Specific requirements vary by age and grade. Children can be opted out for medical or religious reasons.
Source: Rules and Regulations of the State of Georgia
Children attending more than 200 Georgia schools are in classrooms where vaccination rates fall short of the level needed to protect them from catching and spreading a variety of diseases, according to an analysis of state data by The Atlanta Journal-Constitution.
But when data shows high rates of students who are not fully vaccinated or of parents opting their children out of vaccinations, the Georgia Department of Public Health doesn’t take key steps that could prevent outbreaks, the AJC found.
It doesn’t check the numbers. It doesn’t focus education or vaccination programs at the schools. And not once in the past 10 years has it taken legal action to prevent or stop potential violations of state vaccination laws.
Nor does it check that, during an outbreak, unvaccinated children are kept out of school, as the law allows.
» SEARCHABLE DATABASE: See how many students at Georgia schools were vaccinated
Other states have taken strong measures to prevent contagious diseases. After a 2010 pertussis, or whooping cough, outbreak in California, linked to more than 9,000 illnesses and 10 deaths, that state passed a law generally requiring a doctor's signature before parents opt out of vaccinations. Washington and Oregon have similar laws, prompted in part by concerns about anti-vaccine misinformation and rising opt-outs.
In Colorado, the governor in May signed a bill requiring schools to provide information about vaccination and exemption rates upon request.
About 18 states publish information online about rates at local schools, giving parents information to help them understand the risks for their children and the potential for outbreaks. Georgia does not.
The reason: the Department of Public Health knows the data is flawed.
After obtaining the data under the Georgia Open Records Act, the AJC found that it shows some schools with hundreds of students as having none. At other schools, it shows dozens of unvaccinated students when school officials say nearly all were vaccinated.
"The only way one knows where there may be problems with low rates of immunizations and the prevention of outbreaks of vaccine-preventable disease is knowing what the vaccination rates actually are," said University of Michigan Professor of Pediatrics Gary Freed.
But Department of Public Health Director of Health Protection Dr. J. Patrick O’Neal said there’s no evidence that flawed data made it difficult to combat an outbreak. He also said he’s less interested in punishing people for violating state vaccination laws then educating them.
And he doesn’t think the state Department of Public Health is missing opportunities to keep children safe.
“I think that individuals at the local level are very happy with more local control than central control and feel that the advantages outweigh the disadvantages,” he said.
“I don’t think Public Health is ideal at being the health police. I think our role is much more effective when we become the health educators.”
The state generally leaves it up to local health departments to take action during an outbreak. “If they need help from the state, they call us,” O’Neal said.
Georgia's vaccination rate has been rising, according to the most recent national data. But at the same time, so is the rate at which parents opt their children out of vaccinations.
This may be happening because fewer children are falling into a middle category: They’re not exempt, but they’re also not fully vaccinated. Another reason could be that vaccinations are better documented.
In 2013, at least 94 percent of Georgia kindergartners were fully vaccinated against measles, mumps, rubella, chicken pox, diphtheria, tetanus and whooping cough. That puts Georgia roughly on par with the national median. And it's an increase from 10 years earlier, when about 92 percent of kindergartners were vaccinated against a similar list of diseases.
Still, Department of Public Health data shows Georgia parents may be declining to vaccinate their kindergartners at about four times the rate of a decade ago.
There are two ways Georgia parents can opt their children out: submitting a statement swearing that vaccination conflicts with their religious beliefs; or having a doctor certify that one or more vaccines would hurt the child’s health.
Most are exempted on the basis of religious beliefs. Often, though, parents cite other reasons.
Leaders at Amber McBride-Sapp’s mosque suggested some vaccines were unsafe. The Atlanta woman also believes herbal remedies and diet are more effective at preventing disease. So she chose not to have her two children, ages 8 and 10, receive all the state-required vaccinations.
“Sure, I can get them vaccinated, but that won’t protect them from everything,” she said. “Why pump them full of these chemicals and medications if there’s still a chance they might not work?”
The children’s grandmother, Georgette McBride, worries, though. She had Amber McBride-Sapp vaccinated as a child.
“I’m concerned because it might be putting them at risk,” she said.
So far, she said, the children have been lucky. The worst thing they’ve caught at school was a case of pink eye.
Religious exemptions cluster at a small number of schools.
At the Waldorf School of Atlanta, 14 of 34 kindergartners were excused last year under religious exemptions, according to state data. The school, which has no religious affiliation, attracts parents who are looking for an alternative to traditional schools, “the type of people who do their research and question the status quo,” School Administrator Sara Walsh said.
