Terrible diseases like measles, diphtheria and polio wrought generations of suffering and death before they were nearly eradicated in the United States 50 years ago. The fix: widespread vaccination.
However, unvaccinated populations remain vulnerable, and they are growing — across the country, and here in the Bluegrass State.
A WFPL News investigation reveals more than half of kindergarten classes in Jefferson County have vaccination rates that put students at risk for an outbreak of measles or polio. Schools that serve more low-income students and Black students are most at risk.
“It’s terrifying,” University of Louisville public health professor Monica Wendel said. “This is making kids from communities of color more vulnerable.”
Today, children in the U.S. start an immunization schedule at birth. The Centers for Disease Control and Prevention recommends completing most before kindergarten.
That’s the stage when many kids attend school full-time, creating opportunities for socialization and learning, as well as the sharing of germs. But the benefit of vaccination is contingent on how many students are protected, said Dr. Daniel Blatt, an infectious diseases specialist at Norton Children’s.
“A vaccine-preventable illness in a singular classroom can spread to every kid in that classroom if they’re not vaccinated. Something like measles could spread like a wildfire,” he said.
Given the opportunity, these relatively rare diseases can take hold again, as witnessed in a 2015 measles outbreak in California and a recent case of paralytic polio in New York.
While many health officials have blamed low vaccination rates on COVID-19 disruptions to the health care system, data obtained by WFPL shows Kentucky schools had dangerously low vaccination rates well before COVID-19 made its American debut.
Experts say that’s in large part because low-income children don’t have adequate access to these essential immunizations, and that Kentucky has to do better to make sure kids are protected.
Half of Jefferson County kindergarten classes at risk
State health officials say at least 95% of kids in a classroom should be vaccinated against measles, mumps and rubella — collectively known as MMR — and polio to have the best chance of preventing outbreaks.
But in many Kentucky schools, that’s not happening.
Blatt said that can lead to a much higher risk for outbreak.
“When you’re talking about getting vaccine rates down into the 70s for routine childhood immunizations, you’re really looking at an at-risk community,” he said.
The lower a classroom’s vaccination rates, the further away the group gets from herd immunity, which decreases the likelihood that a disease will circulate.
Before vaccines for polio and measles were developed in the 1950s and 1960s, the diseases hospitalized, paralyzed or killed thousands of people in the U.S., including many children.
“If we went back in time and asked people, before the vaccines existed, what it was like to have measles … people were scared,” Blatt said. “They were scared because kids are getting sick, they were ending up in the hospital, they were ending up on ventilators, they were ending up with brain problems.”
Today, the numbers show students across Jefferson County are vulnerable. And, as with many health issues, some communities are at greater risk than others.
Unequal risk
At Engelhard Elementary, near downtown Louisville, records show 14% of kindergarteners were vaccinated against measles last school year.
In the Parkland neighborhood in west Louisville, Maupin Elementary staff reported 28% of kindergarteners were up to date on their polio vaccines.
And at Wheatley Elementary, in Louisville’s California neighborhood, records show less than half of kindergarteners are protected against polio or measles.
These schools have the lowest vaccination rates in the district. They also serve families with some of the lowest incomes in the county, and most of their students are Black.
The state advises caution comparing different schools, which may report vaccination records at different times in the fall.
But looking at the countywide data, there is a clear trend: Schools with higher proportions of Black, Latino and low-income students are more likely to have lower immunization rates.
“There are a lot of schools, particularly in areas that are predominantly minority…or just in a poor area…that there are gonna be a lot of barriers in health care in general,” Dr. Mark Burns said.
Burns is an infectious diseases specialist at UofL Health. He grew up in Louisville’s majority-Black West End, and has worked to improve COVID-19 vaccination rates in Black communities.
He’s not surprised by what a data analysis shows. Neither is Wendel, the public health professor.
“I think that that is another way that structural racism reinforces itself,” Wendel said.
She pointed to how historical redlining and other racist policies have created racially and economically segregated neighborhoods in Louisville. Students in those communities are often from families that struggle to meet basic needs, including health care.
“When you talk about the lowest-income schools, the schools with the highest population of Black students, and the students with the lowest immunization rates — those things are all interconnected. It's not coincidence,” she said.
Burns said a lack of reliable transportation may be the biggest barrier for families trying to get themselves or their children to the doctor for vaccinations. A 2016 analysis found about 11% of families in Louisville don’t have a car.
JCPS District Health Manager Eva Stone also pointed to other challenges families have getting to the doctor, like finding child care or having a job with flexible working hours.
“There's a lot of system problems I think that makes it challenging for families,” she said.
One particularly troubling disconnect, Stone said, is that sometimes the physicians available to families on their Medicaid plan refuse to provide routine childhood immunizations because the reimbursement rate is so low.
“They lose money to give those vaccines,” Stone said.
Stone said in those cases, doctors may see children for a checkup and physical exam, but then send families to the local health department for their shots. The added trip to the health department is a barrier wealthier families don’t have to navigate.
Last year the Louisville Metro Department of Public Health and Wellness gave routine childhood immunizations to 345 children.
Federal data show gaps in vaccination rates nationally between children on Medicaid and children who are privately insured. And vaccination rates in Louisville’s private schools, which tend to serve wealthier families, have some of the highest vaccination rates.
But there are some exceptions.
At Waldorf School of Louisville in the St. Matthews neighborhood, almost a third of the 29 students in the 2019-2020 kindergarten class were unvaccinated for MMR, polio, diphtheria and other required immunizations, citing a religious exemption. Though it’s not affiliated with any religion, the Waldorf School had the most religious exemptions of any school in the county.
In 2021-2022, a Catholic school in the Audubon neighborhood called St. Stephen Martyr reported a vaccination rate for measles and polio of just 14%. The school did not report any religious exemption claims.
