The percentage of Hawaii children not vaccinated for illnesses such as mumps and measles, or not receiving the full roster of shots required for school, has jumped since the arrival of the COVID-19 pandemic, according to new data released by the state Department of Health, augmenting concerns that there will be new outbreaks of long-controlled diseases.

During the 2019-2020 school year, 3.4% of schoolchildren had missed routine vaccinations or had incomplete immunization records. This figure jumped fivefold this school year to 18.6%.

The numbers include children who obtained religious and medical exemptions from state vaccination requirements, as well as students who didn’t provide medical records showing that they had all of the required shots.

“I am concerned that we are seeing this up-creep in the number of exemptions and that we are seeing incomplete immunization schedules in general due to some of the access issues we have had in our state,” said Dr. Sarah Kemble, state epidemiologist for DOH. “This does create risk for the return of childhood diseases that have long been very well controlled in our state and in the U.S.”

The percentage of students claiming religious exemptions from vaccination requirements increased from 2% during the 2019-2020 school year to 3% this year. Just 0.1% of students have medical exemptions. Kemble said that part of the increase in Hawaii’s incomplete immunization rate can be attributed to the COVID-19 pandemic, when doctors’ offices were at times closed for in-person visits and kids fell behind on their shots. She said that other kids have been slow to fulfill new vaccine requirements implemented in 2020. Students transitioning from sixth grade to seventh grade are now required to receive the human papillomavirus, meningococcal conjugate and tetanus-diphtheria-pertussis vaccines.

Hawaii is not alone in seeing a slide in vaccination rates among schoolchildren. A World Health Organization report released in July found that the COVID-19 pandemic had fueled the largest sustained decline in childhood vaccinations in three decades. Nationally, a wave of parents radicalized by COVID-19-era misinformation have been rejecting routine vaccines for their children, The New York Times reported. The trend has reinvigorated an anti-vax movement that took hold in the late 1990s and has been blamed in recent years for outbreaks of measles, mumps and chickenpox.

In 2022, Dr. Anthony Fauci, chief medical adviser for the Biden administration, warned that the anti-vax sentiment stirred up during the pandemic could spill over into routine childhood vaccinations.

At the time, New York public health officials were concerned that polio, a life-threatening disease eradicated in the U.S. decades ago, could see a resurgence after a polio case was confirmed and the virus was detected in wastewater.

Hawaii also has faced challenges in controlling old diseases thought to have been stamped out. In 2017-2018 a mumps outbreak sickened more than 1,000 people in the islands. The disease, marked by swollen and painful salivary glands, can cause serious complications including orchitis, an infection of the testes that can cause sterility, deafness and encephalitis, or brain swelling. During the outbreak, 33 people suffered complications, according to DOH.

In 2019 a measles outbreak in Samoa killed nearly 90 people, mainly children, in just a few months. The outbreak hit close to home in Hawaii and prompted Gov. Josh Green, who was lieutenant governor at the time and who is also a doctor, to lead a medical mission to administer thousands of measles vaccinations.

Kemble said Hawaii’s waning vaccination rates could lead to an outbreak of the disease in the islands. Measles spreads so easily that it’s estimated that 95% of the population needs to be vaccinated in order to stop it from spreading.

“I think many people haven’t experienced what a major outbreak of measles might really look like,” said Kemble. “But it can be scary.”

Hawaii schools

In Hawaii, private and charter schools have had particularly high rates of unvaccinated students.

At Kona Pacific Public Charter School, 36% of its 188 students have claimed religious exemptions from state vaccination requirements, according to DOH’s data for this school year. Overall, 66% of its students had incomplete vaccination records. At Montessori School of Maui, 1 in 5 of its 171 students had religious exemptions from vaccinations, a rate similar to Myron B. Thompson Academy on Oahu.

Some of the state’s public schools also have high rates of unvaccinated students, including Hanalei Elementary School on Kauai, where 37% of students have religious exemptions, and Haiku Elementary School on Maui, where 25% of students have exemptions.

Many of the schools with the highest rates of students with vaccination exemptions had similarly high rates prior to the pandemic, but the latest data also shows there has been an uptick in some schools. For example, at West Hawaii Explorations Academy, a public charter school serving students in grades 6 through 12 in Kailua-Kona, the percentage of students with religious exemptions increased from 19.4% just prior to the pandemic to 25% this year. The rate at Hanalei Elementary School jumped to 37% from 26% during that same time period, while the rate at Doris Todd Christian Academy on Maui jumped to 22% from 11%.

The religious exemptions are widely seen as a legal loophole that allows parents to skirt vaccine mandates for their kids, and some states have tried to reign them in. In 2015, California became the first state to repeal religious and personal belief exemptions from school vaccinations following a major measles outbreak at Disneyland.

In Hawaii if a student doesn’t have an exemption, state law requires that they be vaccinated against a range of illnesses in order to attend school. But this requirement, which schools are responsible for implementing, isn’t being strictly enforced.

Kemble said the state remains in an “atypical situation” due to lingering impacts from the COVID-19 pandemic. Schools can allow students a three-month grace period to get caught up on shots, but Kemble said that time frame is being drawn out. She said limited staffing has made it difficult for some schools to follow up and report missing immunization records.

“We also know families of students continue to have challenges getting in for appointments to catch keiki up on required vaccines, especially on some of our neighbor islands,” said Kemble. “We are working collaboratively with schools to address these issues.”

Schools also are required by law to report their data annually to DOH in October and again in January. But 100 schools, about one-quarter, have yet to provide their student vaccination reports to DOH this year.

Kemble said DOH has been trying to help the schools report their information and is looking at ways to automate the data collection to make it easier. “It’s still a pretty manual process,” she said.

She said DOH isn’t looking to penalize schools that haven’t reported their data.

“It’s the carrot rather than the stick right now,” she said.

RELIGIOUS EXEMPTIONS

Schools with the highest percentage of students with religious exemptions in the 2022-23 school year. Only schools with at least 50 students are included.

Hawaii island

>> Kona Pacific Public Charter School: 35.64%

>> West Hawaii Explorations Academy: 24.63%

>> Makua Lani Christian Academy: 22.51%

Oahu

>> Hawaiian Mission Academy — Windward campus: 22%

>> Myron B. Thompson Academy: 21.09%

Kauai

>> Hanalei Elementary School: 36.55%

>> Kilauea Elementary School: 31.27%

>> Kanuikapono Public Charter School: 28.99%

>> Kauai Christian School: 21.08%

Maui

>> Haleakala Waldorf School: 55.22%

>> Haiku Elementary School: 24.5%

>> Roots School: 23.64%

>> Doris Todd Christian Academy: 21.54%

>> Montessori School of Maui: 20.47%

More information

Vaccination rates for individual schools can be viewed at bit.ly/3lxThka.