The number of unvaccinated children in Michigan continues to climb, especially among the state's youngest children, and as southeast Michigan has struggled with a measles outbreak.

Statistics from the Michigan Department of Health and Human Services show that 14,874 children, or 3.8%, had vaccine waivers in 2018. A waiver opts them out of getting vaccinated before entering school or day care. That's compared with 14,365, or 3.6%, in 2017.

Search: Vaccination waiver rates for Michigan schools and childcare facilities

Each year, Michigan schools are required to report the immunization status of children enrolled in kindergarten, seventh grade and new entrants to a school district.

"Any time we see an increase in vaccine waivers, that is concerning," said MDHHS spokeswoman Lynn Sutfin. "It means a child, and potentially a community, is now more vulnerable to a vaccine-preventable disease."

"There are individuals who cannot be vaccinated due to medical reasons, and ensuring those around them are vaccinated helps protect them through herd or community immunity," Sutfin said. "It also helps to prevent outbreaks like the ones being experienced across the country and recently in southeast Michigan."

In Michigan, the number of kindergartners with immunization waivers was 4.55% in 2018 compared with 4.2% the year before. Immunization waiver rates for seventh grade students stayed the same at 3.4% from 2017 to 2018.

More new entrants to a school district had waivers in 2018, with 3.5% compared with 3.3% in 2017.

Kierra Hardwick of Detroit had both of her children, son Travis Noble, 7, and daughter Tavayah Noble, 15 months, vaccinated for measles at the Children's Hospital of Michigan in Detroit earlier this year. She said she made the decision after hearing media reports.

“They said there was an outbreak, and I wasn’t trying to take ... chances,” she said.

The latest measles cases was reported Wednesday in Grand Traverse County involving an unvaccinated person who recently traveled to Eastern Europe and returned to Traverse City.

Michigan has had 45 measles cases statewide, with three related to international travel and 42 to the outbreak in southeast Michigan, which began in March.

The number of cases in Michigan is the highest since 65 in 1991. On May 17, the latest case was confirmed in St. Clair County.

The state health department waits for two incubation periods, or 42 days, to declare an outbreak is over, state health officials said. The St. Clair case wasn’t an outbreak but a single case, unrelated to any other cases in the state.

Sutfin said June 26 the measles outbreak is over in southeast Michigan. Referring to the case reported, Sutfin said a single case does not constitute an outbreak and "if additional cases develop, then it would be considered an outbreak."

The state Department of Health and Human Services created stricter new rules in 2014 for families seeking immunization waivers in response to outbreaks of whooping cough and measles in several Michigan school districts, said Bob Swanson, director of the department's immunization division.

Parents can no longer obtain a non-medical waiver through the mail. Instead, they must apply at their local health department so they can be educated on the safety of vaccines and potential consequences of going without them.

The new rules resulted in a 35% decrease in the number of waivers in 2015. Though the current number of waivers is still 21% lower than in 2014, the number has begun to creep up. That worries Swanson.

"The disease we’re going to see first, if there are going to be outbreaks, is always going to be measles because it’s so highly infectious, it’s so communicable," Swanson added. "And so my fear is if we’re starting to see an increase in measles cases, that it could be followed by other vaccine-preventable diseases that aren’t quite as communicable."

From Jan. 1 to July 3, 1,109 cases of measles have been confirmed in 28 states, according to the Centers for Disease Control and Prevention, which said that's the largest number since 1992.

Health officials have said a “vaccine hesitancy” — fueled by a vocal anti-vaccination movement that contends some shots are unsafe despite overwhelming evidence to the contrary — has contributed to rising levels of unvaccinated schoolchildren in the U.S.

Waiver rates vary across Michigan school and day care centers. For seventh graders, more students had vaccinations in public schools — 93.9% — than in private schools at 88.25%, according to state data.

The percentage of Michigan children with immunization waivers continues to be higher in private schools, 8.55%, than at public schools, 4.19%, for kindergarten students, state data shows.

Some schools have much higher waiver rates, such as the Detroit Waldorf School, where 36% of students required to provide an immunization status had a waiver, according to 2018 state records.

The private school did not have a measles case this past school year but did send out a notice to all parents reminding them of the school’s policy regarding immunization and illness reporting, pointing them toward the state website, where information is available about the symptoms of measles, possible exposure locations and vaccination clinics.

"The Detroit Waldorf School is in full compliance with all national, state and local laws regarding immunization waivers and the reporting of immunization and communicable disease information," said Julia Toro, an administrative coordinator with the school. "We do not involve ourselves in decisions made by parents and their child's physician."

Toro said state statistics represent "a small portion of our total student body and do not give an accurate picture of the total vaccination rate at the school."

In the city of Detroit, the waiver rate dropped from 2% in 2014 to 1.7% in 2018. Dr. Teresa Holtrop, the executive/medical director of the Wayne County Children's Health Access Program, said the best approach to improving vaccination rates is to address parents' fear with facts.

