In April, parents of students at Cedar Park Middle School received an email that one of their children’s classmates had contracted pertussis, commonly known as whooping cough. The highly contagious respiratory disease is on the rise nationwide, according to the Texas Department of State and Health Services. While the email did not specify whether the sick student was vaccinated against whooping cough, it emphasized the importance of administering immunizations to students. “Immunization records should be checked, and any child or adult who is under-immunized or not immunized should follow up with their physician to receive [an] age appropriate pertussis-containing tetanus/diphtheria vaccine,” wrote Dr. Mary Ann Rodriguez, interim medical director of Health Authority Austin/Travis County Health and Human Services, in the email. Jinny Suh is the founder and leader of Immunize Texas, an advocacy group promoting immunizations. Suh said while there has not been an outbreak in the Lake Travis area, she has concerns with the lifestyle of people in that specific community. In her estimation, people in the Lake Travis area engage in behaviors highly conducive to outbreaks, including a high frequency of traveling abroad. People can return home from a trip symptom-free but still carrying a disease, and by the time they start exhibiting symptoms and see a doctor, they could have exposed hundreds of people, she said. “The fact that we haven’t seen an outbreak yet is not a source of comfort,” Suh said. Becca Harkleroad, district lead nurse for Lake Travis ISD, said in the five years she has been with the district, vaccination rates have held steady. She said that education is a top priority on the issue, especially within the nursing profession. One facet of the growing debate Harkleroad said she finds difficult to deal with centers on people who want to be able to choose not to vaccinate their kids. They seem to look at people who understand vaccines and support the idea of all healthy people getting vaccinated almost as a threat, she said. “I don’t want to tie your kid down and force them to get a vaccine,” Harkleroad said. “I want those parents to be educated about how vaccines work, why vaccines work, the concept of herd immunity, the safety of vaccines.” Area exemptions to vaccines rise A common problem with the rising trend throughout the country of parents opting out of vaccinating their children is that most of those parents have not been alive to see the devastating effects of the diseases that were more prevalent in people decades ago, whether because they were vaccinated themselves or simply have not experienced those diseases personally, Harkleroad said. Without exemptions, families of children attending school in Texas are required to prove that they have been vaccinated to the minimum state requirements. Per state law, parents and guardians may elect not to administer vaccines to their children under medical or conscientious exemptions. Medical exemption statements may be written by physicians to excuse individuals who would be medically harmed by the vaccines, such as due to an allergy or chronic condition. Conscientious exemptions, however, are provided for children of parents who voluntarily decide to decline vaccinations for reasons of conscience, such as a religious belief. Statistics from DSHS state that in Travis County, the rate of students with conscientious exemptions to vaccines has jumped from 1.53% for the 2011-12 school year to 2.72% for the 2017-18 school year. For the 2018-19 school year, DSHS statistics show conscientious exemptions within LTISD at 3.82% and Eanes ISD at 3.1%. On a broad scale, the World Health Organization lists “vaccine hesitancy” as one of its top 10 threats to global health in 2019. According to the organization, vaccines prevent 2 million-3 million deaths per year across the world, and if coverage of vaccinations improved, another 1.5 million deaths could be prevented. Opposition to vaccination One of the biggest challenges to educating people on the facts of the issue has been competing information channels that can often be misleading or false, Harkleroad said. “Sensationalism wins every time, and that is challenging and frustrating,” she said. “A lot of the sensationalism and the anecdotal evidence that the people who are vaccine-hesitant cling to is not necessarily based in science.” Michelle Evans—the former communications director and founding member of Texans for Vaccine Choice, a political action committee that advocates for conscientious exemptions—said most of the families she knows who opt out of immunizations had been previously vaccinated but decided to stop after what they found to be adverse reactions to the vaccines. Evans, who is no longer involved with Texans for Vaccine Choice in an official capacity, said she followed the recommended vaccine schedule for her first child, who experienced reactions. Evans decided to pick and choose which vaccines to give her second-born child, and after she, too, had a series of reactions, Evans decided not to vaccinate her third child at all. She did not seek medical exemptions for any of her children because of the conscientious exemptions available to them. “It’s a basic human right that we not be forced to undergo any medical procedure,” Evans said. “It’s something that I should have the choice to accept or deny based on any reason I feel is valid.” Suh said the issue is impactful for the entire community because an individual’s decision not to vaccinate can harm others by weakening herd immunity. She said oftentimes people are contagious before knowing they have a communicable disease and thus expose others to it. “So that’s the reason why we try to focus so much on immunization rates … because as a society we have an interest in making sure our communities don’t suffer from an outbreak,” she said. Harkleroad said LTISD has recently held internal reviews on the characteristics of measles and how it presents itself in people. The issue has become so politicized largely because politicians set rules on vaccines from state to state, she said, adding it is not the district’s policy to campaign in one direction or the other regarding vaccinations. “But I feel like our nurses at individual campuses are really good at answering questions for parents and having open dialogue free of judgement,” Harkleroad said. Compared with other counties in the state, Harkleroad said Travis County has relatively high percentages of people who opt out of vaccinations, though she said she cannot say why that may be. Outbreak risks Dr. MaryAnn Tran is an infectious diseases physician for Baylor Scott & White Health who sometimes works at the Lakeway branch of the hospital. Tran said promoting educational outreach is crucial to helping stem outbreaks, especially in light of recent national trends. “The [national] measles outbreak has sort of stirred the controversy up because it’s something we really don’t see that often,” Tran said. “This year we’ve had the highest number that we’ve had in decades from when the Centers for Disease Control [and Prevention] in the U.S. eradicated measles. The reason is because of those pockets of unvaccinated children or adults.” Because measles spreads so easily and quickly, an outbreak made worse by lower vaccination rates in a given area can spiral into a need to isolate and quarantine infected persons, which is necessary because complications from measles can lead to pneumonia, brain infections and even death, Tran said. Tran said at Baylor Scott & White, there is a focus not only on educating patients, but on educating physicians as well. The majority of physicians have not seen measles because it was almost totally eradicated in the 2000s, and now there are doctors who have never had to encounter measles. “They don’t think about measles when someone comes in with a fever, and that’s very important because the faster we can diagnose it, the faster we can treat the patient,” Tran said. Any delay in diagnosis can potentially expose many more people for a longer amount of time to the disease, she said. Sharmae Erickson was a nurse with LTISD for eight years, seven of those as a campus nurse at Serene Hills Elementary School. Erickson left the district in 2015, and she said when she was with the district, vaccination rates were low and she was getting to a point where she was requesting permission to give parents information about vaccinations and rates in the area as well as the importance of herd immunity. “While I was with LTISD, I felt the [vaccination] rates were getting worse,” Erickson said. “I felt I should be permitted to let my school population know what the rate was. Yeah, it’s public information, but I think it needed to be made known … what the rates are, what the danger is.” Erickson said regarding the specific example of measles, a recommended vaccination rate within a given population is 90%-95%, but she prefers to err on the side of caution and said 95% or higher is a much better rate. “That’s not something you want to take a chance on,” Erickson said, adding another reason it is important to have a high vaccination rate is because of those who cannot be vaccinated for medical reasons. “Those are the ones who need to be protected the most.”