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For Utah, it started with two unvaccinated Utah County boys.
On a trip to Disneyland over the holidays, the two teens contracted measles and brought it home. They went to the movies, the grocery store and church before they headed to the Timpanogos Regional Hospital emergency room.
As a result, one child who came in contact with them got infected and 117 other Utahns spent 21 days in voluntary quarantine. The outbreak cost the state and county health department $115,000 to contain.
It could have been far worse. They could have gone to school.
An analysis of immunization data for the 2014-15 academic year shows that Utah County parents are less likely to immunize their 5-year-olds than those who live in Salt Lake County.
Throughout Utah County, two out of five public elementary schools failed to have enough kindergarteners vaccinated to meet "herd immunity" benchmarks for measles, the level the government says is needed to stop the disease from spreading rapidly. The rate is even worse for charter and private schools in the county; three out of four fail the herd immunity test.
And just one elementary school in Utah County Ivy Hall Academy boasted a 100-percent vaccination rate for incoming kindergarteners at the start of the school year.
The anti-vaccination movement in Utah, as in other places, is driven by families that distrust the medical profession and believe vaccines are dangerous, even though the science says otherwise. State law allows parents to exempt their children from required vaccinations, putting education managers in a tough spot as they try to protect kids from contagious, and sometimes deadly, diseases.
"We are concerned. We want healthy children and safe schools," said Lois Bobo, the elementary director for the Walden School of Liberal Arts, a charter school based in Provo. Walden has 39 kindergarteners this year and only 23 are adequately immunized, giving it the fifth-worst ranking in the state.
Bobo wonders if it's a paperwork problem, where parents are getting tripped up by the school's registration process. She's not willing to assign motives to the decision parents make.
But over in Salem at American Preparatory Academy, which used to be called Liberty Academy, principal Richard Fillerup says some parents are simply making a decision one that bucks the health departments, school officials and pediatricians, but a legal decision nonetheless.
Fillerup noted that many parents who place their child in a charter school are less inclined to go with community standards.
"Charter schools are schools of choice," he said. "The choice resides with the parents and we're happy to respect their choice either way."
But those choices can have broad consequences.
Getting the exemption • The Centers for Disease Control and Prevention places the herd immunity rate at 92 to 95 percent for measles. That recommended minimum vaccination rate is important because herd immunity protects the tiny percentage of children for whom the vaccine is ineffective and those who can't be immunized because of a health condition or allergy.
Statewide, 23 percent of schools miss that mark. The percentage in Salt Lake County is 14 percent. In Utah County, it is 43 percent.
More than a dozen parents contacted by The Tribune were surprised to learn their school didn't meet the standard.
"I had no idea," said Jenny Timmerman, who has three vaccinated children attending Traverse Mountain Elementary in Lehi. "I know a handful of people who didn't like it, but I assumed most of the people I knew were pro-vaccination."
They probably are.
In reality, it doesn't take many parents withholding vaccines for a school's herd immunity rating to drop below the necessary 92 percent. If a school has 75 kindergarteners, it would only take seven unimmunized kids for the percentage to drop below the protective threshold.
Traverse Mountain has 159 kindergarten students this year and 128 were adequately immunized in September. Fifteen students had exemptions.
The school statistics The Tribune reviewed count not only parents who refuse to vaccinate their children, but also those who have fallen behind, haven't provided their papers or accidentally started the vaccination series early.
Many schools' vaccination rates will increase throughout the year.
Using Traverse Mountain as an example, 15 students had vaccine exemptions and 16 others didn't have the required vaccinations at the start of the year. If all 16 get immunized, the school's rate would jump from 80.5 percent to 90.6 percent a big improvement, but still below the national goal and the herd immunity standard.
Getting the vaccine • By comparison, Salt Lake County is far ahead of Utah County when it comes to immunizations.
It has 22 schools where every kindergartener is fully vaccinated. Utah County has just one.
And four out of every 10 schools in Salt Lake County have already met the federal government's lofty goal of having 95 percent of all students immunized. Just one in 10 schools in Utah County can say the same thing.
But that doesn't mean there aren't pockets of parents in Salt Lake County who are wary of vaccinations.
Take Riverton Elementary, where 13 of the 114 kindergarteners received exemptions through the county health department.
One of them is Beth Kunz's child. While Kunz was vaccinated as a child, her husband was not, and they decided to follow the tradition that her in-laws set. So Kunz did not vaccinate her four children, including a kindergartener at Riverton Elementary.
"My kids do not get vaccinated," said Kunz. "My husband's family has had some issues with vaccinations. His parents didn't, so he didn't."
The Kunz family grew up hearing stories of adverse medical reactions from the shots.
"They just believe it is bad," she said.
More Utahns are getting immunization exemptions for their children.
In the mid-2000s, the rate of parents seeking a pass held steady at 2.8 percent. But for the past two years, statewide exemptions have topped 4 percent and that figure has trended up in the past decade.
A 2012 survey of Utah parents who requested an exemption shows many had the same concern as the Kunz family.
Nearly 20 percent said they were worried a vaccine would cause a chronic condition and 17 percent were worried about a serious reaction.
Anti-vaccine websites often link MMR shots to autism, though no reputable studies have ever made such a connection.
Each of the 398 parents who filled out the survey could pick as many contributing factors to their decision as they liked. Nearly all of them, 97 percent, were white; 56 percent had a college degree; and 72 percent made a decision after researching the issue online.
The survey found that 25 percent of Utah parents said they received an exemption because vaccinating violated a philosophical belief.
And nearly one-third, 32 percent, said they got a release so they could enroll their child in school. Almost none of the parents said they got an exemption because they couldn't pay for a vaccine.
School nurses and county health officials are frustrated by the pockets of parents who don't believe in vaccines, despite the near-eradication of serious illnesses and the lack of proof of any widespread side effects.
"It is really bad science and it isn't a correct way to be thinking," said Joseph Miner, a medical doctor and the director of the Utah County Health Department. "They are attached to that, almost religiously attached to that. It is just their strong opinion that vaccines may be harmful."
There are plenty of efforts to make vaccines accessible, but managers of the major county health departments and the state health department have not actively tried to correct what they see as misinformation. Instead, they rely on the persuasiveness of pediatricians.
In the end, they note, vaccination is a medical decision that each parent must make.
Reporter Benjamin Wood contributed to this article
States debate exemptions
Utah allows parents to receive a vaccination exemption for school children for three reasons: religious, medical or personal. The first two require letters, either from a religious leader or a doctor. The third requires no additional information, so the overwhelming majority of the parents requesting an exemption cite personal grounds.
Lawmakers in Washington and Oregon tried to eliminate personal exemptions after the recent measles outbreak at Disneyland, but ran into stiff pushback from parent groups who argued it should remain a choice.
Several other states debated similar bills that would have made it tougher for parents to get an exemption allowing their unimmunized children to attend public schools.
No such proposal was presented during Utah's legislative session, which ended Thursday.
The only states that require vaccinations unless there is a medical concern are Mississippi and West Virginia.
Tribune and wire services