FARGO - The immunization rates for North Dakota school children, which once lagged among the 10 lowest in the nation, have risen in recent years as officials have joined together to boost vaccinations.

New figures released by the Centers for Disease Control and Prevention show that North Dakota's immunization rate for measles, mumps and rubella has reached 93.8 percent, which almost matches the national median, 94 percent.

North Dakota ranked 27th for measles, mumps and rubella immunization, shared with four other states. The immunization rate was up from 89 percent two years earlier, said Molly Howell, immunization program manager for the North Dakota Department of Health.

"We've increased pretty significantly over the last two years," she said.

The recent increase is the result, she said, of a concerted effort involving health officials, the North Dakota Attorney General's office and the state Department of Public Instruction, which works with local schools.

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Among other efforts, state education officials now send a letter to school districts reminding them of a state law requiring schools to exclude students who lack required vaccinations from attending until they've been immunized.

Many local education officials were not enforcing the exclusions because they didn't want students to be absent from school, not realizing that it was required by law, said Kirsten Baesler, North Dakota's superintendent of public instruction.

"Our school districts, they want our kids in school," she said. "They have their own mandates to meet."

But school officials ultimately agreed that they have an important role in enforcing the law, and came onboard, Baesler said. She believes the state has turned around its declining immunization rates.

"It's a different environment," she said. "It's a different mindset." She attributed the turnaround to the partnerships between a wide variety of state and local officials.

"It was a very concerted, collaborative effort," Baesler said.

West Fargo public schools now are enforcing the exclusion, said Heather Konschak, the district's public relations coordinator.

"Last year was the first year that we enforced the exclusion date," she said, referring to an immunization deadline that falls in November. "This will be the second year that we'll be doing that, so we're working with families now."

Students are sent home with forms. Parents also are contacted via email and, if confirmation of vaccination has not been received as the deadline approaches, follow-up contacts will be made, Konschak said.

"We do make phone calls and walk them through the process," she said.

A spokesperson for the Fargo public schools was not available Friday.

Children who are not fully immunized according to state requirements have 30 days to receive any missing shots or they must be excluded from school.

For the 2016-17 school year, North Dakota's immunization rates for three key vaccines were 93.8 percent for measles, mumps and rubella; 93.8 percent for diphtheria, tetanus and pertussis; and 93.5 percent for varicella, or chickenpox.

Those compared to the national median of 94 percent for measles, mumps and rubella, 94.5 percent for diphtheria, tetanus and pertussis; and 93.8 percent for varicella.

Before the recent upswing in immunization rates, North Dakota's rates had been declining. In 2000, for example, 95 percent of North Dakota's kindergartners were fully immunized against diphtheria, tetanus, pertussis, measles, mumps, rubella and varicella.

The state has a goal of regaining the 95 percent rate under its Healthy People 2020 goals. "This threshold is important to achieve herd immunity, which occurs when a critical percentage of the population is vaccinated against a disease," a state report said. "When herd immunity is achieved, outbreaks are prevented by limiting the spread of disease."

Although school immunization compliance is improving, the percentage of North Dakota children obtaining exemptions from the immunizations for religious, moral or philosophical reasons continues to increase.

The exemption rate reached 3.14 percent in 2016-17, up from 0.5 percent in 2000, or a six-fold increase over the period.

A stakeholder group last year including educators, health providers and parents overwhelmingly agreed that immunization exemptions are too easy and should be made more stringent. The report found that most schools around the state were not enforcing the exclusion law.