A medical technician with the Wiesbaden Army Health Clinic prepares a vaccine shot. Photo by Carol E. Davis courtesy of U.S. Army Corps of Engineers.
A medical technician prepares a flu vaccine injection. Credit: Courtesy / Carol E. Davis, U.S. Army Corps of Engineers

In 2003, about 2,000 children in Texas opted out of required vaccinations for non-medical reasons. Today, that number has risen to almost 45,000, according to the Texas Department of State Health Services (DSHS).

Even though statewide levels of vaccinations remain high at more than 98%, public health officials are concerned about the growing clusters of geographic areas with high rates of unvaccinated children.

In Bexar County, individual school data show that 23 private schools and three public school districts have non-medical exemption populations greater than 1% – the range for these 26 schools/districts is 1.03% to 8.09%.

Colleen Bridger, director of San Antonio’s Metropolitan Health District, told the Rivard Report that she “will go on the record saying that one of the best solutions to the immunization problem would be better legislation to make opting out more difficult.”

Texas is one of 18 states that allows non-medical exemptions to the vaccines required for school attendance. Texas law allows for exemptions from immunizations for reasons of conscience, including religious beliefs. Studies show that many parents choose not to vaccinate their children due to vaccine safety concerns and perceived fewer benefits.

The federal government’s Healthy People 2020, which provides 10-year national objectives for improving the health of all Americans, has set a goal of 95% immunization coverage in every population. Coverage at this level builds “herd immunity,” which results in most members of the community being protected against vaccine-preventable diseases and significantly reduces the risk of an outbreak.

Even those who are not eligible for certain vaccines – such as infants, pregnant women, or immunocompromised individuals – get some protection because the spread of contagious disease is contained through majority vaccination.

In San Antonio, the coverage level at at least six private or charter schools has fallen below what is needed to achieve herd immunity.

Great Hearts Texas, which includes three charter school campuses located in north and south San Antonio, has an 8.09% non-medical exemption vaccine rate for the 2016-2017 school year. The River City Believers Academy, a private school in Selma, has a campus exemption rate of 7.09%.

Public school districts report district-wide figures rather than data from individual schools. Since those who choose not to vaccinate tend to cluster, building close communities with shared personal or religious beliefs, individual schools within districts likely have much higher rates of non-medical exemptions than reported school district data indicates.

Alamo Heights Independent School District had Bexar County’s highest total of vaccine exemptions with 1.73% for the 2016-2017 school year, an increase from the previous year.

Cherise Rohr-Allegrini is the San Antonio program director with the Immunization Partnership, an advocacy organization working to eradicate vaccine-preventable diseases through public policy initiatives.

“When someone chooses not to vaccinate their child, they need to have a thorough understanding of the risk that they are taking for their their own family but also their entire community,” Rohr-Allegrini told the Rivard Report.

To claim an exemption for reasons of conscience, a student’s parent or legal guardian must request, sign, and submit an official DSHS affidavit form to the child’s school. The affidavit is valid for two years.

California had a similar law allowing non-medical exemptions, but in 2015 the state enacted one of the strictest vaccination requirements in the country after a 2014 outbreak of measles traced to the Disneyland theme park in Anaheim, Calif. infected more than 100 people around the country. Exemptions are now allowed only for documented medical conditions.

The rate of non-medical exemptions continues to rise in Texas. Bexar County has fewer non-medical exemptions than the state average, but has followed a similar upward trend in the past six years.

The average percentage of non-medical vaccine exemptions in Bexar County is 0.69%. The counties in Texas with the highest rates of vaccine exemptions include Kendall (2.95%) and Bandera (2.24%) counties in Health Services Region 8, which includes San Antonio. Of the estimated 3 million people living within the region’s 28 counties, more than half of this population resides in Bexar County.

“While public school districts have a fairly high rate of vaccination, non-medical exemptions have increased dramatically in recent years,” Rohr-Allegrini said. “When you have pockets of non-vaccinated people, you increase the chance that an outbreak will occur in that population and spread to vulnerable populations.”

A 2013 measles outbreak in Texas infected 20 people, many of them unvaccinated children who were homeschooled, so their parents had not been required by state law to have them vaccinated against measles, mumps, and rubella (MMR).

The outbreak occurred among members of a North Texas megachurch, which draws Sunday crowds in the thousands. The church is a division of Kenneth Copeland Ministries, which maintains a position on “faith healing” that encourages people to make up their own minds about vaccines rather than relying on the scientific community.

While the Texas county where the church is located had an overall vaccination rate of about 98% at the time of the outbreak, pockets of unvaccinated individuals left the community vulnerable to outbreaks of vaccine-preventable diseases. Sixteen of the 20 people infected were unvaccinated. Others may have had at least one vaccine, but were unable to provide documentation.

