disneyland, not a single case has appeared among students in the district's schools, she says.

"Even most of our students who have exemptions have some immunizations," she says. "The kids are for the most part protected."

Whether they — or any of the children across the country whose vaccination status is recorded as "incomplete" or "conditional" — ever get fully caught up on vaccines is less clear.

In Virginia, 104 schools have conditional entry rates above 10%. Parents have 90 days to get their children caught up, state epidemiologist Sandra Sommer says.

Sommer's office doesn't track or follow up on the conditional enrollment figures provided by each school, she says. More than half the schools with high conditional enrollment are in Northern Virginia's Fairfax health district, but only a "low" number of students have been taken out of school for failure to comply with the law.

Los Angeles school district officials couldn't say how many students had been taken out of school for not completing their vaccinations.

"That's always a last resort," Ross says. "We want all kids to be in school."

Epidemiologist Saad Omer of Emory University's Vaccine Center said his research had shown that many students who fall behind on immunizations never catch up.

"We do know that some parents eventually complete, but a majority of them don't," he says.

To look at the issue of incomplete records, USA TODAY analyzed immunization data collected from more than 42,000 public and private schools in 25 states across the country. Half the states don't require schools to report incomplete cases — Massachusetts, Illinois, Minnesota, New York and Arizona are among those. Some track the matter internally — Illinois law dictates that each school must keep a list of all students who aren't fully vaccinated.

In Arizona, state law says students without proof of all vaccinations are required to stay home during outbreak incidents. This year, unvaccinated students at two California high schools — in Huntington Beach and Palm Desert — were told to stay home after measles cases were diagnosed.

Starting in April, California's Oakland Unified School district won't allow students to attend school unless they have all their vaccines on file or have an exemption. The district has 40 schools that had conditional entry rates over 10% at the beginning of the school year.

Spokesman Troy Flint says those numbers are mostly because of untrained staff and spotty internal record keeping. Last week, the district trained employees how to properly report and follow up on vaccinations.

"I've seen this happen in schools where you do the training, and the vaccine rate goes from 20% to 90%, it was all just clerical error," he says.

Ross says her district works to see that students receive all their shots. School administrators pass pamphlets to parents about public health and school-based clinics. In areas where students often don't regularly see a doctor, school nurses host vaccine clinics. Nurses use the state's immunization registry to check whether proof of immunization for students has ever been entered in another city.

"We do hear a lot about that it's a burden for schools to monitor this information," says Shannon Stokley, associate director for science at the CDC"s immunization services division. "But it's in their best interest, so they know their children are protected."

Steve Reilly and Elizabeth Weise contributed to this report