Dr. Amy Watson opened a pediatric practice in Concord in 2021, using a membership-based model that bypasses insurance. She quickly found that it attracted people looking for “an alternative approach to care” – including some families who chose not to vaccinate their kids.
At first, she was open to working with those families. But eventually, she started referring them to other providers: Their unwillingness to trust her on something so fundamental, the importance of childhood immunizations, led to breakdown of the doctor-parent relationship.
“It led us to a place where appointments weren't comfortable,” she said. “There was just like a palpable divide in the room.”
She said the safety of other patients at her small clinic was also a concern. She no longer accepts families who choose not to vaccinate.
“If I see an unvaccinated child and I don't know for sure if they have a vaccine-preventable disease, and in that same day, I see a one-month-old baby – who can't be vaccinated, and who is vulnerable – and that child ends up with a vaccine-preventable disease, that wears so heavily on my heart,” she said.
Pediatricians, school nurses and public health leaders around the state say these kinds of uncomfortable conversations about routine childhood immunizations are becoming more common, particularly after the pandemic.
And as the country grapples with its worst measles outbreak in years, some in New Hampshire worry that falling vaccination rates – and clusters of undervaccinated students in some communities – could leave the state more vulnerable to measles and other highly infectious diseases.
New Hampshire doesn’t track vaccination rates for measles specifically. But state health officials do track how many children are up to date on all required immunizations — and that has been falling over the past few years. At a handful of private and charter schools, fewer than half of all students were fully vaccinated, according to state data reviewed by NHPR.
Because measles is so contagious, experts generally say at least 95% of a community needs to be vaccinated to prevent outbreaks. Declared eliminated in the U.S. in 2000, the disease has surged back in recent years due to falling vaccination rates in certain communities – including the one at the center of the current outbreak in west Texas.
No measles cases have been reported in New Hampshire this year. But public health experts worry that pockets of the state where fewer people are vaccinated could create openings for a highly infectious disease like measles to spread – even if the vast majority of kids statewide are vaccinated.
“Measles is just so, so transmissible that you get one student in a small classroom in the middle of winter where everything's closed up, and we could be taking out a whole school due to exposure,” said Lisa Therrien, a school nurse in the Fall Mountain Regional School District, north of Keene.
Uneven vaccination coverage draws concern
New Hampshire requires children entering school be immunized against measles, mumps, rubella, diphtheria, tetanus, pertussis (also known as whooping cough), chicken pox and hepatitis B. Exemptions are allowed for medical or religious reasons.
Last fall, only 89.2% of kindergartners were up to date on all their required immunizations – down from 91.5% in 2019.
(Just because a student isn’t included in that count doesn’t mean they’re completely unvaccinated. While some fall into that category, others might be “conditionally enrolled,” meaning they had at least one dose of each vaccine series and have an upcoming appointment to get the next shot.)
State Epidemiologist Dr. Benjamin Chan said the decline in the overall vaccination rate — combined with spottier vaccine coverage in certain communities – is a worrisome trend.
“Even small drops in vaccination rates can have a big difference on whether or not highly infectious diseases can spread in a congregate setting, like schools,” Chan said.
In many schools, nearly all students are fully vaccinated. But state health data analyzed by NHPR shows that roughly one-quarter of schools were below 90% last fall, and about one in ten were below 80%.
“If you're in a classroom where 95 to 98% of the kids are immunized against measles and measles is introduced in the classroom, it's not going to spread very far,” said Dr. John Modlin, a professor emeritus at Dartmouth College and expert on childhood vaccines.
But if that goes down even to 80% or 85%, there are a lot more students who can catch measles and spread it to others, he said. The Texas county at the center of the current outbreak – which has sickened hundreds of people and caused the deaths of at least two children – has a measles vaccination rate of 82%.
“It's like the phrase ‘All politics are local,’” Modlin said. “Much can be said the same for certain transmissible diseases.”
“It's like the phrase ‘All politics are local.' Much can be said the same for certain transmissible diseases.”Dr. John Modlin, Dartmouth College
According to the state data, private schools in New Hampshire tend to have lower rates, with 87% of private school students statewide up to date on their vaccinations, compared to 93% at public schools.
A handful of schools were far below that. At High Mowing School, a Waldorf School in Wilton, around 56% of students were fully vaccinated. Lionheart Classical Academy, a charter school in Peterborough, was a few percentage points lower. Heritage Christian School in Rindge had a vaccination rate of just 23%.
Jessica Hipp, High Mowing School’s director of marketing and communications, said they follow state vaccine requirements.
“We encourage our community members to consult with their healthcare providers for personalized medical guidance,” Hipp said in an email. “In the event of a disease outbreak, we follow directives from the state and federal health authorities.”
Representatives for Lionheart Classical Academy and Heritage Christian School did not respond to requests for comment.
