Laura Blaisdell’s youngest son just started second grade at their local school in the Willard Square section of South Portland. He’s her second boy to head off to the Dora L. Small Elementary School in this comfortable coastal neighborhood, about a mile from the beach.
Besides a beloved bakery known for its chewy bagels, there’s little about Willard Square that makes it stand out among other like Maine neighborhoods filled with school-age children — except one thing that surprised Blaisdell.
Only about 75 percent of the 101 kindergarteners and first-graders at the Small school were vaccinated against measles, far under the 95 percent that experts say is needed to prevent the spread of the highly contagious measles bug.
The Small school’s vaccination rate is too low to create what’s known as “herd immunity,” when enough people in a group are vaccinated to prevent the spread of disease, even to unvaccinated individuals.
The Small school is not alone. Across Maine, more than 160 kindergarten classes fall short of 95 percent vaccination for measles. While most people recover from the illness, complications such as pneumonia and brain swelling can be life-threatening, according to the U.S. CDC.
Blaisdell knows this well. She’s also a pediatrician who researches vaccine skepticism and how parents make decisions about immunization.
But she didn’t expect the issue to hit so close to home.
“I didn’t realize that there was such a hesitation to vaccination in my neighborhood, among people who are sending their kids to our school,” Blaisdell said. “I was a little taken aback. The choice to not vaccinate is not as marginal as it used to be. It’s becoming more mainstream.”
While students are required to get shots to attend school, Maine is among 18 states that allow parents to exempt their children from school-required immunizations for philosophical reasons. Parents may also decline immunizations on medical or religious grounds.
Now, for the first time, Maine parents can look up the exemption and vaccination rates at their local elementary and middle schools.
In May, the Maine Center for Disease Control and Prevention released the data, an unprecedented step here and one many public health experts hope will lead to more community discussion about vaccines. The information details rates for kindergarten, first and seventh grades.
Most Maine parents do vaccinate their children. But a Bangor Daily News analysis of the data, covering the 2014-15 school year, identifies several trends that vaccination advocates have long cited, though lacked hard data to support:
— Overwhelmingly, parents opt out of vaccines for their children for philosophical reasons, as opposed to religious or medical grounds.
— Lower-income families with kids in Maine’s rural interior refuse vaccines less often.
— Parents who send their children to the private and charter schools sprinkled across Maine are more likely to refuse immunization.
— Along the coast, parents opt out of vaccines in greater numbers than in northern and central Maine, with Hancock County in particular appearing susceptible to disease outbreaks.
Nationally, anti-vaccine sentiment has persisted among the affluent and well-educated, a broad trend the Maine data seems to echo. As Dr. Lawrence Losey, a Brunswick pediatrician who sits on the state’s immunization task force, once put it, “the smell of saltwater puts you at risk.”
Yet Maine’s data fails to explain why vaccination rates in rural areas are higher, even though families in those regions have greater challenges to immunization, such as fewer overall health care options and longer distances to travel.
The trend defies easy explanation, said Cassandra Grantham, director of child health at MaineHealth. Some research indicates, however, that families in rural areas are more likely to trust their doctor’s advice, she said.
“Rural Maine can be really hard, there might be one pediatric practice or maybe a couple of family medicine practices in a community and you might have one car for the family,” Grantham said. “But people still find a way to get there, which I find kind of fascinating.”
What’s also interesting is a simple reason why certain parents are exempting their children from vaccines: It’s easy.
North Yarmouth Academy, a private school for toddlers through grade 12, ranks among the top 10 in Maine for kindergarten, first- and seventh-graders who have opted out of vaccination.
The school is an example of how the vaccination data requires context. The state’s assessment reflects just fewer than a dozen students in NYA’s kindergarten class, for example, meaning that group’s opt-out rate of more than 30 percent stems from just three philosophical exemptions.
“We have so few students that all it takes is one or two kids to really dump our numbers into huge percentages,” said Ashley Moody, a nurse and the school’s health services coordinator.
In many cases, children who have received a first or second dose in a series of immunizations, but not the final shot, appear in the data as unvaccinated, said Moody.
Tonya Philbrick, director of the Maine Immunization Program, notes children may be exempted from one vaccine, such as measles, but current on others. Also, the state data reflects one point in time, and not all schools reported their rates by the deadline of last December.
“Even though a school may have had a certain number of exemptions at that time, it doesn’t mean that those children are still exempt,” Philbrick said.
While some NYA parents vehemently reject vaccines, said Moody, others use philosophical exemptions for practical reasons. Some find it difficult to schedule appointments for physicals at busy local pediatricians’ offices before their child’s fifth birthday, she said.
“We do have a couple of families that philosophically do not immunize their kids,” Moody said. “It’s not widespread. I have a lot of kids that don’t meet the exact state standard — their parents are spacing out their immunizations a little bit further than what pediatricians and the state recommend.”
