Health & Medicine

Kentucky students were required to get the Hepatitis A vaccine. Many didn’t bother.

Roughly a year after Kentucky mandated Hepatitis A vaccinations for all students, more than a third still have not received the shot, according to new state data.

While Hepatitis A rates were the lowest of all required vaccines, they reflect a broader trend: Kentucky students still aren’t getting the required number of shots. Kindergartners, who have the highest compliance rates to meet, failed to meet state standards in all categories.

Immunization rates for the 2018-2019 school year, released Tuesday by the Kentucky Department for Public Health, show that just 65 percent of the 209,904 Kentucky students in kindergarten, seventh, eleventh and twelfth grades received at least two doses of the Hepatitis A vaccine. Only kindergartners came close — at 84.3 percent — to meeting the state’s target compliance rate of 85 percent.

Rates were lowest among high school seniors, at 46 percent, followed by high school juniors at nearly 50 percent, and seventh graders at 76 percent.

Hepatitis A is a highly infectious virus that attacks the liver. Unlike the blood born C strain, which is often spread through intravenous needle sharing, Hepatitis A is spread primarily through contact with an infected person, or through consumption of fecal material, usually by way of unclean food or water.

The state was hit in late 2017 with one of the worst outbreaks nationwide — by late September of this year, Hepatitis A had infected 4,943 people and killed 61, according to the state health department — causing health officials to declare it a public health crisis. Kentucky then began recommending that everyone receive the vaccine, and lawmakers before Christmas that year made it mandatory for all students to get the two-shot series before the start of the 2018-2019 school year.

That didn’t happen, but one health official says initially low rates of compliance are normal, even in the face of a public health crisis.

“Anytime there’s a vaccine that’s added to school requirements there’s some hesitancy among parents,” said Dr. Sean McTigue, a University of Kentucky infectious disease pediatrician, “even though this is not by any stretch of the imagination a new vaccine.” Since at least 1999, the Centers for Disease Control and Prevention has recommended that all children receive the Hepatitis A shots, though not all states have made it mandatory.

Part of the lag is timing, said McTigue, who thinks it’ll take “at least two years,” to get close to compliance rates. Most children and teens get vaccines from their pediatricians, who they might only otherwise see once a year. Since the Hepatitis A immunization requires two doses six months apart and the school year is about 10 months long, there’s going to be a lag before full compliance is met, he said.

There’s also conflated stigma to contend with, McTigue said, especially as other strains of Hepatitis, especially C, are spread primarily by sharing needles for injection of drugs like heroin and methamphetamine. The rates of Hepatitis C, which can cause liver cancer if untreated, have spiked in recent years across Kentucky as an outgrowth of the drug epidemic, and curtailing the spread of that strain has become a public health focus as well. More than 50 Kentucky counties, primarily in Appalachian parts of the Bluegrass, were identified by the CDC as some of the most at-risk areas in the country for HIV and Hepatitis C outbreaks.

Hepatitis A vaccination rates for kindergarteners fell at or below 50 percent in seven Eastern Kentucky counties — Bell (44 percent), Knott (50 percent), Knox (41 percent), Lawrence (48 percent), Leslie (47 percent), Rockcastle (50 percent), and Rowan (42 percent).

For high school seniors, the rates of Hepatitis A shots rose above 70 percent in only eight counties, mostly in central and western Kentucky. Only one county — Hickman — met the state’s standard for Hepatitis A vaccinations among high school seniors, with some county rates coming in as low as 9 percent.

In Magoffin County, where 21 percent of high school seniors, 14 percent of juniors, 29 percent of seventh graders and 70 percent of kindergartners received the Hepatitis A shot, Superintendent Scott Helton said convincing parents to adopt a sense of urgency has been a challenge.

“When it’s change, it’s always hard at first,” Helton said, who thinks part of the issue in convincing parents to immunize their kids against a disease that “most people seem to think it won’t happen to them.”

Other immunization changes last school year included requiring students 16 or older to receive at least two doses of the booster to protect against meningococcal disease, which is in the same family as meningitis. Roughly 64 percent of eleventh and twelfth graders got this shot, and 91 percent of seventh graders. Kentucky’s target compliance rate for this booster is 80 percent.

Vaccines to ward off chicken pox, particularly for kindergarten students, fell short of the recommended rate in 59 counties, and, at 92 percent overall, fell just shy of the state’s sought after 95 percent compliance.

State law requires immunization records to be filed within two weeks of when a student begins attending school, but the report shows 796 high school seniors didn’t provide vaccination records to their schools at all, along with 1,087 11th-graders, 674 seventh-graders, and 1,696 Kindergartners — 8 percent, total.

Some counties reported significant numbers of students who had no vaccination certificate on file. In Robertson County, 23 percent of high school seniors had no immunization record on file. The same went for 25 percent of Wolfe County kindergartners, 10 percent of Magoffin County seventh-graders, and 15 percent of Clark County juniors.

Missing from the latest annual report are the estimated 19,250 students in Kentucky, ages 5 to 17, who are home schooled. Current state law “does not mandate immunization requirements for children in Kentucky who are home schooled,” according to the report.

Roughly 4 percent, or 2,040 students, claimed a religious exemption, while 2.3 percent, or 1,175, claimed a medical exemption. In some counties, medical exemptions across grades topped out in double digits. Nearly 12 percent of seventh graders in Martin County, for example, claimed a medical exemption, as did more than 13 percent of Bracken County high school juniors.

Carlisle County had the most high school seniors — 6 percent — who claimed a religious exemption, followed by 3.4 percent of Jessamine County eleventh graders, 5.5 percent of Clinton County seventh graders, and 5 percent of Crittenden County kindergartners.

State epidemiologists who authored the report seemed to touch on the threat posed by the anti-vaccination movement and how “maintenance of high coverage is particularly difficult” as frequency of certain diseases declines and “as populations become more sophisticated and more likely to question recommendations.”

“Unless direct communication about the social benefits of vaccinations are relayed to parents, there will continue to be increases in ‘free-ride’ or reliance on herd immunity to avoid vaccination within school settings,” they wrote.

In other words, “more education needs to be provided to parents about the public health impacts vaccinations have within schools, especially for the protection of vulnerable students who are immunocompromised.”