"I believe in this so strongly I made sure my children got it," Holtrop said. "Would you put your children into a day care center if you knew that a number of kids not immunized is so high there is a very real risk that measles spreads through the child care center?"

Waiver rates decrease in 50 of 83 counties

Fifty of Michigan's 83 counties saw a decline in waiver rates from 2014 to 2018, according to state data. Thirty-one counties saw an increase, one saw no change in its rate, and one county, Keweenaw County in the Upper Peninsula, doesn’t have enough children to report data, state officials said.

Most medical experts attributed the change to the new waiver rules in 2014.

Dr. Joshua Meyerson, medical director of the Health Department of Northwest Michigan, which covers Charlevoix, Emmet, Antrim and Otsego counties, said his department has worked diligently to educate the public about the risks of contracting measles.

"It is no longer happening in far off countries," he said. "We used to say it’s a plane ride away. Now it's just a car ride away. It's very contagious."

Emmet County has a 7% waiver rate, which Meyerson acknowledges is higher than he would like. The other counties are down to about 4%.

"You can have differing waiver rates depending on the population you are looking at," he said. "When you have unprotected populations with measles, you want at least 95% of the population vaccinated to prevent measles and continuing transmission of the diseases."

Meyerson said his department called parents, sent reminder cards to homes, increased social media posts and issued news releases to inform the public on the importance of vaccinations.

"It's too early to know whether that will impact the 2019-20 school year," Meyerson said.

Summer is a great time to think about back-to-school preparations, which include doctor visits for health appraisals and vaccinations, Meyerson said.

"The doctor's office can get very busy in the fall. Ideally, do it right now," he said.

Teresa Frankovic, medical director health department of the Western Upper Peninsula Health Department, which represents 10 counties and three regional health departments, said waiver rates vary dramatically across her counties from a low of 2.6% in Gogebic County to a high of 12.9% in Houghton County.

"So it’s a constant struggle. Ideally, we want to see in our school-age kids' immunization rates in the high 90s, and we don’t meet that anywhere, and that’s concerning," Frankovic said.

"We work to address issues like access. In rural areas, it's just getting people to care. Geographic issues are always a challenge."

In certain areas where religious communities seek waivers, it's been difficult to lower rates, she said.

"People across the board from my counties see the value of taking a child into a doctor when they are ill. They accept antibiotics when they are ill," Frankovic said. "It's been challenging to get a parent to see areas of prevention. That is our ongoing challenge."

Summer camps and travel risk exposure

The measles outbreak might be over in southeast Michigan, but medical officials are warning that summer is not the time to give up the push to increase vaccinations, especially as children head to camp and families launch travel plans.

“Now is the time to be vigilant and not forget about it and continue the efforts to make sure children and adults are vaccinated,” said Dr. Michael Ambrose, an Ann Arbor-based emergency room pediatrician.

For the first time, the American Academy of Pediatrics issued a position on vaccinations at summer camps last month, saying participation by campers and staff whose immunizations are incomplete or who are not immunized because of non-medical exemptions is "inappropriate for individual, public health and ethical reasons."

"Nonmedical exemptions to required immunizations are inappropriate, and these exemptions should be eliminated by camps," the statement says.

While Oakland County declared an end to a measles outbreak on June 5 after 40 of the 44 confirmed measles cases in Michigan occurred there, Ambrose says there is still a real risk a measles outbreak could resurface anywhere in the state.

Other vaccine-preventable diseases

Pockets of unvaccinated people across the state make Michigan vulnerable to a variety of vaccine-preventable diseases, according to Swanson at the state health department. And Michigan has already had problems with pertussis and mumps.

"It seems that we have smoldering pertussis in the state of Michigan all the time," Swanson said.

According to provisional state data, there were 656 cases of whooping cough in the state in 2018, down from 749 cases in 2017.

There have been no pertussis deaths in Michigan in recent years, but it can potentially be deadly for infants. According to the CDC, about half of babies with pertussis under the age of 1 require hospitalization. Symptoms — including low-grade fever, runny nose and cough — usually develop within five to 10 days of exposure.

"For adults, it’s going to be a bad cough that can last a long time; they used to call it a 100-day cough," Swanson said. "It’s the infants that we worry about.

"Infants are not able to tolerate that severe infection in their lung. Our biggest fear is we protect those infants from pertussis."

Mumps is a virus that affects the salivary glands. Symptoms often include fever, muscle pain, headache and poor appetite, which is generally followed by painful swelling of salivary glands.

Michigan had 42 cases of mumps in 2018, compared with 31 in 2017, according to state data. Though rare, the disease can result in brain swelling and other serious complications.

Parents and guardians of incoming kindergartners, seventh grade students and newly enrolled students are being reminded this summer by school officials that up-to-date immunizations or waivers are required.

jchambers@detroitnews.com

Staff Writer Candice Williams contributed.