Multiple times in the past four years, three rural Alabama counties — Perry, Pickens and Russell — have reported having students without immunization documents at more than four times the statewide rate.

Health providers say a main reason for that gap is a general lack of health care in sparsely populated areas. Those counties are short on health care providers, and county health departments are understaffed. A lack of knowledge about the need for vaccines also is a factor.

Meanwhile, the Centers for Disease Control and Prevention reported that 764 cases of measles were confirmed this year across 23 states. According to the agency, that’s the highest number since 1994 — for a disease that was eradicated in the U.S. in 2000.

Earlier this month, Alabama officials announced that an infant in St. Clair County was considered presumptive positive for measles from early testing. However, more accurate tests conducted by the CDC showed the girl did not have measles, officials with the Alabama Department of Public Health announced Friday.

Each year the Health Department releases its School Entry Survey, showing the number of students who have the certificate of immunization — and the number who don’t.

Statewide, 1.15% percent of Alabama students did not have a certificate of immunization in the 2017-2018 school year.

But Pickens County, with a population of 20,176, had 8.51% of its students without a certificate that year.

Perry County, population 9,339, had a rate of 0.49% in the most recent survey, but it has had rates of 12% and 14% in the past four years.

These percentages don’t include students with medical or religious exemptions from vaccination. For the 2017-2018 school year, Alabama had 3,587 students with religious exemptions. That represented about 0.47% of those enrolled. For medical exemptions, that number was 284.

Dr. Karen Landers is the district medical officer and medical consultant for tuberculosis control and immunization for the Department of Public Health.

She said many factors can produce a higher rate of students with no certificate of immunization. Not having a certificate doesn’t necessarily mean a student is unvaccinated. Students could transfer from other states and their parents could have been unable to find the documents by the time survey results were sent to the state.

One example of that is Russell County. In the past four years of survey results, it has seen rates of students without certificates between 4% and 6%.

Mandy Hussey is the school nurse at Oliver Elementary in Russell County. She said the area has a large military population, which means many students transferring from other areas. That accounts for much of the county’s higher rate, she said. Another part is parents without health insurance failing to take advantage of resources that could get their kids vaccinated, she said.

Shortage of Health Care Resources

But for many rural counties, those resources can be hard to find.

“Access is definitely an issue,” said Wes Stubblefield, president of the Alabama chapter of the American Academy of Pediatrics.

According to the Robert Wood Johnson Foundation, Perry County’s ratio of population to primary care physicians is 3,190 to one, about triple the state rate. Russell County’s is 4,470 to one, and Pickens’ is 2,540 to one.

But Stubblefield said there’s another issue affecting vaccination rates in rural areas. It involves the Vaccines For Children program, a federal program that provides vaccines for uninsured or underinsured children as well as children on Medicaid.

Stubblefield said the program is highly regulated and requires extra documentation, which often serves as a disincentive for care providers. He said his chapter has discussed workshops for doctors in rural areas that will make the business case for participating in the program.

Another issue, Stubblefield said, is that county health departments are giving fewer vaccines because of a lack of manpower.

Stubblefield said the state could improve immunization rates by holding vaccine clinics in underserved counties or having more school-based vaccination programs.

Education Efforts

Both Landers and Stubblefield said the biggest priority is to educate the public, particularly on misinformation about the links between autism and vaccines.

“Vaccines. Do. Not. Cause. Autism,” Landers said.

Landers pointed out that Alabama’s overall vaccination rates are high. According to data from the United Healthcare Foundation, Alabama tracked higher than the national immunization rate for four of the seven years between 2012 and 2018.

That’s a testament to Alabama parents as well as the work of public health officials, schools and local doctors, Landers said.

“It’s something we’re all passionate about,” Stubblefield said.