Greencastle Children at Risk for Contagious Disease

Only 47 percent of three year olds in Putnam County have received the mandatory vaccines of their age group. This is below the Indiana state average of 56 percent.

If these numbers are accurate, they are the lowest rates in the country according to the Center for Disease Control (CDC). Though the CDC should be reporting the data given by the Indiana State Health Department, the data reported by the CDC does not match the report available from the Indiana Health Department. The CDC did not respond to phone or email inquires about the discrepancy.

Indiana law requires by three years old children are expected to have gotten 3 Hep B (Hepatitis B), 4 DTaP (Diphtheria, Tetanus & Pertussis), 3 Polio (Inactivated Polio), 1 MMR (Measles, Mumps, Rubella), and 1 Varicella immunization. This series is abbreviated by 3:4:3:1:1.

Immunization Assessment Epidemiologist for the Indiana Department of Health, Kimberly Cameron says she doesn’t know why there is a large group of children not meeting state requirements for immunization. Cameron stated firmly that unvaccinated kids could not be in public school, since it is against the law.

However, according to records kept by school nurse Rhonda Kessler, in the Greencastle school district of Putnam County, the beginning of the 2016-2017 school year began with 215 under-vaccinated students in the elementary and middle schools. With a total population of 985 across these schools, this means at some point over 20% of children were not fully vaccinated while attending public school. A majority of these students were in their first year of school and were catching up as fast as the vaccination schedule allows them. 26 students received religious objections, the only way to legally excuse oneself from vaccinations in Indiana.

Though a majority of the lack of immunization comes from students enrolling in Kindergarten or first grade, 15 returning students were not properly immunized. Several of these students are at Tzouanakis Intermediate School, meaning they have been avoiding one or more immunizations for many years in a row.

Since Kessler is the nurse for almost 1,000 students, there is often a delay in identifying under-immunized children. First, Kessler must sort through almost 1,000 student records to input them in into CHIRP (the statewide database to monitor immunization rates), Skyword (the school database), and fill out by hand a file card for each student. According to Kessler this takes about two and a half hours per class. Then, if Kessler notices a child is under vaccinated or unvaccinated, she sends a letter to the family. If the letter goes unanswered, she has the principal call the family. This process of the warning phase takes about a month before a child is told to not come to school.

Students are allowed to remain in school as long as they are attempting to get the missing vaccine/s. This means a child can remain in school as long as their parent has made a doctor’s appointment, regardless of whether or not the student goes to the appointment. Technically, this can happen over and over for the entire length of a student’s schooling in Greencastle with no repercussions for the school or parent.

Kessler says the low immunization rates in her schools are not a health risk to the children. However, 20% of the student body missing immunizations falls below rates needed to maintain herd immunity. Herd immunity ensures all children are protected even if not every single child can be vaccinated. Though rates needed to ensure herd immunity are different for every disease, according to the CDC and World Health Organization, for measles, 90-95% percent of students must be immunized to achieve herd immunity. Pertussis is a similarly contagious disease and has the same herd immunity requirement.

The 78.18% rate of herd immunity at the beginning of the 2016-2017 school year put children at Ridpath Primary School, Deer Meadow Elementary, and Tzouanakis Intermediate School at risk for at least Diphtheria, Measles, Pertussis, Polio Rubella and Smallpox.

Immunization Assessment Epidemiologist, Kimberley Cameron says she does know why children are not being vaccinated, she is confident it isn’t for lack of resources. Cameron says, “Lack of access to health care is just an excuse.”

However, former head of Johnson Nichols Center, Ruth Ralph disagrees. According to Ralph, “the system is not set up to be easy for working families.” Ralph is adamant that there are plenty of barriers to working families’ ability to follow the vaccination schedule. Two major barriers are scheduling doctor’s appointments in the middle of a workday and payment.

Technically under the Affordable Care Act, vaccines are free for everyone. However, according to Ralph, insurance companies still charge co-pays. During her time at the Johnson Nichols Center, she saw families turned away who couldn’t pay the vaccine co-pay. The Center was concerned about families missing vaccine appointments and had a policy to continuously call parents who missed vaccine appointments. However, private doctors offices in Putnam County have no obligation to ensure their patients come to their appointments.

For Hoosiers that qualify for Medicaid, vaccines are free but difficult to come by. According to Ralph, private doctors in Putnam County have stopped offering vaccines to Medicaid patients because of the logistical nightmare they cause.

At the beginning of each year, a doctor with Medicaid patients must order all of the Medicaid vaccines from the state they might need for the year. Throughout the year, the stock of vaccines for Medicaid patients must be kept separate from vaccines ordered for other patients. At the end of the year, the doctor must pay for any unused vaccines leftover.

With vaccines difficult to come by, Kessler expressed she would love to be able to offer vaccinations in school but the logistics of transporting huge amounts of vaccines, storing them at the appropriate temperature, and keeping them safe is too big a burden to bear.

For Medicaid patients, care is becoming increasingly segmented in Putnam County. More and more private doctors’ offices and the Johnson Nichols Health Center no longer offer vaccinations in Putnam County. Often, Medicaid patients’ only option is to bring their children to the Putnam County Health Department for their vaccines. This means a Medicaid family has to go their regular doctor for regular child wellness check ups and be sent separately to the Health Department for the vaccines. The Medicaid population in Putnam County with children must make double the doctors appointments for each child as a family without Medicaid.

Even with private insurance, getting a vaccine in Putnam County can be difficult. According to Kessler, around 2010, vaccines became too expensive and all private physicians in the area refused to give immunizations. At that time, the Putnam County Health Department only gave vaccines to underinsured and uninsured patients. Local pharmacies and supermarkets were forced to set up large emergency clinics because there was nowhere else for insured patients to get vaccines. Kessler says it is likely that parents wait to immunize their children until they reach school age because of the many barriers to immunizing children in Putnam County.

The same problem may exist across the Hoosier state. Data shows around 90 percent of children meet Indiana immunization law requirements by the time they enter Kindergarten. This 200 percent increase from age three to six likely means that parents are only immunizing their children when entering school. Though this may seem harmless, children are at risk for contracting many contagious diseases before they reach school age. Under-immunized children can catch vaccine-preventable disease at the park, at the grocery store, or at day care.