Closing the gap: The uphill battle to get Idaho students immunized amid rising exemption rates

The Idaho Panhandle has some of the highest vaccination exemption rates in the country, a 2018 study found, and those rates for students continue to climb in the midst of a political tug-of-war.

Bonner and Idaho Counties had the highest rates last school year, at 23% and 21.8%. Boundary County is close behind with 19.6% of its students using exemptions to attend school without being immunized.

Idaho requires students in public, private and parochial schools – as well as licensed day care centers – be immunized. There are exemptions to the vaccine requirements listed in that same rule, however, which are easy to get. Idahoans can seek medical, religious or other exemptions to any vaccination.

While a medical exemption requires a doctor’s signature, the other exemptions do not. The majority of exemptions in the state are because of nonmedical reasons.

The Idaho Department of Health and Welfare had created an exemption form for families to fill out regarding their children. The form has since been deemed unnecessary and now parents can provide schools a signed statement, with their child’s name and birth date.

Enforcing the immunization requirements is now left to school nurses and public health districts.

Nichole Piekarski, the lead school nurse in Coeur d’Alene Public Schools, said her district and staff take exemptions in all forms, stapling them to the official health department forms for ease of data entry.

“If they (parents) send us an email, we can print it, staple it and then we have it recognizable in our records and we move on,” she said. “Sometimes we get things on the back of receipts, and we say thank you and put it on the form.”

While exemptions are rising in the region, public health officials in the Panhandle say the region has an adequately immunized population. These trends point to school nurses and health district workers’ persistence in eliminating the number of students who are out-of-compliance with immunization requirements rather than those with an exemption.

Piekarski said this is the group she is focused on.

“We have this gap in there where they haven’t submitted an immunization record, and they haven’t submitted an exemption record, so we don’t know what they want,” she said.

Schools collect immunization data for students in kindergarten, first grade and then again in seventh grade. A new rule up for public comment will require a meningococcal vaccine booster for 12th graders in the state, but that rule won’t take effect until the 2020-2021 school year. This limited data collection can be challenging for local health district officials, said Nick Swope, program manager at the Panhandle Health District.

“Those are the most important three years you could be grabbing data, but you definitely do have some limitations based on people moving in and out of the region that have incomplete records and other types of limitations,” he said.

School nurses, with help from the local health districts, work to triage that gap. Piekarski said seventh-graders are the largest “incomplete” population in the Coeur d’Alene schools, and this year, the district sent out a mass email reminder to parents about the required immunizations for middle school students. Piekarski said that usually when her staff is calling families to try to complete students’ paperwork, the responses are positive.

“We send them a reminder, and most often times the response is, ‘Thank you, it’s on my to-do list and I appreciate the reminder,’ which is a wonderful surprise for us,” Piekarski said. “We have not had people complaining at us for contacting them and reminding them.”

Piekarski said her main goal is to close the paper trail gap in the student population, not try to convert those with exemptions to change their minds or engage in a conversation.

“We are recognizing, and we support that choice,” she said.

On Monday, more than 40 Idaho residents spoke out against a slate of proposed Idaho Department of Health and Welfare rules targeting the state’s immunization requirements.

While the public comment meeting in Coeur d’Alene covered several rules after the Idaho Legislature failed to renew them in the most recent legislative session, the lion’s share of comments were aimed at the state’s immunization requirements. Many families drove from Bonner and Boundary counties, some even taking off work to be there.

Rep. Heather Scott, who represents residents in both Bonner and Boundary counties in the Idaho Legislature, advocated for parental rights as she spoke about the state’s immunization requirements for children attending licensed day care facilities on Monday.

“The language needs to be changed to ‘recommended,’” she said, referencing the rule in Idaho’s administrative code that spells out “immunization requirements.”

Her comments were echoed with “Yeps!” and “Amens!” as she spoke to roomful of similar-minded Idaho residents. She received loud applause at the end of her five-minute comment.

People in the crowd cited varied reasons, from religious to political, for their opposition to current immunization requirements in the state. Some former nurses and health care providers spoke in favor of parental choice for vaccinations, expressing concerns about risks, data and reporting systems.

Immunization requirements have stirred political turmoil for years.

Dr. Lisa Barker, a Boise pediatrician and chairwoman for the Idaho Immunization Coalition, was at the statehouse during the most recent legislative session advocating for stronger immunization requirements. She said rule changes suggested by the Department of Health, like requiring a booster of the meningococcal vaccine for high school students entering 12th grade, were a part of what led to the legislative stalemate, expiring rules and the subsequent public hearings.

State agencies remain unclear what the Legislature will do with the rules once they have completed the public comment process. Health department officials said this has never happened before. Usually they have public comment periods for a singular rule change, not a slew of rules.

In her practice and her work with the coalition, Barker said a majority of Idahoans support immunizations.

As a pediatrician, she has found that having honest conversations with those families worried about vaccines and answering their questions can help improve immunization rates.

“That 30% to 40% (of people) that walks in the office and says, ‘I don’t know,’ or ‘I want to space them out,’ those are the people where if you are willing to stop and have the conversations about, ‘What are your concerns?’ or ‘What happened?’… if you get to what their questions are, you can improve your rates,” she said.

School district and school-based data from the Department of Health illustrate the vast differences in exemption rates across schools and regions in the state. The majority of students in Coeur d’Alene Public Schools, the largest school district in North Idaho, are immunized, and statewide 86.5% of students are adequately immunized.

In Kootenai County, 15% of students have one or more exemption to a vaccine, and Swope said the Panhandle Health District is focusing its efforts in that county, because of the higher concentration of students. The Panhandle Health District, which covers Boundary, Bonner, Kootenai, Shoshone and Benewah counties, has after-hours clinics as well as school partnerships to help families access vaccinations easier.

But it is an uphill battle.

“In general over the past five or 10 years, there has been a steady decrease (in adequately immunized students), but you could also see in many of our counties a continual increase in things like exemptions,” he said. “All that said, we’re pretty optimistic in being able to kind of curb that.”

Health district officials have found school districts to be their biggest partners as they work to increase their adequately-immunized rates, Swope said.

“We’ve seen some really positive impacts; for example, we worked with two schools last year, and it was one of the first times within the last five years at least, where we actually saw an improvement in the adequately-immunized population,” he said.