“As a member of a community you are protecting not only your family, but everyone around you,” Rohr-Allegrini said. “Even if you feel that you’re not interacting with anyone that’s at risk, when you go to the store, or school, or shop you are potentially exposing your child to someone else who is at risk.”

Metro Health’s 2017-2019 strategic plan identifies immunizations for vaccine-preventable diseases in children as a priority focus, noting that such diseases have a costly impact on society, leading to large-scale epidemics that take tolls on communities both emotionally and financially.

The estimated vaccine coverage for the core series of childhood vaccines recommended by the CDC for children 19-35 months of age in 2014 was 66% in Bexar County, compared to 64% in Texas, and 72% in the U.S.

Bexar County data show a decline in the series doses given between 2013 and 2014, which Bridger said could be due to vaccine cost or availability, lack of knowledge about vaccine schedules, or due to medical and non-medical exemptions.

“There are plenty of precedents where we tell parents what they can and cannot do for the health and safety of their children,” Bridger said. “If you don’t feed your kid we take your kid away – that’s for the child’s health and well-being. Vaccinations protect them against deadly diseases. To choose not to vaccinate for no reason other than you heard that you shouldn’t – that isn’t a valid argument to make.”

All states require a schedule of vaccines that children must have before they can be enrolled in school. Every state allows exemptions from vaccines for medical reasons, and all but Mississippi and West Virginia allow exemptions for religious reasons.

During the 85th Legislative Session, House Bill 126 would have required parents to take a quick online course about vaccination before they could exempt their children from the state’s immunization laws, but the bill failed to make it out of committee.

House Bill 2249, which would have required individual schools within a district to make available the rate of non-medical exemptions on their campus, was voted out of committee, but failed to make it to the House floor for a vote.

Doctors, public health experts, parents, and others had testified in favor of HB 2249, calling it a transparency measure that would simply provide information about vaccination rates at individual schools.

Texans for Vaccine Choice, a political action committee aiming to preserve parents’ rights to opt out of immunization requirements, argues that vaccines can cause autism, overwhelm the immune system, and contain toxic chemicals.

These activists, many of them mothers, frame their position as one of parental choice and personal freedom — a message that commands attention at the Texas Legislature and in communities throughout the state.

Texas has allowed schoolchildren vaccine exemptions for religious and medical reasons since 1972. In 2003, legislators approved reasons of conscience.

“People trust people they know more than they do experts,” Bridger said. “We have failed at getting the right information to people in the right way, and we need to fix that.”

In Bexar County, District Attorney Nico LaHood is a strong voice within the anti-vaccination community. In 2016 he and his wife claimed publicly that a change in their son’s behavior took place after a series of vaccinations, leading them to conclude that “vaccines can and do cause autism.”

LaHood was recorded making the statement from his desk in the county office, which added controversy to an already polarizing topic.

The efforts of discredited former researcher Andrew Wakefield and other anti-vaccine activists have worked to spread mistruths, and despite claims regarding adverse effects of vaccines being thoroughly discredited due to procedural errors, undisclosed financial conflicts of interest, and ethics violations, people continue to rely on that information as truth.

Numerous large-scale studies involving thousands of participants in several countries join research conducted by the CDC, confirming no causal link between autism and the MMR vaccine; studies continue to be published re-confirming that there is no causal link.

Metro Health’s key strategies for raising vaccination rates in Bexar County include addressing the need for community and provider education, debunking patient’s misconceptions, educating parents on the importance of vaccinations, and educating providers on the intricacies of vaccine schedules.

Vaccines for Children is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated due to inability to pay. Today there are more than 6,500 Texas providers enrolled in Texas Vaccines for Children. Texas leads the nation in the number of uninsured and underinsured children, and there are more than 3 million Texas children on Medicaid.

However, the highest resistance to vaccines for non-medical reasons often occurs within more affluent communities. Within Bexar County, private schools have higher rates of vaccine exemptions than those of public school districts. And those districts with higher rates of exemptions – Alamo Heights and North East ISDs – include some of the more affluent neighborhoods in San Antonio.

“It’s not the low-income parents who aren’t vaccinating,” Bridger said. “It’s the ones who have more education, have done internet research, and unfortunately that information [they find is] or wrong or misleading.”

Metro Health plans to target more intervention and education efforts toward providers. Just as drug companies advertise directly to patients in addition to providers, Bridger said that targeting communities and providers will ensure that the right information is out there.

“We have a more educated population when it comes to drugs than we ever have. That [outreach] model is working for the drug companies, and we can adopt that to educate people about the benefits of vaccines, ” Bridger said.

In the first half of the 20th century, public health officials worked to ensure that vaccines reached disadvantaged communities. Now, as fear of the targeted diseases has waned, parents may be more fearful of vaccines, leaving the entire population vulnerable.

“There will always be [medical] exemptions for people who need them,” Bridger said. “We aren’t forcing it if it’s dangerous. We are saying that it’s more dangerous [to opt out] if there is no known medical reason to not vaccinate.”

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.