Pandemic accelerated Arizona’s years-long decline in childhood vaccination rates

Schools report vaccination information to ADHS each year for child care, kindergarten and sixth grade. A student is either immune, which means fully vaccinated, or exempt for a medical or personal reason. Any student without vaccination records or an exemption is prohibited from attending school, according to state law.

While the pandemic caused substantial drops in some vaccination rates, the number of vaccine-exempt students has also increased over the past decade, driven in large part by higher rates of personal belief exemptions. ADHS and Maricopa County piloted a limited education program to reduce those exemptions in schools in 2017, but ADHS scuttled the initiative based on public backlash. The department did not reinstate the program. Instead, ADHS said it relies on promoting “the benefits, safety and effectiveness of childhood vaccinations.”

The U.S. Centers for Disease Control and Prevention recently voted to add COVID-19 vaccination to the recommended schedule for children and adults, but Arizona has moved in the opposite direction. In 2022, the Republican-controlled Arizona Legislature passed a bill barring the COVID-19 vaccine, for any variant, from ever being required for school attendance. Gov. Doug Ducey signed the bill into law.

England, a former director of the Maricopa County Department of Public Health, is concerned about what this may mean for uptake of all vaccinations. “What I’m really, really worried about…,” he said, “is that for the first time, vaccines and vaccine requirements became a partisan issue.”

A ‘precipitous drop’

Vaccination rates across the nation for kindergarten students declined overall by around 1 percentage point during the 2020-2021 school year, according to a recent CDC estimate. A drop of this magnitude equates to tens of thousands of children becoming more vulnerable to vaccine-preventable diseases.

According to Dr. Sean Elliott, a pediatric infectious disease specialist in Tucson and emeritus professor at the University of Arizona, the “precipitous drop has everything to do with the pandemic.” Elliott, a member of the American Academy of Pediatrics, said he does not think anti-vaccine sentiment has contributed as much to the recent extreme decline in Arizona, instead calling it “an underlying trend.”

AZCIR contacted more than two dozen school districts and charter schools to better understand drops in student vaccination rates between the 2018-2019 and 2021-2022 school years. Among the eight districts that responded, six provided interviews or statements and two declined to comment.

For sixth grade students, the rate of the meningococcal and Tdap vaccines decreased the most over the course of the pandemic. Children receive these vaccines at age 11, right around the time they enter sixth grade. About two-thirds of schools analyzed had these vaccination rates decrease from 2018 to 2021.

At Thompson Ranch Elementary in El Mirage, the meningococcal and Tdap vaccine rates for sixth-graders decreased by about 30 percentage points. The school is part of the Dysart Unified School District, where, according to district spokesperson Renee Ryon, much of the student population suffers from a general lack of access to health care, including vaccinations.

Ryon said the school, which has a large share of students from low income families, is aware of the problem and has worked “tirelessly to improve” immunization rates through partnerships with local health providers.

The federally funded Vaccines for Children program allows children who are on Medicaid, uninsured or underinsured to be immunized, but the number of providers in the network has shifted over the years. England said he and his group, the Arizona Partnership for Immunization, are now trying to determine if the number of federally funded Vaccines for Children providers has decreased overall.

At Dr. Daniel Bright School in Yavapai County, MMR immunization rates dropped by 23 percentage points to 63.9%. Bob Clark, the district nurse for the Cottonwood-Oak Creek District, said this is because students also lacked access to routine vaccination in 2020 and 2021.

“We were hearing wait times of two months or more in order to get in and vaccinated,” he said about the time when health care was focused on COVID vaccines and not as much on other well-child care.

Rising exemptions, declining vaccinations

Before the pandemic, an increase in vaccine exemptions played a significant role in Arizona’s multiyear, downward trend in immunization rates. A large share of the exemptions are for non-medical reasons, better known as personal belief exemptions, which are permitted by 15 states nationwide.

In Arizona, a parent only needs to sign one form to receive a personal belief exemption for one or all required vaccines. The rate for such exemptions in the state jumped from 3.9% to 6.6% for kindergarten students over the past decade, AZCIR’s analysis showed. For sixth grade students, 7.4% have an exemption from at least one vaccination.

The American Academy of Pediatrics, which advocates for the elimination of personal belief exemptions, views them as “inappropriate for individual, public health, and ethical reasons.”

Nothing prevents a school administrator from using the personal belief exemption form as a way to keep kids who have fallen behind on their vaccines in school. Looking at the number of personal belief exemptions is a way to measure vaccine hesitancy, said England, but “some of that is parents signing an exemption form out of convenience.”

In Cottonwood-Oak Creek, for example, Clark said only a small percentage of students with exemptions in his district have received no vaccines at all. He said students have fallen behind on vaccinations but cannot go to school until they are either immunized or exempt, so they sign an exemption form instead.

That tactic could explain why a decade-old study commissioned by the ADHS found that schools likely have an inflated rate of personal belief exemptions, or what the report called “record keeping challenges.”

State and county health departments attempted to reduce the number of personal belief exemptions through a course that provided access to educational materials before parents sign an exemption form. But after a 2017 pilot at 16 schools in Maricopa County, the state canceled the program. The video-based education course, which is still available on the ADHS website, was meant to expand across the state in an extended pilot in 2019.

ADHS said it is working with partners such as the Arizona Partnership for Immunization to conduct outreach about the importance of vaccines.

This spring, the Republican-controlled Arizona Legislature voted along party lines on a bill to reduce the power of the health department, making it unable to require vaccinations for COVID-19 or the human papillomavirus vaccine for school attendance. The legislation was opposed by the Arizona Education Association, the Arizona Partnership for Immunization, the Arizona Public Health Association and the Arizona chapter of the American Academy of Pediatrics.

Experts such as England remain concerned about the trend of vaccination rates, indicating these discussions about required school vaccinations could be a harbinger of problems to come.

“There has never been a public health problem that has been solved through education and voluntary behavior change,” he said. “It’s always something in the environment we’ve done around people, or something in policies and systems that we’ve created. And for vaccine-preventable diseases, it was school requirements.”

This article first appeared on Arizona Center for Investigative Reporting and is republished here under a Creative Commons license.