“We don’t make any statements one way or another about whether we think immunization is correct or not correct,” she said.
The school, which has about 210 families, follows state laws about tracking student vaccinations and keeping unvaccinated children out of school during any outbreaks, Walsh said. Two years ago, administrators asked some children to stay home during a chicken pox outbreak shortly before December break.
“Some people were upset that we followed the rules and [we] said, 'Sorry you have to stay out until after the break,' ” she said. But she stood firm. “I’m a dog on a bone about it because I don’t want any insinuation that we aren’t following the regulations.”
As the number of children opted out of some or all vaccines has grown nationally, so has the number of outbreaks of diseases you may have thought were gone.
During 2012 nationwide, more than 48,000 cases of pertussis were reported to the Centers for Disease Control and Prevention, including 20 deaths – the most since 1955.
This year, through Sept. 29, the U.S. had 594 reported cases of measles and 18 outbreaks, the highest number of documented cases since 2000. None of the cases was in Georgia, according to the CDC.
From 2012 through this August, Georgia did report 13 outbreaks of whooping cough and varicella, or chicken pox, traced back to schools or childcare centers. Some of the chicken pox outbreaks involved infants too young to be vaccinated.
Health experts say that school vaccination rates below about 90 percent can leave a community vulnerable to outbreaks by eroding “herd immunity,” the concept that the more people who are immune, the harder it is for the disease to spread.
Unvaccinated children aren’t the only ones at risk, experts say. So, too, are others who come into contact with students—like infants or grandparents. Even vaccinated children can become ill since some vaccines don’t always fully protect against disease.
"Even if you do the right thing and get your child vaccinated with a vaccine with 80-percent efficacy, there's a 1 in 5 chance that your child could still get infected," said Saad Omer, an associate professor in Emory University's Rollins School of Public Health.
Debbie Parsons’ son, Brandon, caught whooping cough five years ago, even though he had been vaccinated. Brandon, then a fifth grader at Rocky Mount Elementary School in Cobb County, was a few months short of receiving a booster shot when he first started showing symptoms. For months he had a cough that at times took his breath away.
Brandon was one of at least 18 students affected by the 2009 outbreak, many of whom had been vaccinated. Parsons said the disease was “a nightmare.”
“It’s very scary especially because it’s breathing,” she said. “You’re scared to go to sleep at night because what if you miss something?”
Three years later, Parsons’ daughter, Katie, also caught whooping cough—also while in fifth grade. Katie has a genetic condition that makes it harder for her body to fight off disease, but like her brother had been vaccinated. It took her months to recover, and battling whooping cough affected her blood system, heart and overall functioning, Parsons said.
“Your body is trying to fight something that it already doesn’t have the energy to fight as it is,” she said.
The experience changed her mind about parents who decide not to vaccinate and don't have a medical exemption. While it didn't used to bother her, now it does because she believes it puts her children - and other children - at risk.
To help prevent outbreaks, the CDC suggests that states use data to identify schools where fewer children are vaccinated, investigate why and find ways to improve local vaccination rates.
"That's the real advantage of these surveys. It allows you then to apply your resources to those specific areas where the rates of unimmunized kids are high," said Dr. Larry Pickering, with the Advisory Committee on Immunization Practices.
The state health department runs public campaigns about various issues, including vaccination. And it works with doctors’ offices to help them educate parents.
But it has no plans to focus education or outreach programs on schools with low vaccination rates. That’s something it leaves up to local health departments to pursue if they wish, O’Neal said.
The data the department has on vaccinations and exemptions is collected from schools and entered by county or district health department staff and forwarded to the state.
Until the AJC began contacting schools about possible errors, the state didn’t check the data for obvious errors. It is now considering doing so, O’Neal said. The department plans to publish the data once it is sure that it is completely accurate, he said.
“Having those rates available empowers parents,” said Omer, the Emory associate professor.
As far as using its enforcement powers, O’Neal said that the health department was made a separate department just three years ago and previously had not been tasked with actually enforcing state laws.
Today, O’Neal believes local schools are primarily responsible for ensuring vaccination laws are followed. And he said with Georgia’s relatively high immunization rates, he’s not particularly concerned.
“From a health perspective I don’t have a lot of worries of the risk of something terrible spreading rapidly through a school population,” he said. “That makes me far less interested in pushing for enforcement. And far more interested in pushing for education… on the value of immunizations.”