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Schools don't track whether under-vaccinated kids get all of their shots

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Sara Martín is not against vaccinations. But that didn’t make it any easier to cart her two young kids on two buses from East Los Angeles to a downtown clinic to get their required immunizations.

"Somewhere when they became toddlers I started to fall a little behind on the vaccinations," says Martín, 29. "Not intentionally, just that’s kind of how it happened for me."

Martín’s children, 3 years old and 18 months, are now up to date.

But 20 percent of children entering Los Angeles Unified School District kindergartens are not.

With 79  confirmed cases of measles in California as of Wednesday and a 2014 statewide pertussis (whooping cough) epidemic with more than 10,000 cases and two infant deaths, public attention has focused on the controversial Personal Belief Exemptions, which allow parents to refuse to vaccinate their children.

But experts say under-vaccination may also be a pressing problem.

The state requires kindergartners to be up to date on immunizations for diphtheria, tetanus and pertussis; measles, mumps, rubella; polio; hepatitis B and chickenpox. Most require multiple doses given at specific intervals.

State law allows incoming kindergartners who have received at least one dose of each required vaccine, but are not up to date, state law allows schools to accept them as to enter school as "conditional entrants." 

Then it’s up to the school to notify a family when a "conditional" kid’s next shot is due. But, this doesn’t always happen.

"It’s a challenge when you’re busy during the school day, and the days roll by, and then three months later you realize you have a student who you missed notifying them and the parent forgot," says Tonya Ross, Director of District Nursing Services. "And that happens all the time."

In some L.A. Unified schools, 60, 70, and even 80 percent of incoming kindergartners were enrolled conditionally in the 2013-14 school year. The District says it is unable to report how many of those students ended up fully vaccinated by the end of the school year. 

"Once they’re in, if there’s no nurse there tracking that, it may flag on a system but there’s really no one looking at that," says Ross, citing the lack of school nurses as a barrier for tracking students’ immunizations. "So it’s very difficult to get those kids the follow-up, the appropriate follow-up."

This year’s numbers are even higher than last year’s. State numbers show 97 percent of Dolores Street Elementary’s 133 kindergartners entered this school year on a conditional basis, closely followed by 94 percent "conditionals" out of 141 incoming students at George de la Torre Jr. Elementary. Dr. James Edward Jones Primary Center, Lenicia B. Weemes Elementary and Raymond Avenue Elementary each had 92 percent of their kindergarteners entering conditionally this year.

(Illustration by Dan Carino)

For its part, the state requires schools to report their rates in the fall, but there is no additional reporting requirement, though it randomly audits about 3 percent of kindergartens every third spring. In 2011, the most recent available review, the conditional rates in the 286 audited kindergartens declined from 6 percent in the fall to 3 percent in the spring.

The state is not tracking the conditionals, either. And while state law requires schools to track conditional entrants and exclude those who don’t get fully vaccinated, schools don’t risk any sanctions for failing on either of those fronts.

When discussing vaccine-preventable diseases, experts often talk about "herd immunity." A certain threshold of immunized people — over 90 percent of the population — will keep those who are unvaccinated largely safe from disease. Those who are too young or too frail to receive vaccines must rely on the inoculated to keep them safe.  

In fact, add conditionals and Personal Belief Exemptions to those who have permanent medical exemptions from vaccinations, and the average California elementary school begins classes with nearly 10 percent of its kindergartners un- or under-vaccinated.

This issue came as a surprise to LAUSD school board member Bennett Kayser.

"I mean, if there really is an issue as you’ve described, and there are many kids who have inadequate vaccinations — that can spread throughout their classroom, throughout the school," he says. "There’s a lot to worry about with that if it isn’t working properly."

Kayser believes the problem can be easily solved.

"It shouldn’t be difficult to generate a report that says who’s needed a booster shot for the longer period of time, and sort the list of students who are still in need of boosters," he says.

Under-vaccinated children are not found only at the LAUSD. Los Angeles County had a conditional entrant rate of 12.3 percent, almost double California’s 6.9 percent. In Northern California, Alameda County also stands out: 9.7 percent of its students entered kindergarten on a conditional basis this school year.

This issue worries Dr. Richard Pan, a pediatrician and state senator (D-Sacramento) who sits on the senate health committee and who sponsored last year’s legislation requiring parents opposed to vaccinations to have a conversation with their care provider before enrolling their unvaccinated child in school.

"It certainly is a public health problem, because you have people who are under-vaccinated," says the senator, who plans to introduce more legislation this year to require schools to provide parents with statistics on their students’ vaccination status. 

The senator says he supports increased funding for school nurses, so they have the ability to ensure that all kids get vaccinated.

Tracking whether students get fully vaccinated "is something that’s been falling by the wayside," says Pan, who adds, "We need to focus on that again."

This story was the result of a collaboration between KPCC and the California Healthcare Foundation's Center for Health Reporting.