Parents might have to work a little harder to opt their children out of required immunizations if the State Board of Health approves a set of policy changes on Wednesday.

Currently, parents can submit a “personal belief” or religious exemption form just once during their child’s K-12 schooling. If the new rules pass, parents would have to submit those exemption forms annually.

The rule changes also include a provision for a new public database of immunization and exemption rates for all Colorado schools and childcare facilities.

Such a database would be a significant expansion of the work Chalkbeat Colorado began in February by publishing a first-of-its-kind immunization database for schools in the state’s 20 largest districts.

State health department officials said the database amendment was a last-minute addition that came in response to feedback from stakeholders during the last two months. A state law passed last year — House Bill 14-1288 — requires schools to release immunization and exemption rates upon request.

That law doesn’t specify that the health department collect the data, but officials there believe it’s within the department’s broader legal authority as long as the Board of Health approves the plan.

Advocates of the new exemption requirements and database which would take effect in  2016, say they could help push down exemption rates and better inform the public about communicable disease risk in their communities.

Last year, about 4.6 percent of the state’s kindergarteners — around 3,000 — had “personal belief” exemptions from some or all shots.

At individual schools, those rates vary wildly. More than 140 schools in Chalkbeat’s database posted exemption rates of 10 percent or more and several had exemption rates higher than 30 percent.

It’s those schools that worry public health experts most.

That’s because exemption rates of 10 percent or higher can threaten herd immunity, which offers protection against disease outbreaks. Herd immunity usually requires immunization rates of 90-95 percent.

Toughening exemption rules…a little

Colorado currently has one of the most lenient personal belief exemption policies in the country.

To qualify for such exemptions parents simply sign a form on a one-time basis. In contrast, many of the other 19 states that allow philosophical or personal belief exemptions make the process tougher.

Some, such as Arkansas, require parents to submit notarized documents every year. Others, such as Washington and Michigan, require that parents be briefed by doctors or county health workers one or more times during the K-12 years.

Childhood vaccination rates in Colorado and the nation | Create infographics

Advocates of the exemption frequency rule say it will require parents who exempt to put forth a similar level of effort as parents who vaccinate — a tenet know as “equal effort.” 

“It should not be easier to exempt your child than to vaccinate your child,” said Rachel Herlihy, acting director of the Disease Control and Environmental Epidemiology Division at the Colorado Department of Public Health and Environment.

Under the proposed change, the increased number of times parents must submit paperwork aligns with the childhood schedule for doctor visits. While parents of school-age children would have to submit the forms annually, parents of younger children would have to submit the forms at any point new shots are required — up to five times before kindergarten.

Better data versus extra red tape

Proponents of the new rule also say increasing exemption frequency could also yield more accurate data. For example, when family circumstances change — say a hesitant parent later decides to vaccinate — the decision is recorded and the outdated exemption is removed.

Opponents worry the provision will heap new administrative work on already stretched schools and child care providers. One large district that is speaking out is the Boulder Valley School District, which has a districtwide exemption rate of 12 percent. In a letter to the state board, the district’s director of health services calls the new requirement an unfunded mandate.

But districts like Greeley-Evans, where school exemption rates range from 1 to 13 percent, have fewer concerns about extra work.

“It would put a burden on us…but it wouldn’t be a lot,” said Lead nurse Maribeth Appelhans.

Opponents of the frequency rule also worry that it amounts to government interference in carefully considered health care decisions.

“We believe it should, like any other medical decision, rest in the hands of the people who are taking the risk,” said Theresa Wrangham, executive director of the National Vaccine Information Center, a group opposed to vaccination mandates.

Besides worrying about new administrative burdens on schools, she has concerns about data privacy since the new exemption rule would shift from the current paper exemption form collected by schools to a new online exemption form that would go to the state health department.

“My concern is it’s not [the health department’s] job,” she said. “The law says the schools gather it… It’s information they should be handling and protecting.”

Combatting convenience exemptions

One amorphous group that comes up often in immunization discussions are parents who choose “personal belief” exemptions for convenience rather than strongly held convictions.

These might be frenzied parents who aren’t particularly worried about the risks of vaccinations, but signed the exemption form because it was quicker than searching for lost paperwork or scheduling last-minute doctors appointments.

The state health department has no firm data on convenience exemptions, but both advocates and opponents of the rule changes say they’ve heard anecdotal accounts of school staff offering parents the exemption option if their immunization paperwork is missing or incomplete.

“That’s a school problem, not a parent problem,” Wrangham said. “We need to revisit how school personnel are trained.”

But Appelhans said while some district staff may have taken such shortcuts years ago, they don’t anymore. Health clerks, and even substitute health clerks, now receive comprehensive training about immunization rules, she said.

While Wrangham doesn’t believe the rule change will reduce Colorado’s exemption rates, Stephanie Wasserman, executive director of the Colorado Children’s Immunization Coalition, does. 

“Other states that have…common sense parameters around how parents can claim an exemption get much more meaningful, accurate data…in terms of getting rid of the convenience factor,” she said.

She doesn’t expect the rule to affect the decisions of parents who have strongly held beliefs about vaccinations, but thinks it could impact parents who are “fence-sitters.”

A missing conversation

Regardless of what happens at the Board of Health meeting, some observers say immunization advocates need to look at how they communicate with parents who are hesitant about vaccines.

Jennifer Reich, a sociology professor at the University of Colorado Denver, has studied how parents make vaccination decisions and found that those who opt out see it solely as an individual choice with little or no health impact on the broader community.

“The problem is that’s just not how vaccines and illness work,” she said.

Still, she said most messaging about immunization doesn’t focus on community benefits.

“We don’t talk about vaccination like that,” said Reich, who will publish a book about vaccine decision-making in 2016. “Most parents didn’t recognize the problem of free-riding.”

Even among parents who fully vaccinate, 25 percent have concerns about the standard immunization schedule, she said.

“I’m wondering more broadly how we haven’t succeeded in communicating science in a way parents can trust.”

Proposed changes