In January, the principal of Pflugerville High School sent a letter to parents and staff confirming that one of the school’s students had contracted pertussis, commonly known as whooping cough. Three months later, a second case of whooping cough was confirmed at the school by district officials. The highly contagious respiratory disease is on the rise nationwide, according to the Texas Department of State Health Services. While the principal’s letter 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. Philip Huang, former medical director of Health Authority Austin/Travis County Health and Human Services, in the email. According to a new community health assessment by the Williamson County and Cities Health District, conscientious exemptions to immunizations among Williamson County students in kindergarten through 12th grade is at the highest it has been in the past eight years, with 2.68% of students receiving a conscientious exemption to at least one immunization in 2017-18. Travis County’s conscientious exemption rate is above Williamson’s at 2.72%, while the statewide rate is 1.07%. In Austin ISD, the conscientious exemption rate was at 2.47% of the student body in 2018-19, the highest rate it has been since at least 2013-14, according to data from the Texas Department of State and Health Services. The rate at AISD has continued to climb over the past handful of years, and, according to 2012-17 data, AISD’s rate is consistently above the statewide conscientious exemption rate each year.

CONSCIENTIOUS EXEMPTIONS

Without exemptions, families of children attending public or private school in Texas are required to prove that they have been vaccinated to the minimum state requirements, which include immunizations for conditions such as polio, measles, mumps, tetanus and more. 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. Some local religious private schools have conscientious exemption rates high above those of local independent school districts. Over 10% of the students at Hill Country Christian School of Austin had conscientious exemptions in the 2018-19 school year, per the DSHS. At Brentwood Christian School, 6.3% of students had conscientious exemptions in the most recent school year. Conscientious exemption rates do not necessarily represent the number of completely unvaccinated children at a school, but rather the number of children with a conscientious exemption to at least one vaccine. For instance, while 13.93% of students at Hill Country Christian School had some kind of conscientious exemption to an immunization in 2018-19, over 90% of seventh graders had their hepatitis A and B, MMR, polio and varicella vaccinations, according to the data. Dr. Caroline Hilbert, the director of immunization advocacy for the WCCHD, said there are a number of reasons why the Central Texas area has lower immunization rates. “It’s these two extremes where it’s a mix of higher-educated, well-off, misinformed individuals making decisions that are affecting their child’s health and community’s health, and then individuals from families who just are struggling to make ends meet,” she said. As for private schools, she said parents with the resources to choose specialized education for their children may want to have control over other aspects of their children’s lives as well. “Parents who have actively researched and chosen a private educational path for their children are often doing the same thing regarding their child’s health, but with so much misinformation, some parents are making ill-informed decisions,” Hilbert said. However, Holy Family Catholic School, located in Northwest Austin, has reported between 98.04%-100% immunization rates across all required vaccines among its kindergarten and seventh-grade students in 2018-19. The school has a 0% conscientious exemption rate, per the policy of the Diocese of Austin, which does not accept conscientious objections or waivers to immunizations, according to the school’s handbook.

RAISING CONCERNS

There are a number or reasons why parents and guardians decide to opt out of vaccinating their children. Michelle Evans—the former communications director and founding member of Texans for Vaccine Choice, a political action committee that advocates for conscientious exemptions—said the majority of families she knows that do not vaccinate used to do so but decided not to 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. Evans said her second child, too, had a series of reactions, so 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. ... It’s not really anybody’s business why I would choose to have this not done for my children or myself.” Jinny Suh is the founder and leader of Immunize Texas, an advocacy group promoting immunizations. She said the pros of vaccination far outweigh the risks, and that the entire community is protected when immunization rates are high. She said people are introduced to pathogens throughout the day, and by having low vaccination rates in a community, more people are protected from dangerous diseases. “The idea behind herd immunity is at a basic level [to cut] off the potential places where a pathogen can jump to from a person who’s infected,” Suh said. “When you have drops in immunization rates you’re just allowing for more places for that germ, that pathogen … to continue growing and propagating and continue infecting.” She said different diseases have different levels of immunization needed for herd immunity, such as measles, which needs 95% of community members to be immunized to contain an outbreak. “That’s why we have outbreaks, it’s when we get to such a low level that it’s just too hard to contain the disease without resorting to something like a quarantine,” Suh said. Additionally, she said oftentimes people are contagious before knowing they have a communicable disease and expose it to people. “As a society we have an interest in making sure our communities don’t suffer from an outbreak,” she said. “In order to have that protection for the community you have to focus on the immunization rates for the community and not just on an individual vaccination status.”

VACCINE HESITANCY

In 2015, Austin Regional Clinic announced that its clinics would not accept new pediatric patients if parents did not permit vaccinations. The mandate came shortly after an outbreak at Disneyland where a total of 125 measles cases were connected to the case, according to the Centers for Disease Control and Prevention. Dr. Elizabeth Knapp, a pediatrician at ARC Far West, said the vaccination policy was enacted to protect the “public safety” of the clinic’s staff and patients. In the time following ARC’s policy update, Knapp reported the clinic saw higher vaccination rates for pediatric patients. “After our policy went into effect we found many of our patients did choose to become vaccinated because they found trust in their doctor was very important,” Knapp said. 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. WHO named complacency, lack of confidence and inconvenient access to vaccines as the reasons behind vaccine hesitancy. Hilbert said the benefits of immunizations far outweigh the risks, and that it is important for anyone who is able to be vaccinated to do so in order to maintain public health and herd immunity. “Nothing in the world is 100% safe, and with vaccines they’ve shown that there’s a 1 in a million to 1 in 2 million chance that you can have really severe side effects from a vaccine,” she said. “From a public health standpoint and [with] how deadly a lot of these diseases can be, that’s the individual, very minimal risk that we take on for the protection of our population as a whole.”