Doctors, nurses struggle to overcome political messaging
Local doctors and school nurses said the drop in immunizations could be partly a lingering side effect of the COVID-19 pandemic, when some children fell behind on routine medical appointments where they’d usually catch up on immunizations.
But pediatricians say they’re also noticing an uptick in vaccine hesitancy, as trust in medical institutions eroded during the pandemic and prominent figures – including Republican state lawmakers and federal health secretary Robert F. Kennedy Jr. – have spread misinformation about vaccines.
“I have had conversations in my office with parents, concerned parents, who say, ‘I hear what you're saying – and yet I hear RFK or I hear my local state representative say that there might be something about this vaccine that's not safe for my child, and I just don't know who to believe,’” said Dr. Christine Arsnow, a pediatrician in Concord and vice president of the New Hampshire chapter of the American Academy of Pediatrics.
Republicans at the New Hampshire State House have also been pushing to make it easier for families to opt out of required vaccines, citing personal freedom.
“Personally, I'm not anti-vaccine,” said Rep. Jim Kofalt, a Wilton Republican behind one of those proposals. “I am in favor of vaccine freedom, meaning I think that people should decide for themselves and for their families.”
This year, the House passed a pair of bills that would have effectively eliminated most of the state’s existing vaccine requirements – including chickenpox, hepatitis B and polio – and limited health officials’ authority to add new ones. Those bills were strongly opposed by state health officials, and were voted down last week by the Republican-led state Senate.
Republican Sen. Kevin Avard of Nashua, who called himself “the most vocal critic of vaccine mandates in the Senate,” was among those who voted against the bills. He noted the state health department has not added any new immunization requirements in 20 years, and any such changes would have to go through a legislative committee that approves new regulations.
Meanwhile, an earlier change to the state’s vaccination rules appears to be having an impact. Until 2022, parents or guardians who wanted to object on religious grounds had to sign a notarized form and submit that to the school. A law passed that year no longer requires notarization. Since then, the share of kindergartners with religious exemptions has gone up, from 3% to 3.9%.
Therrien, the nurse in the Fall Mountain school district, said she has also observed more parents exempting their kids from vaccination since those requirements were relaxed. She said that typically seems to be based more on personal than religious objections.
Therrien has also seen a shift when it comes to vaccinations that aren’t required but are still important for public health, like the flu vaccine. She oversees four schools with about 200 total students. Before the pandemic, in-school flu vaccine clinics would easily get 90 students each fall, and parents would thank her for holding them. Those numbers have since taken a “nosedive.”
“I almost think there's a little bit of fatigue in people's minds about these infectious diseases,” she said. “[They think] that they're really not so bad because they don't know people that have died from it, so it's not going to affect them.”
A reminder of those risks came earlier this year, when a local 21-year-old, Brayden Ring of Alstead, died from flu during the worst flu season in years.
“It's a huge hit to the community because, you know, good kid, young – and just died from flu,” Therrien said. “It was just very, very sad. But does that translate into more people taking up the vaccine?”
Eroding trust, deadly consequences
Public health experts say there’s no way to reach vaccination rates high enough to stop outbreaks of measles and other highly infectious diseases without those requirements.
“If those were to go away, the concern and the likelihood is that vaccination rates would decline,” Chan, the state epidemiologist, said. “To what level? I don't think we really know.”
Brendan Nyhan, a political scientist at Dartmouth College who has studied vaccine-related misinformation, said it’s not actually clear that correcting someone’s false beliefs about vaccines makes them more willing to vaccinate.
What does work, he said, is mandating vaccines for school and child care attendance. Advice from a family physician can also carry weight: People tend to trust their kid’s doctor, even if they distrust the medical system at large.
Nyhan said the politicization of vaccines, in New Hampshire and nationally, could drive immunization rates down even if policy doesn’t change, by eroding the longstanding social consensus in favor of vaccination.
“It was really important in this country to get to the vaccination levels that we achieved to develop this consensus where every major political party, every major religion, all aspects of society said you should go ahead and get vaccinated,” he said.
Meanwhile, doctors like Arsnow worry about what could happen if vaccination rates keep dropping. It’s not just measles. Pertussis, or whooping cough, is also on the rise in the U.S.
To younger doctors like Arsnow, these diseases largely seemed like solved problems. But she’s heard stories from more senior colleagues about what it was like before certain vaccines came out.
Haemophilus influenza B, for example. A nasty bacterial infection known as hib, it used to kill about a thousand kids a year in the U.S. When a young child had a high fever, Arsnow said, parents would be told to bring them in for a spinal tap and antibiotics – until they could be sure it wasn’t hib. Some would need a breathing tube placed preemptively, in case their throat swelled.
“When this vaccine came out, the residents felt like it was like magic,” Arsnow said her colleague told her.
Today, Arsnow has a standard speech when a parent calls about a fever in the middle of the night: “It's probably okay. We'll see you in the morning.”
