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School nurses on front line against anti-vaxxers, measles outbreaks. Why aren’t there more of them?

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Cleveland Clinic explains how measles comes on, develops, can get complicated and how to prevent the infectious disease.

There’s something missing in many schools that could help forestall an outbreak of diseases like measles and improve vaccination rates among children.

A school nurse.

But nearly half of California’s school districts don’t have an adequate number of school nurses on campus, a Sacramento Bee analysis of state data shows. And many districts that do have them often fail to employ enough.

Experts say nurses play a key role in containing communicable diseases by spotting and isolating infected students and keeping track of children who haven’t been vaccinated. Nurses also can more easily detect whether parents are using a bogus medical exemption to prevent their children from getting vaccinated.

There is no state standard for how many nurses a school district should have — if any. The National Association of School Nurses recommends one nurse for every 750 students or one nurse for every school.

Although the number of school nurses has increased in recent years, 40 percent of school districts in California do not have any nurses. School nurse advocates said the state does not require districts to keep nurses on staff — local board members and superintendents must make those decisions.

“Throughout the state, we have districts that have one nurse for roughly 1,000 students to one nurse for 14,000 students. It’s all over the map in California,” said Pamela Kahn, president-elect of the California School Nurses Organization.

But having a medical expert on staff could be more important than ever.

Five years after one of the largest measles outbreaks in recent history, confirmed cases are on the rise again. There were 42 cases as of Monday, with small outbreaks stretching from Butte to Los Angeles counties, according to the California Department of Public Health.

The Centers for Disease Control and Prevention warned that many originated from overseas. But California is facing a different — albeit related — problem of its own.

Following an outbreak that started in Disneyland, legislators in 2016 outlawed so-called “personal beliefs exemptions” which had grown to nearly 17,000 that year, state data shows. In the years since, however, the number of medical waivers for kindergarten vaccinations has more than tripled.

Once again, lawmakers are considering ways to tighten the rules on doctors and osteopaths allowed to exempt children from vaccinations.

While school administrators can follow-up with students with incomplete records, some said nurses are more capable of detecting potentially bogus medical exemptions that have proliferated.

In fact, the state is actively soliciting nurses in the crackdown on doctor’s suspected of granting inappropriate exemptions. As a result, the California Medical Board has already received more complaints this year than the whole of 2018, state data shows.

Children should only be released from inoculation in the rarest of cases — only those with weak immune systems or a previous reaction to the vaccine, said Dean Blumberg, an infectious disease pediatrician at UC Davis Medical Center.

“We’ve heard a lot in the news of some of the exemptions being really fishy and way outside of routine medical guidelines,” Blumberg said. “I think a nurse would be much more experienced to be able to detect those than school administrators. There’s certainly a role for that.”

No nurses in 4 out of 10 districts

School nurses have played a role in public health for more than 100 years.

But the Bee’s analysis found that 4 out of every 10 districts did not have any nurses, according to the state’s data for the 2017-2018 school year.

Only 20, mostly smaller districts with less 1,000 students enrolled, met the National Association of School Nurses recommended standard of one nurse for every 750 students.

Otherwise, there was wide variation in staffing among the 760 school districts included in the analysis.

“California has no ratios established and they have no direct funding for school nurses which is unlike other states,” said Samantha Blackburn, a Sacramento State professor who runs the school nurse credential program at the university.

“Some states have general fund dollars that are designated for school health programs, including school nurses. But California does not do that and I think it is a huge missed opportunity.”

Blackburn said some districts have been able to boost their staffing in recent years because of changes to the way schools are funded. The new model favors districts that serve high numbers of poor students, English language learners and foster youth, and penalizes those with chronic absenteeism.

Now her program — only one of four in the state — has seen enrollment rise compared with five years ago from about 40 students to more than 100, she said.

Some districts are finding other ways to bridge the gap. San Juan Unified School District, for example, employed 20 nurses but hired 40 vocational nurses to fill in at schools with the most needs, said Dominic Covello, the district’s director of student support services.

Covello said those additional nurses are not included in the state’s data. He said the district’s head nurses validate the exemptions but districts do not have any power to reject them, even if they appear suspicious.



Complaints against doctors surge

Valid medical exemptions from the measles, mumps and rubella vaccination should be rare, medical experts say. The two common reasons are if a child’s immune system is compromised or has had a previous reaction to the shot.

“The number of people who have true medical reasons is far below one percent of the general population,” said Blumberg from UC Davis. “Those kind of allergies for most vaccines are like one out of a million people so it’s really rare.”

Yet some schools — mostly private and charters — have reported as much as half of their students received a medical exemption, according to state public health department data.

A number of schools with high rates of medical exemptions are clustered in Sonoma County with vaccination rates for measles below 95 percent — the threshold necessary to reduce the likelihood of spread.

“Any time you have a community or a school that has lower rates of vaccination when there are outbreaks and exposures that occur, those individuals are at higher risk for sure,” said Celeste Philip, the health officer in Sonoma County.

The culprit is a few rogue physicians, said Carl Corbin, a lawyer in Sonoma County. As general counsel for School and College Legal Services of California, which represents several districts in the region, Corbin filed a complaint with the Medical Board last June against a physician who signed off on several.

“Culturally, in parts of the west county of Sonoma, Mendocino and Humboldt counties, there are parents who for one reason or another are choosing not to immunize their children,” Corbin said.

“These reasons appear to be philosophical in nature and they have found a doctor who philosophically agrees with them and are issuing slews of these exemptions.”

Corbin did not identify the physician since the matter is still being investigated. But the case is likely one of many the Medical Board is now considering as the number of complaints mounts.

A bill sponsored by state Sen. Richard Pan, D-Sacramento, would give a government agency the final say so on exemptions. But until then districts have to comply with the recommendation of the doctor.

“Right now the law says if it is issued by a medical doctor then school districts have to abide by it,” Corbin said. “The schools are stuck with it. Their remedy for this is to file complaints with the medical board.”

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