As kids revel in the final days of summer break, Pennsylvania school nurses statewide are hustling to make sure students are vaccinated.
The mandatory recordkeeping is routine, and helps school officials to keep children safe from preventable diseases like tetanus and hepatitis B. But rising requests for exemptions to vaccinations are making this work fraught and revealing fears some parents have about caring for their children.
Under state law, parents who object to immunizations for philosophical or religious reasons can still send their children to school, though their kids can be barred from attending during an outbreak of a vaccine-preventable disease.
The growing use of exemptions is a concern in Pennsylvania and other parts of the U.S. During the COVID-19 pandemic, vaccination rates for childhood illnesses decreased, partly due to disruptions to the health care system and to increasing levels of vaccine hesitancy. Among the most alarming infectious diseases making a comeback due to these shifts is measles.
A measles infection can cause earache, fever, diarrhea, pneumonia, and swelling of the brain that can lead to deafness and intellectual disabilities. As of Aug. 15, there have been 219 confirmed cases in the U.S. in 2024, according to the CDC. Kids five and younger comprise 40% of these cases, and more than half of them were hospitalized.
Preventing the resurgence of measles and other childhood illnesses, like polio, requires nearly universal vaccinations, which isn’t the case in Pennsylvania. During the 2019-2020 school year, the kindergarten vaccination rate for measles was 96.4%, according to data analyzed by the state Department of Health. In 2022-2023, that rate dropped to 94%. If the number of unvaccinated kids creeps further upward, Pennsylvania could face a public health crisis that is entirely avoidable.
School nurses play a key role in prevention. They provide parents of unvaccinated children with resources on the importance of immunizations, said Eileen Wallace. A nurse for Bethel Park School District, Wallace told Spotlight PA she explains how skipping vaccines can be bad for community health. A virus that might pose little threat to one person, for instance, can have serious complications to another.
But parents ultimately decide what to do with this information.
“It’s something that we cannot question because it’s a given right,” Wallace, a board member for the Pennsylvania Association of School Nurses and Practitioners, said of parental authority.
For parents who dutifully vaccinate their kids, their hesitant counterparts can be easy to write off as selfish, neglectful, or foolish. But Jennifer Reich, a sociologist at the University of Colorado Denver, argues the issue is much more complicated.
Reich, who wrote Calling the Shots: Why Parents Reject Vaccines, told How We Care that parents often make case-by-case decisions about immunizations. They might be more worried about one infectious illness than another, which influences their views on certain vaccines.
Reich finds that parental vaccine hesitancy is rarely motivated by conspiracy theories or ignorance of how vaccines work. Some perceive immunity acquired from an illness as natural and superior to immunity from vaccines — which they view as artificial and potentially dangerous. Others believe their children can be made sufficiently safe through breastfeeding and organic foods.
Though some parents still worry about the false link between autism and vaccines, Reich explained that a common fear is “overloading” their child’s immune system with too many immunizations. Parents are also concerned about potential side effects, even if they’ve been shown their kids are not at risk, or that such adverse reactions are extremely rare.
Reich also noted people sometimes change their minds about certain vaccines. Their cost-benefit analysis might shift toward immunizations due to an international trip to a place with rising infections, or due to a family member’s serious diagnosis, such as leukemia, that leaves that relative immunocompromised.
“Parents sometimes said, ‘Well, I don't know what the perfect decision is, but I just know I don't feel 100% good about this choice, and so I can wait and change my mind later,’” said Reich.
But with this approach, parents might not have time to take preventative steps before their kids are infected, especially in the case of measles, which is incredibly contagious.
A person can spread the measles virus up to four days before a rash appears, which is the telltale symptom of the illness. And an infected person can pass the disease on to as many as 18 unvaccinated people. In comparison, a person with COVID-19 is likely to infect about three others.
Measles circulates so quickly and efficiently because infected respiratory droplets can remain airborne for hours after a contagious person leaves an area. If someone who doesn't realize they have the virus sneezes in an elevator at 10:00 am, anyone who rides that elevator before noon could be exposed.
Vaccination decreases the chance of such scenarios. When the rate is high, cases of measles become rare. In fact, in 2000, the CDC declared the virus eliminated in the U.S., citing years of high vaccination rates.
To prevent widespread transmission of measles, the CDC and the World Health Organization recommend that 95% of a population be vaccinated or have immunity through a previous infection.
But in Pennsylvania, some counties aren’t meeting this important threshold, according to state data from the 2022-2023 school year. Just 91.8% and 91% of kindergarteners in Bradford and Lancaster Counties had both doses of the measles vaccine. In Dauphin and Forest Counties, the rate was below 86%.
According to Reich, American cultural values drive some of the vaccine hesitancy.
Being told to act communally clashes with public health messaging that emphasizes personal choices, she noted, citing a long history of individualized diet and exercise guidance.
This context can lead parents to reason that if their active kid eats vegetables and gets enough sleep, they can ward off viruses like measles, or that their child will fully recover from an infection. And if their child spreads the measles to someone else, isn’t the other person’s health their own responsibility?
This rationale might seem cold, but the U.S. generally provides minimal support to families, including when it comes to child care or medical coverage. In turn, Reich said, families can feel they have little incentive to act in the name of community health.
For this reason, to increase vaccination rates, it might be most effective for caregivers and clinicians to emphasize why jabs are vital for individual health outcomes. Kate Tigue, a physician and managing partner at Pediatricians of Northeastern Pennsylvania, said she has lengthy conversations with concerned parents at her Scranton-area practice about immunizations.
In the case of measles, Tigue emphasizes to families how agonizing an infection can be for kids and notes that out of every 1,000 children who get it, one to three die.
In these conversations, she also addresses the anxiety that too many shots might overwhelm a kid’s immune system, explaining that by the time an infant gets their first vaccines, they’ve been exposed to an abundance of pathogens from the environment and contact with other people.
“The immune system is more than capable of handling and processing several vaccines at an appointment,” said Tigue, who also is the president of the Pennsylvania Chapter of the American Academy of Pediatrics.
While people like Tigue are providing parents with thorough, evidence-based information to show the many benefits and extremely minor risks of vaccinations, the decision can still be scary for some because if there is a bad outcome, that burden largely falls on individual families alone to bear.
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