Then there’s the convenience factor. In many respects, filling out the exemption form is easier than getting a kid fully immunized, Moody said. Parents sometimes grab the form and check off the philosophical objection box to get their child through the school’s doors in September, then actually follow through with the vaccinations later in the year, she said.
“Parents are just saying, ‘OK, it’s philosophical, I’ll catch up later,’” Moody said. “It’s a convenient opt-out option.”
Grantham wishes it weren’t. A bill debated during the last legislative session would have required Maine parents to consult with a doctor before claiming a philosophical exemption, but it failed to become law. States that make it harder for parents to opt out have better vaccination rates, she said.
“I think there are some folks who would probably immunize their kids, but it’s easier not to, for numerous reasons,” Grantham said.
Certain words crop up when speaking to vaccine advocates about the types of people most likely to refuse immunizations. Affluent. Environmentally minded. Believers in holistic health care. Liberal. Libertarian.
The same descriptions are also frequently applied to Maine’s midcoast region, vestiges of a back-to-the-land movement that took hold there in the 1970s. Today, Hancock County is home to a cluster of schools with high vaccine exemption rates, and public health efforts aimed at encouraging immunizations also focus on coastal Waldo and Lincoln counties.
High opt-out rates also crop up in more urban areas in Lewiston and Portland. Grantham said this could be stem from both being home to large immigrant populations, which may be unaware of vaccination requirements, or hesitant to try newer shots unavailable in their home countries.
Kathryn Colby, Grantham’s colleague at MaineHealth and a former epidemiologist with Maine CDC, suspects that school nurses in areas with high populations may not have the capacity to follow up on all students with missing records. New students, including recent immigrants, also may struggle to get medical appointments due to heavy volumes at area practices, she said, adding that more data is needed on the topic.
Parents who exempt their children from vaccines are less likely to trust mainstream health professionals, the CDC and other authority figures, while placing more confidence in alternative medical professionals, friends and the Internet, according to one study.
“Folks who opt out of vaccination for their school-age children tend to be clustered together in small pockets,” Grantham said. “Like-minded folks will congregate in a certain area, even within a town.”
Those clusters, even when relatively small, pose the biggest threat to herd immunity. A measles outbreak at a Disney theme park in California was sparked by a modest pocket of unvaccinated people, said Blaisdell, the Yarmouth pediatrician. More than 130 people were sickened.
“Measles killed hundreds of thousands of people last year worldwide,” she said. “It’s not that humankind is naive to the virulence of these bugs.”
The Maine CDC announced a record number of chickenpox cases among schoolchildren during the last school year, but has declined to identify the schools involved in such outbreaks, a highly controversial decision.
While schools typically notify parents of disease outbreaks, people with compromised immune systems — such as the elderly and those recovering from cancer treatment — must be wary. Without kids in school, they often remain oblivious to the risk, public health professionals say.
“I think we need more data and I think it needs to be transparent and think we need to be more sensitive about our outbreak situation,” Grantham said.
There are early indicators that attention to vaccination could be changing trends in Maine. Newer CDC data indicates fewer Maine parents are refusing immunizations for their kindergartners, which points toward a reversal in the growing trend toward skipping children’s shots.
During the 2014-2015 school year, Maine parents opted out of vaccines for 4.4 percent of kindergarteners, ranking Maine 10th among states, according to the data. That’s down 1.1 percent from the previous school year, when Maine had the fourth highest rate of parents rejecting vaccines.
Yet although Maine’s opt-out rate dropped, it still exceeded the national average. Across the country, just 1.7 percent of parents refused to immunize their kindergarteners.
While this early news is positive, Blaisdell said Maine will need to improve vaccination rates for many more years to protect public health.
“I’m generally an optimist but I don’t believe that public education is all that’s required to change the tide on vaccination,” she said. “I believe community dialogue and people speaking out in support of vaccination has been helpful, because the vast majority of people are vaccinating their children and believe that’s the right and responsible choice.”
The topic, however, remains polarizing. Blaisdell, as both a parent and a pediatrician, knows talking about vaccination is dangerous territory.
“If you go to a dinner party and you say, ‘So how do you feel about vaccination?’” you might as well ask about abortion,” she said. “It really kills any kind of conversation.”
So while the newly released school-level vaccination data is a big step forward, simply knowing how many kids in your neighborhood classroom received their shots won’t improve immunization rates, Blaisdell said.
“What parents can actually do about that with the data, I’m not sure,” she said. “They can choose to send their kids to another school, I suppose. But there really isn’t any mandate that parents nor school administration has to force parents to vaccinate.”
Maine CDC expects to release school-by-school exemption and vaccination rates for the 2015-16 school year by March 31, 2016.