As students excitedly eye summer break, some parents are in the process of preparing younger family members for kindergarten.
That likely means attending a local kindergarten registration event, where they'll learn it's time to think about immunizations.
School officials generally require parents or guardians to bring an up-to-date record of their kids' vaccines to kindergarten registration in the spring or provide one prior to the start of the school year.
In recent years, Idaho has been a leader in vaccination exemption rates, but not in a good way, according to health professionals. The exemption rate, referring to students whose parents have asked the state for a vaccine waiver, has been one of the highest — if not the highest — in the nation for the past several years.
For the 2016-17 school year, the childhood vaccination exemption rate in Idaho was 6.5 percent, according to the Centers for Disease Control and Prevention. Only Alaska and Oregon beat out the Gem State with exemption rates of 6.8 and 6.7 percent, respectively.
The number of families choosing not to vaccinate concerns local health officials, who say immunizations are the most efficient defense currently available against a variety of serious diseases.
"It provides the best protection we have from childhood illnesses, and that's for the individual child," said Mike Larson, public health nurse at the Idaho North Central Health District. "There are no 100 percent guarantees, but it's the best benefit we have or know of to protect children."
When a child is vaccinated, Larson said, he or she is able to protect others who do not or cannot get their shots.
"It's not only protecting (the child), but also it's protecting the other children who may be medically fragile and cannot be vaccinated or a child that's immunocompromised (has a weakened immune system) that won't respond to a vaccine well," he said. "The more children you have immunized and not susceptible to whatever illness it is, it increases the herd immunity and protects other children who can't be vaccinated, don't respond to the vaccines, or frankly, it protects those that parents don't want to vaccinate."
The number of vaccinated kindergarten students varies greatly throughout the region.
According to the 2016-17 Idaho School Immunization Report, compiled by the state Department of Health and Welfare, McSorley Elementary School in Lewiston had one of the highest rates of students fully up-to-date on vaccinations.
The numbers show 95.5 percent of kids had all the shots they needed, while the remaining 4.5 percent of students had exemptions on file with the school.
But for other schools, particularly in rural areas, the numbers were sometimes dramatically lower.
At Prairie Elementary School in Cottonwood, only 48.1 percent of kindergartners in the 2016-17 school year were adequately immunized. The school had exemptions on file for 22.2 percent of them. The remaining about 30 percent of kindergartners did not show up in the report.
Prairie Elementary School Secretary Lynn Rehder, who is in charge of the school's kindergarten roundup event and who submits immunization records to the state, declined to comment on the topic.
Other schools in north central Idaho ran the gamut.
Webster Elementary had the lowest percentage of kindergarten students immunized among Lewiston public schools during the 2016-17 school year with 82.9 percent. There were exemptions on file for 17.1 percent of the students.
In Lapwai, 76.5 percent of kindergartners were adequately immunized. The school did not have any exemptions on file, according to the report.
Juliaetta Elementary kindergartners had an adequately immunized rate of 61.5 percent, with 7.7 exemptions on file.
In Kamiah, 79.5 percent of students had their required shots, with exemptions for 15.4 percent on file. During Kamiah's kindergarten roundup event, the school made sure a nurse was on hand to discuss any concerns parents had.
At least five area school districts contacted by the Tribune declined to comment, stated immunization information was unavailable or did not return multiple requests for comment.
There are three types of vaccine exemptions parents or guardians of school-age children can request: medical, religious or for philosophical reasons.
For Idaho's kindergarten population of 22,589 for the 2016-17 school year, there were 85 medical exemptions, 127 religious exemptions and 1,265 philosophical exemptions, accounting for 1,478 students in all.
Two percent of the students enrolled in kindergarten were conditionally admitted, which means their vaccinations were not up-to-date, but they had an appointment to do so. According to data in the annual report, it's not uncommon for schools to have a gap between the number of students who are up-to-date on vaccinations and the number of exemptions on file.
The majority of schools, in fact, do have a gap, and some of the students who fall into that gap are kids who are not up-to-date on shots, said Idaho Department of Health and Welfare spokeswoman Niki Forbing-Orr.
Larson cautions that immunization numbers reported to the state represent only a glance at the current situation.
"It gets tricky when you look at the national numbers of what percentage of kids have immunizations," he said. "You have to be careful what you are looking at, because it's a snapshot of a very specific time."
Larson explained some kids may not have the vaccinations required by a certain age, but might come into compliance several days later. Then they're up-to-date, but that's not reflected in the state numbers.
The Centers for Disease Control and Prevention cautions vaccination coverage or exemption estimates may be "under- or overestimated because of improper or absent documentation." The agency also said it's difficult to make state-by-state comparisons, because state requirements differ.
Idaho school districts are required to report their vaccination numbers to the state at the beginning of November. The numbers for the 2017-18 year should be available at the end of May or in early June, Forbing-Orr said.
For the past five years, the exemption rate for kindergarten students has hovered right around the 6 percent mark. The overall percentage statewide of kindergartners who are adequately immunized is 86.1 percent. The Department of Health and Welfare hopes to increase that number to 95 percent.
Opposition to vaccinations is nothing new. According to the National Center for Biotechnology Information — a branch of the National Institutes of Health — opposition has existed as long as immunizations have.
The topic was reignited when President Donald Trump ran for office. He linked vaccines to autism — a claim that has been debunked.
Larson said the autism link is a myth that still lingers.
"That is the challenge that we have today," he said. "It's difficult for people to realize and recognize what the true facts are. Right now, anyone can say anything on the internet and claim they are the expert on it and not have facts to back it up."
Health and Welfare Department officials understand parents may have concerns when it comes to immunizations.
"It's natural to have questions, but consider the source when you are seeking information on immunizations," Forbing-Orr said. "You can trust your pediatrician and your doctor to give you the information you need to make an informed choice."
The department works closely with schools and medical providers to give parents the tools they need to make educated choices about vaccinating their kids, she said.
In January, an Idaho Senate panel introduced legislation that would have made it easier for parents to opt out of vaccinations for their children. The bill would have allowed parents to submit a letter rather than utilize the state exemption form. It never received a public hearing.
The bill was supported by Health Freedom Idaho, which promotes "vaccine choice."
In Washington, the statewide vaccine exemption rate for the 2016-17 year was 4.8 percent. It increased from 4.5 percent the prior year. Out of the 87,142 kindergarten students reported during that time frame, 4,161 were without vaccinations.
In 2015, the Clarkston School District had about 200 students who did not meet the state's requirements. The district organized voluntary vaccination clinics to bring the children up-to-date. About 3 percent of students had vaccine exemptions at that time.
The district was unable to provide updated immunization statistics before the Tribune's deadline.