For years, Lincoln High School nurse Peg Devine had the authority to bar students from school until they had received the vaccines children are required to have under state law.
In 26 years, she estimates, she kept 15 students out of school. Exclusion proved powerful; no students missed more than two days before returning with proof they had been immunized, she said.
But for the last several years, the Philadelphia School District has prohibited school nurses from excluding unvaccinated students, a move that worries Devine and others given the recent local outbreak of mumps and other infectious diseases cropping up across the country.
Across the district, 12,405 pupils lack either all of the state-mandated vaccinations or have an exemption from them because of medical, religious, or philosophical reasons. That’s roughly 10 percent of the district’s student population.
“It’s very dangerous that you’ve got kids who are not immunized, and you have medically fragile kids,” said Devine. “It’s unprecedented.”
Concern over outbreaks has been growing beyond the region. U.S. officials say 626 cases of measles have been reported nationwide, the most since 2014, when 667 were recorded. In New York, Mayor Bill de Blasio declared a public health emergency and required vaccines in some parts of the city after an outbreak of measles centered in an ultra-Orthodox Jewish community. (During a measles outbreak in 1991, Philadelphia officials obtained a court order to vaccinate a group of North Philadelphia children whose parents’ religious faith frowned on immunizations. Nine children died from the disease that year.)
And in recent months, more than 100 Temple University students contracted the mumps, resulting in the university’s changing its policy to require incoming students to have the measles, mumps, and rubella (MMR) vaccine.
Philadelphia’s school immunization compliance numbers are generally in line with the state’s, according to Pennsylvania data. Last school year, for instance, across all Philadelphia schools, 96 percent of students received at least two doses of the required MMR vaccine. That number was 97 percent statewide.
Karyn Lynch, chief of student support services for the district, said the shift in exclusion decisions was needed to standardize procedures “so that across the city, everyone is following the same process. To inequitably implement across the district would be inappropriate."
Lynch said that she is “in constant communication” with Thomas Farley, the city’s health commissioner, when questions come up about whether to exclude a student who, for instance, may have come into contact with a Temple student who had contact with someone afflicted with mumps.
“The health and safety of all of our School District of Philadelphia students is paramount,” said Lynch.
With significant numbers of vulnerable families — hourly wage workers, those whose first language is not English, homeless families ― it’s incumbent on the district to study and implement best practices around vaccinations, she said.
“Making a decision as significant as having a child not coming to school is extremely important,” said Lynch. “Before anyone could think about a child not attending school for any reason, there needs to be a deliberate process.”
But on the ground, nurses bristle at their lack of authority over student health, and say in the past they were following orders of the state Health Department to exclude, when appropriate, students who lack the required immunizations.
Jerry Jordan, president of the Philadelphia Federation of Teachers, which represents school nurses, said the district’s recent shift was “a real concern.”
“This speaks to the question of professionalism, the way people are treated,” said Jordan. “Nurses did not exclude children without the approval of the principal. They’re the medical experts in our school buildings, and we should listen to their advice.”
Colleen Quinn, the nurse at the High School for Creative and Performing Arts, said 42 of the school’s 750 students either have no immunizations or are only partially vaccinated. She also has two students receiving chemotherapy as well as other immuno-compromised students who are particularly vulnerable.
“We also have a lot of young teachers,” Quinn said. “If you have anybody who’s pregnant, you’re putting them at risk.”
When records indicate a student lacks the required immunizations, exclusion is not a nurse’s first step, she said. At the beginning of every month, Quinn pulls a noncompliance list and attempts to call every family. Many students’ contact information is not up to date, so she often brings students into her office and asks them to call their mother or father. She has also sent letters home.
Quinn and other district nurses said they provide families with information on how to get free immunizations at the city’s health centers, and have made appointments for children with parental permission. Reasons for not vaccinating include parents working long hours, fears about side effects, and more.
“You can get the runaround,” said Quinn. “They’ll say, we have an appointment, we’ll get them. This can trail on for two or three years."
At Strawberry Mansion High School, nurse Judith Cocking has made little headway with 28 non-compliant students in an alternative school housed on the fifth floor.
“If you were a parent," she said, "and you had a child in the school setting who was recovering from cancer or recently had an organ transplant — and these are not hypothetical cases, most of us have had these cases — would you want your children in a building with students who were not immunized?”
Cocking, who has worked in elementary and high schools during her decades in community health, said she has excluded a handful of students over the years. Each was out for no more than a few days, she said.
Infection worries are at the top of nurses’ minds, said Cocking, who just received a flier from the city health department warning about the “potential for measles importation following Passover and Easter travel.”
Laurie Combe, president-elect of the National Association of School Nurses, said that in her former school system in Texas, if a student was out of compliance with state vaccination laws, once nurses followed district procedure about communicating the requirements, nurses and principals together signed off on excluding students. Nurses felt empowered, Combe said.
“It concerns me, as it does those Philadelphia nurses, that students are being allowed into school who are not up-to-date on their vaccines,” said Combe. “That could put the general population at risk.”
James Garrow, a spokesperson for the city health department, said that to prevent the spread of vaccine-preventable diseases like measles and mumps, high percentages of children should receive the required immunizations on schedule. Philadelphia is in better shape than many other communities, Garrow said, because about 95 percent of its students have received one dose of a vaccine against measles, mumps and rubella, and 75 percent have received two doses.
“The School District of Philadelphia has policies to enforce the requirement that children receive their recommended immunizations, and the Department of Public Health is working with the School District to assess and maintain high levels of immunization coverage at individual schools,” Garrow said in a statement.
Health department officials do not believe Temple’s mumps outbreak “will spread in a significant way to the school system” because, in part, school-age children may have stronger immune responses than college students, as they were likely vaccinated more recently.
Still, Lynch said, the district “will revisit our policies and practices for the 2019-20 school year.”