Lax vaccination rules put Texas kids at risk

At the time of this writing, the Minnesota Department of Health has declared an end to a measles outbreak that sickened 79 people, exposed 8,000 to the virus and required 500 people to stay home from school, child care or work. The monetary costs involved in responding to this measles outbreak are estimated to be upward of $5 million. Strategies for preventing such outbreaks that occur in large urban areas are complex. One strategy is strict enforcement of school immunization mandates.

School immunization mandates have been in place in the United States since 1827, when the city of Boston required students to give evidence of smallpox immunization before entering school.

In 1905, the U.S. Supreme Court affirmed the right of states to pass and enforce immunization directives for school entry in the landmark trial, Jacobson v. Massachusetts. It took, however, almost eight decades for all 50 states to implement school entry immunization rules. Ironically, it was a 1971 measles outbreak involving Texas and Arkansas that fostered national alignment around school mandates.

In Texas, responsibility for enforcement rests within each school district, not the state. The Texas Administrative Code stipulates that the Texas Education Agency “administers the laws and rules that govern education in the state,” however, TEA has no enforcement power. Similarly, the Department of State Health Services is responsible for conducting school audits but has no power to penalize non-compliant districts. Thus, the state has no power in the enforcement of the code it develops and monitors.

In contrast, California and North Dakota have maintained some enforcement power at the state level. In response to the Disneyland measles outbreak, California restricted daily attendance funding of schools not in compliance with school mandates starting in 2016. In North Dakota, the state attorney general is empowered to withhold funds from non-compliant schools.Such strategies would counterbalance perverse district incentives where budgets are based on attendance.

Accurately identifying and auditing non-compliant schools would also assist in strategically mobilizing public health resources to address mandate enforcement. Texas school districts report the vaccine status of students in only three grades (pre-K, kindergarten and seventh grade) annually to DSHS. Districts and private schools that either 1) had rates less than 95 percent for any state-required vaccine, 2) did not submit an Annual Report of Immunization status or 3) had unusually high numbers of delinquent or provisionally enrolled students are identified by DSHS. For public school districts to be audited, three schools (ie, one lower, one middle and one upper) within that selected ISD are identified by DSHS to be reviewed by the local health department. The departments randomly select 100 vaccine records from the selected schools to be reviewed. Thus, the state auditing process, based on district data, may miss non-compliant schools and students. Additionally, the DSHS does not interact with principals of non-compliant schools. Local health departments are tasked with this optional outreach. Simply changing the process to target known non-compliant schools and students and incorporate feedback to the principal would assist in identifying areas in need.

Opportunities also exist to increase principal engagement in mandate enforcement within Texas. Currently, principals are not required to monitor campus level vaccination rates. School nurses maintain immunization records. Campus level data is assembled into a district report that is signed by the superintendent and forwarded to the DSHS. Unless monitoring independently, principals have no incentive to track campus level data. One solution for increasing awareness among all stakeholders — students, parents, school nurses and principals — would be to simply post campus level vaccine rates. Such a policy had a dramatic impact on immunization rates in California.

Reminding principals of their ethical and legal obligation to follow state vaccine mandates may also improve enforcement. Principals are expected to make “the well-being of students the fundamental value in all decisions” per their code of ethics. Ensuring students have received mandated vaccines prior to enrollment ensures communities are protected against vaccine preventable diseases. Additionally, reminding principals of possible legal consequences for not following enrollment requirements — leading to disciplinary action and possibly teacher certificate suspension as was seen in TEA v. Sonia Sanchez — also may assist in achieving increased compliance.9

Unfortunately, many children remain at risk because mandates are not followed. Within the largest school district in Texas, more than 5 percent of the prekindergarten, kindergarten, and seventh-graders were delinquent for the measles vaccine as of two months into the school year in 2017. Such rates of vaccine delinquency threaten herd immunity and put communities at risk for outbreaks similar to the one in Minnesota. Standardizing enforcement of mandates has been in place for more than40 years in the United States and is an important tool in maintaining herd immunity. Wootton is associate professor of pediatric infectioous diseases at McGovern Medical Center at UTHealth, Elam is a doctoral candidate in health policy at UTHealth School of Public Health, and Winnike is president & CEO , The Immunization Partnership.