GRAND FORKS, N.D.-As public school students make their way to class, health professionals are tasked with making sure they come prepared with a full sheet of state-mandated immunizations.
In North Dakota state law grants a 30-day grace period at the beginning of the year for parents to see to it that their students are either vaccinated or exempted from their required shots.
After that point, students whose immunization records are still not up-to-date are to be excluded from class until they meet their recording obligations.
Across the board, North Dakota had a kindergarten student immunization rate of about 91 percent for the 2015-16 school year, according to the results of a recent study by the Center for Immunization Research and Education. That same report indicated that more than 3 percent of kindergarteners had immunization exemptions on file. The remaining 7 percent were unaccounted for either way.
MaryAnn Delisle, lead nurse for Grand Forks Public Schools, said the district has recorded a 96 percent immunization rate among its total student body.
Delisle said that, while Grand Forks students have been excluded from classes in the past, they're usually back in school before long.
"It rarely happens," she said of exclusion, "but when it does happen, usually the parent will come pick up the child and take them right away to Public Health or a clinic like Altru and they will bring them back either that day or the next day. They usually take (students) right back, it might take an hour at the most."
State law requires public school students to receive seven different types of vaccinations over the course of kindergarten through high school. Those immunizations are aimed at preventing illnesses including polio, measles, tetanus and chicken pox.
Delisle said the district will either send letters or make phone calls to parents of students who are not up-to-date with their vaccinations.
Grand Forks schools also distribute back-to-school checklists informing parents what immunizations their children need to come back to class.
Exemption forms can be completed by parents at the school's office without a nurse present, Delisle said.
Overall, she added, the district's nurses take a serious approach to immunizations.
"We want our schools to be totally up to date," Delisle said. "It's something we really strive for."
Enforcement may be key
Kylie Hall, project manager for the Center for Immunization Research and Education at North Dakota State University, said Grand Forks schools have some of the highest vaccination counts in the state.
She attributed that in part to a commitment to enforcing the mandated immunization schedule through potentially excluding students from class.
"Schools have concerns about the number of days kids were going to miss and how that would affect how they'd pass or fail, as well as graduation rates and funding for schools," Hall said. "But we found that was a non-issue. Once parents are motivated, they get the job done."
When examining public schools, Hall said the center's researchers found an increased emphasis-and clear explanation-on the role of public schools in enforcing the public health requirements seemed to make a difference in boosting rates.
Last October, a representative from the Attorney General's Office outlined North Dakota's laws and rules regarding immunizations for an audience of school administrators at the annual North Dakota School Boards Association Conference.
Hall said that explanation included points on how obligations for schools had changed.
After that conference, Hall said, vaccination numbers started going up.
"The changes were drastic, significant," she said. "We saw in some districts a change of 5-7 percent increase in immunization rates. We might be able to look back and say, 'When schools started enforcing a strict mandate, we saw an increase in immunization rates.' "
Hall said that the permanence and scope of that shift remains to be seen, but added that a strong stance from state leadership could help eliminate any mixed messages to the state's schools.
Beyond the schools themselves, Hall said immunizations presented a challenge that required networks of support, including public health entities and parents.
In the meantime, she said, vaccinations rates are something that residents "should take very seriously."
"We have some counties and schools that are less than 90 percent, less than 85 percent vaccinated," Hall said. "There are some pockets of the state with a real risk for an outbreak to occur, should someone come into these schools with an infectious disease."
Higher in Minnesota
On the whole, vaccination rates are a little higher in Minnesota than in North Dakota.
According to Minnesota Department of Health records for the 2015-16 school year, 93 percent of kindergarten students and 95 percent of seventh-graders were vaccinated. Minnesota law requires the same vaccinations for public schools as in North Dakota, but the exemption process is more stringent and requires parents to have exemption forms authorized by a notary.
The state's exclusion process also allows schools to bar non-compliant students from the first day of class, provided they are returning to a district.
Some school districts in the Red River Valley surpassed state averages for both kindergarten and seventh-grade cohorts.
In the state health department's 2015-16 data, Thief River Falls Public Schools recorded an average kindergarten vaccination rate of slightly more than 98 percent.
The same data indicated that Crookston Public Schools was about half a percentage point higher still in terms of total kindergarten compliance rates.
Nicole Wienen, the district nurse for Thief River Falls, said she felt she received a "tremendous" amount of support from the Minnesota Department of Health, which served as an asset when keeping up with the state-mandated schedule.
"They're very easy to deal with and very knowledgeable," Wienen said, adding that she met twice a year with department representatives to discuss the state's approach.
Wienen said exemptions for medical or philosophical reasons were relatively rare in her district.
She added that she has "sent many kids home if they're without shots," though as Hall observed in Grand Forks, Weinen said students are usually cleared to return to school either the same day or the next.
"Administration here are very good on backing me up on that, and I've never seen anyone stay home long," she said. "And of course, we want kids here, we don't want them at home."