The following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.
School vaccination records were missing or incomplete among roughly 1 in 5 sampled Ohio middle and high school students last year, despite state law requiring local boards of education to track immunizations records of all enrolled students.
All Ohio students, per state law, must be vaccinated against mumps, tetanus, polio, measles, Hepatitis B, chicken pox and meningococcal diseases. They can claim exemptions in writing due to natural immunity from prior infection; a medical contraindication; or for “reasons of conscience, including religious convictions.”
Though the law requires county boards of education to keep immunization summaries available on request for inquiring parents, schools statewide are failing to track vaccination among tens of thousands of students.
“The question is, why are the schools not collecting this data?” said Madhav Bhatta, an epidemiologist at Kent State University. “If it’s required by law that every child either get vaccinated or have a medical exemption … then why is there missing data?”
In the 2020-2021 school year, when a nascent pandemic shuttered schools and doctors’ offices, only 76% of 12th grade students submitted proof of receiving the meningococcal vaccine, according to immunization data obtained in a public records request from the Ohio Department of Health. The vaccine protects against meningitis and other, sometimes-lethal illnesses caused by the same bacteria.
About 22% of 12th graders had no exemption on file, leaving the picture unclear whether communities have high enough vaccination coverage to protect students.
That same year, only 78% of 7th grade school students statewide showed proof of receiving all vaccinations. Data was missing or incomplete on 19% of all 7th graders.
The missing data spans beyond the threshold for herd immunity for some vaccines. For instance, in the 2019-2020 year, 7.2% of kindergarteners and 9.4% of 7th grade students didn’t have all vaccination records or exemptions on file.
According to the World Health Organization, a community loses “herd immunity” — a threshold of community protection where a disease lacks viable hosts to spread — against measles when coverage falls below 95%. About 2.5% of students claimed a “conscience” objection, and a fraction of a percent claimed medical contraindications — which means they have diagnosed conditions where certain medical treatments such as a vaccine may cause harm.
“If [students with incomplete data] don’t have it on file because they are not vaccinated, that’s a problem,” Bhatta said. “We want as high a level of vaccination as possible to reduce the risk of transmission within a community.”
CDC research shows childhood immunization rates dropped significantly in 2020. However, the problem predates the pandemic. State data shows between 7.2% and 12.5% of sampled Ohio students did not show proof of vaccination or claim any exemption in 2019-2020 either.
The reports also lack data on vaccination by race or socioeconomic status, two major social determinants of health.
When contacted, different state agencies passed the blame or pointed fingers at county school boards, which are responsible for collecting data at the local level.
Vaccine hesitant?
Amid a COVID-19 pandemic that has hospitalized nearly 64,000 Ohioans and killed more than 20,600, 38% of the age-eligible population remains unvaccinated after eight months of availability.
The COVID-19 vaccine data stands in stark contrast to the roughly 3% of public-school students who formally claim a nonmedical exemption year over year, raising more questions about the missing data.
Concerns about outbreaks of rare diseases among unvaccinated communities isn’t just a hypothetical.
Widespread vaccination eradicated measles in the U.S., but the virus can cause outbreaks when a host imports and spreads it among unvaccinated people. In early 2014, two unvaccinated Amish men returned to Knox County from the Philippines, unknowingly carrying measles, a highly infectious but vaccine-preventable disease. Amish communities tend to abstain from vaccination.
The two men seeded an outbreak that caused 383 infections in nine counties over four months, according to a report in the New England Journal of Medicine. About 90% of the victims were unvaccinated. Health officials mounted an awareness campaign and surged in more than 12,000 MMR vaccine doses for some 10,600 people to eventually smother the outbreak.
Researchers also note that unvaccinated people are not randomly distributed. Rather, they tend to concentrate in certain areas. Thus, statewide vaccination numbers can mask the vulnerability of some specific counties.
The missing data is a “significant concern,” according to Amy Bush Stevens, vice president of the Health Policy Institute of Ohio.
HPIO analyzed the data obtained from the Ohio Department of Health. According to its analysis, students in non-Appalachian, rural communities are most likely to claim exemptions to vaccination mandates. Students in metropolitan counties are most likely to not submit their vaccination records.
The missing data blurs a critical picture of whether students are protected, she said.
