This is not a story about why you should vaccinate your children. Every state, local and federal public health agency says you should, and if you don’t, you’re required to notify your child’s school that you didn’t, and allow your child to be quarantined in the event of an outbreak of a potentially fatal but vaccine-preventable disease like measles, polio, pertussis or diptheria. The Colorado Department of Public Health and Environment (CDPHE) estimates vaccines save the lives of 3 million children every year, and it encourages every parent to vaccinate their kids.

Instead, this is a story about why, despite increased educational outreach, Boulder County persists in having some of the lowest child vaccination rates in the country — with some schools reporting less than 50 percent of their students are fully vaccinated — and what local and state health officials are doing to educate communities, protect vulnerable populations and prepare for potential outbreaks.

“A lot of what we are trying to do is because there’s so much misinformation and fear out there,” says Teresa Luker, Boulder County’s immunization program coordinator. “It confuses some people, especially new parents, and we just try to provide an avenue to encourage anybody who is unsure just to talk to their health care provider about their concerns so they are fully understanding how vaccines work and the risk from getting a vaccine versus getting a vaccine-preventable illness.”

Skepticism of vaccines is not unique to Boulder County. In fact, it’s not unique to the most recent generation of parents. People were skeptical of early versions of vaccines for smallpox going back about 1,000 years ago. But, certainly, the internet has allowed for the proliferation of dubious science, including the roundly debunked study by Andrew Wakefield that linked the measles, mumps and rubella (MMR) vaccine to autism.

Lindsay Diamond, who holds a Ph. D. in molecular biology and who gave a talk at TEDxBoulder on immunization, says there are myriad reasons — some legitimate — why parents are skeptical of vaccines. The biggest reason is because parents aren’t properly educated about vaccines before bringing their child into a doctor’s office to have a big needle (often several) and some potent medicine injected into their newborns.

“I had this gut instinct that we’re just reaching parents too late,” Diamond says. “In many cases, you don’t [consider] the topic of vaccination until you’re at your pediatrician’s office, completely lacking sleep, completely stressed out, and then you’re presented with this quick decision whether to vaccinate your child.”

Diamond runs the advocacy group Community Immunity with another Ph.D., Karli Carston, and together, they help reach new parents by hosting educational events in hospitals and parent groups.

Diamond says the skepticism of vaccines is actually best represented by a bell curve — there are relatively few staunch anti-vaxxers and a similarly small amount of people who believe they’re completely safe. In Boulder, Diamond says, the largest reason for skepticism is a mistrust of pharmaceutical companies and what people see as non-natural ingredients in vaccines (like small amounts of aluminum and thimerosal, a preservative containing a type of mercury that the body processes quickly and differs from the toxic form of mercury found in fish).

“There’s this emphasis on natural living,” Diamond says. “This organic, natural lifestyle, and now you’re presented with this preventative medicine, but it’s filled with ingredients you otherwise wouldn’t choose for yourself.”

Vaccinated rates tend to be lower in more rural and poor, urban areas, but they’re also high in affluent areas like Boulder County and Orange County, California. This is actually a harder population to convince for a number of reasons, Diamond says.

“By and large, our vaccine rates reflect the decisions of generally affluent, well-educated, Caucasian populations. Not surprisingly there isn’t a lot of government funding to tackle that problem,” Diamond says.

Rachel Herlihy, the state epidemiologist with CDPHE, says her department works with local public health agencies to provide information to parents. The CDPHE has been collecting vaccination rates from schools throughout the state for years, but just last year started making that information available online, so parents who want their children to go to schools with high vaccination rates can do some home research.

Still, Diamond’s group is one of the only groups in the state working to actively engage parents well before they have to make a vaccination decision. Luker says Boulder County parents are invited to attend meetings with physicians, school officials and other parents to discuss vaccinations. But that may not be enough to encourage parents who are on the skeptical side of the bell curve to attend.

Students in Colorado are required to get a panel of vaccines, including the one for MMR, and those for polio, tetanus, diptheria and pertussis, chickenpox, hepatitis B, and certain bacterial diseases. However, parents can opt out either though a medical exemption (a child is unable to get a vaccine for legitimate health reasons) or a personal/religious exemption. Getting a personal/religious exemption is as simple as filling out a form and submitting it to the CDPHE.

Anne Nadelson is the lower school administrator at Shining Mountain Waldorf School in Boulder, which has a fully vaccinated rate around 62 percent or below for most of the required vaccines. A personal exemption is the main reason cited for those relatively low rates. Nadelson says Shining Mountain does not provide educational materials outside of what’s available from public health agencies to parents.

“We don’t have these conversations with parents because that’s consistent with state law,” Nadelson says. “Decisions about vaccinations are made by parents in consultation with their children’s health care providers. We don’t engage in these conversations. We strive to be an inclusive community. We know based on the numbers we don’t have every child fully vaccinated. According to the law, that’s OK in Colorado. … I actually don’t know why people choose to vaccinate or not.”

Shining Mountain, other Waldorf schools, and schools in certain Boulder County communities like Jamestown and Gold Hill have similarly high personal exemption rates, creating “pockets,” which the CDPHE’s Herilhy says are of particular concern.

“It’s really those smaller counties or individual small communities or play groups or small towns where the numbers really count,” Herlihy says, “where if you see the immunization rate isn’t high enough for a particular disease, we know that community could be at risk.”

A certain amount of any population needs to be vaccinated in order to achieve what’s known as herd immunity — if, say, 95 percent of a community gets the MMR vaccine, those diseases are far less likely to infiltrate the community than if the rate was even 90 percent. Herlihy says “a certain percentage of the population” won’t respond to vaccines, and so even if a child gets a vaccine, a low herd immunity rate may allow a disease to enter a community, and affect both vaccinated and unvaccinated children, and kids in early grades, who are more susceptible to contracting vaccine-preventable diseases because of their undeveloped immune systems.

Vaccine-preventable diseases have cropped up in recent years — a measles outbreak hit Boulder in 2013, and a recent Southwest flight had to be medically cleared after a passenger was identified to have measles. Measles and other vaccine-preventable diseases are easily spread, and so if one person gets it and brings it into a community that has not met a herd immunity quota, it could create a health crisis.

This education, Diamond says, needs to be spread. Even though Boulder County has raised its total immunization rates to somewhere around 90 percent in recent years, that is still below average and still poses a major health risk.

“I think in the end, the most clean data we’ve received from CDPHE, it puts across [BVSD] as 89-90 percent [fully immunized], and I think to the average person that seems like that would be fine. At least for me, you think B-plus, we’re doing well,” Diamond says. “I think it’s really hard to convey the messaging that the difference between 85 and 89 percent is the difference between major gaps in public health and [total community] health.”

Luker says Boulder County does “have an outbreak protocol.” The state and the school would be responsible for removing sick and vulnerable students, and Nadelson says Shining Mountain has records on every student’s vaccination history and would work with the state to appropriately handle an outbreak.