On top of economic barriers, experts also said a mistrust of the medical establishment may be driving down vaccination rates in Black and Brown communities.
“It’s from historic practices,” incoming Louisville Urban League President Kish Cumi Price said, pointing to the Tuskegee experiment and other unethical and harmful medical practices carried out against Black people and other people of color.
Price said policymakers need to raise awareness about the benefits of vaccination, and that Black members of the medical community are likely the best messengers.
Bad to worse
COVID-19 didn’t cause low rates of uptake for routine vaccines, but it made things worse.
Data show that 83% of public elementary schools in Jefferson County failed to meet the state’s threshold in the fall of 2019. Two years later, 93% of local schools were falling short.
Dr. Steven Stack, commissioner for the Kentucky Department for Public Health, said the pandemic’s effects on routine or preventive health care is a widespread issue.
“We've seen both in Kentucky and across the nation that there was a substantial decline in vaccination rates during the COVID pandemic, probably in large part because people didn't have as ready access to normal or routine medical care,” he said.
Studies show many families avoided doctors’ offices during the pandemic.
Reports based on an April 2021 Health Reform Monitoring Study from Washington D.C.-based think tank the Urban Institute show around one in 10 of adults in the U.S. admitted they’d avoided or delayed at least one type of care for themselves over the previous 30 days, because they were worried about getting COVID-19. A quarter of respondents said they’d skipped care at least once over the previous 12 months.
One in five respondents said they’d missed health care visits for their children over the previous year for the same reason. That included visits for check-ups and routine childhood immunizations.
Low-income families were more likely than wealthier families to delay visits to the pediatrician. Those with income below 250% of federal poverty level – $66,250 in 2021 for a family of four – were twice as likely to miss visits.
Jefferson County isn’t alone when it comes to low vaccination rates. Statewide data show polio vaccinations were just under 95% in the 2014-2015 school year, and haven’t reached that level again. With MMR, it’s been at least a decade since rates hit 95%.
Rates for polio and MMR have trended down since 2018 in Kentucky.
But things look different across the region. Tennessee’s measles and polio vaccinations for kindergarteners have hovered around 97% over the past few school years. Ohio’s stayed around 92% from the 2014-2015 school year until the pandemic. Nationwide, numbers have trended around 94% over the past decade.
Stack said some parts of the state and region had lower routine vaccination rates, in some cases due to hesitancy or lack of access.
He also pointed to overall poorer health metrics in Kentucky, like high rates of cancer and hypertension.
“So this is really a societal challenge we face overall. It's not unique to or limited to vaccines, it's more of a broad-based challenge,” he said.
He said it’s too early to tell how the pandemic will affect immunization rates in the years to come.
“I share the concern that we need to do everything we possibly can to get these vaccination rates higher across all of our counties in Kentucky,” he said.
He said that will “require an active partnership,” between the state, local health departments and private physicians.
Burns, with UofL Health, said government and health leaders shouldn’t wait for an outbreak to act.
The number of reported polio cases in the U.S. fell to zero after 2013 — until this year. But in July, New York health officials identified a polio case in an unvaccinated man in Rockland County.
“Could this be the beginning of something? It's hard to tell,” Burns said. “But… I think just one case is enough for people to at least think about, and perhaps maybe have some type of contingency…should more cases start occurring.”
That case prompted local researchers to begin testing for polio in Jefferson County wastewater. They haven’t detected signs of the disease so far. The screening, which also includes other viruses like RSV and influenza, is an expansion of the program started in 2020 to test wastewater for COVID-19.
Price, with the Louisville Urban League, said the city’s “multi-pronged” COVID-19 vaccination effort could be a good blueprint for boosting other immunizations. That initiative brought together resources from the city government, school system, private practices and community groups.
And, Price said, there’s another lesson to learn from the pandemic:
“Don’t wait until it gets bad,” she said. “We can be more preventative or proactive in our efforts, instead of reactive.”
What JCPS is doing and what’s next
While state law requires students to have many vaccinations prior to entering kindergarten, JCPS doesn’t usually bar unvaccinated children from the classroom.
Stone said that’s for good reason, especially considering that unvaccinated children tend to be from low-income households and other groups that already face educational barriers.
“If we were to start telling those kids they can’t come to school, then we’re making their lives worse, not better,” Stone said.
“We want our approach to be not, ‘Hey, here’s this letter that says don’t come back,’ it’s going to be, ‘How can we help?’”
She said the district tries to connect families with the health department, community health agencies, or other social services. Eventually, Stone said, she would like JCPS to give vaccines directly to students at school-based clinics.
The district recently went through the rigorous regulatory process to become a Vaccines For Children provider. VFC is a federal program that distributes doses of routine childhood immunizations to approved physicians and other providers at no charge.
So far JCPS has used its new VFC designation to deliver COVID-19 vaccines, but Stone said eventually the district could provide routine childhood immunizations as well.
Wendel, the public health professor at U of L, said school-based initiatives like the one JCPS is planning can’t solve the problem alone.
“I think that that is a school being a really good partner, and being about the welfare of the kids they serve. But that is not a school's job,” she said.
Wendel said she believes getting more vulnerable kids vaccinated will take a seismic shift in how Americans think about health care.
“In America, we basically don't consider health a human right,” she said. “If you can pay for good health care, then you get it. If you can't, then you don't.”
That mentality is putting kids at risk, Wendel said. And the rest of us, too.
Resources
The Louisville Metro Department of Public Health and Wellness provides routine childhood immunizations. You can call 502-574-5380 to schedule an appointment.
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Dr. Jonas Salk, inventor of the polio vaccine, triumphantly holds up jars of his vaccine in 1955 at the University of Pittsburgh.