“Childhood vaccinations are a highly effective way to prevent infectious diseases among kids that have killed many children in the past,” she said.
Who’s to blame?
The law requires local boards of education to provide a summary of student immunizations to the state health director every year.
When contacted, both the Ohio Department of Education and the Ohio Department of Health sidestepped blame and pointed at the local schools.
Alicia Shoults, an ODH spokeswoman, said ODH provides funds for local health departments to do “assessment site visits for compliance.” The pandemic, however, limited this practice, and officials are still reviewing data to determine why so many students’ immunization records were missing last year.
“Ultimately, at the local level, schools are responsible for enforcement,” she said.
The Ohio Capital Journal requested data on school vaccination exemptions in May from the Ohio Department of Education. Spokeswoman Mandy Minick initially stated no such data exists. When asked about the data later obtained from ODH, its missing components, and the state law that requires it, she deflected blame.
The law prescribes roles to local schools and the state health director, not ODE, she said.
“The Department of Education does not have a prescribed role in the collection of this data,” Minick said.
A spokesman for the Ohio School Boards Association reviewed the immunization data but said he didn’t have anything to add.
OCJ contacted six county school boards overseeing schools with high rates of incomplete data. Only Youngstown City School District responded.
Of 152 seniors at Chaney High School in 2020-2021, 122 didn’t submit proof of vaccination or notice of exemption for the meningococcal vaccine — the only vaccine students must receive while in high school.
In the 2018-2019 school year (the 2019-2020 data is not broken out by high school), 89 of 158 students were missing meningococcal vaccine records.
If a meningitis outbreak emerged, officials wouldn’t immediately know who’s protected and who isn’t, costing precious time as vaccines are surged in.
Denise Dick, communications director for Youngstown City Schools, said while the pandemic worsened things, there has been a historical problem getting families to submit paperwork related to vaccination. However, the district is establishing in-school, optional vaccination appointments for a full spectrum of shots.
No one is forced to vaccinate, she said, but the goal is to make it as easy as possible for students. In the meantime, she acknowledged the district is flying blind as far as protection against infectious disease.
“Whether they’re not getting them, or they’re not giving us the record, we just don’t know that,” she said.
Solutions?
Amy Bush Stevens, from HPIO, has the fixes large and small.
On the mechanical side, HPIO analyzed a 2012 CDC survey of states and found Ohio is one of 18 states that doesn’t require health care providers and payers to report immunization data.
Some choose to, but others don’t. Mandatory reporting, she said, would clear the air on who’s vaccinated and who isn’t. (An ODH spokeswoman did not respond to an interview request with an administrator of ImpactSIIS, the state’s immunization information system.)
The current system, Stevens said, puts the burden on parents to submit records. For parents, especially those with lower incomes who move more often or change physicians, it’s too easy for documentation to get lost in the shuffle.
Another idea: tie reimbursement funding from Medicaid managed care plans more strongly to vaccination rates. More vaccination now equals lower costs of care down the line. And more outreach to eligible families to the Children’s Health Insurance Plan, which covers childhood vaccination, would help as the rate of uninsured children ticks up in Ohio.
And then there are structural changes. Public health departments are chronically underfunded in Ohio and one of the few fail safes for low-income, undocumented, or uninsured families. The Columbus Dispatch reported last year that Ohio spends less per capita on public health than all but three states.
“Anything we can do to increase the public health workforce will help with that and make sure that kids with no other source of care get their childhood immunizations,” Stevens said.
The chances of a serious legislative fix are slim. Anti-vaccination attitudes are prevalent among Ohio’s Republican-controlled legislature. Earlier this summer, lawmakers passed (and Gov. Mike DeWine signed) one bill restricting schools from mandating vaccination against COVID-19 while the shots are available under a more limited emergency use authorization from federal regulators. The House Health committee has teed up a hearing on a much broader bill imposing a number of restrictions related to all vaccinations for Tuesday morning.
Other pending legislation would ban “vaccine passports” related to COVID-19. Discussion of the bills among proponents often dubiously characterizes a heavy-handed government forcing vaccines on the unwilling.
Among health experts, however, the reality is simple: Less vaccination equals more infectious disease.
“If you don’t rely on the school system to report — that’s the only way we could get a semblance of aggregated data,” Bhatta said.
