Jody Thompson was sitting in his Grand Forks office nearly seven years ago when the phone rang.

On the other end of the line, Thompson recalls, was an official with the local health department, who calmly explained there was a “strong suspicion” that tuberculosis was poised to put Grand Forks students in danger. What followed was a flurry of emailed information, an immediate outreach to school nurses — a sudden institutional call-to-arms. From the moment he put down the receiver, Grand Forks’ school system would never be the same.

“I think (the general mood) was apprehension,” Thompson, an associate superintendent for Grand Forks Public Schools, said. “If you don’t know anything about TB, and you hear ‘TB outbreak,’ or the potential for that — that’s going to get everybody’s attention.”

According to Herald archives, there were three cases of the disease confirmed throughout the community that October; it eventually ballooned to 16 total cases and hundreds of check-ups with medical professionals. Thompson says the outbreak transformed the way Grand Forks Public Schools approaches vaccinations, despite the fact that tuberculosis itself is rarely prevented via vaccines.

“There’s no question that we’ve got more procedures and protocols in place than we did before the TB outbreak,” he said. “But that’s with all immunizations.”

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Those kinds of strategies are important as, around the state, many students continue to miss out on vaccinations. Though students are required to have vaccines to attend school, data on file with the North Dakota Department of Health shows that, especially among kindergarten students, the rate of personal exemptions remains higher than recorded a decade ago. In Grand Forks county, the past three years have seen nearly 3 percent of kindergartners or more with “personal belief” exemptions on file with the school district. That’s up from 1.35 percent in 2016.

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That “personal” designation is important. North Dakota offers various medical exemptions to vaccines — for students who have a history of the disease, and thus don’t need the shot, or for students whose life would be endangered by a vaccine. Those require sign-off by a health care provider. But “personal belief” only requires a parent’s pen stroke, allowing a child to skip vaccines that could help protect both themselves and the children around them simply because a parent wants it (the same is true for an exemption based on religious beliefs, which are also counted by the state).

The rate of exemption varies by county, but North Dakota’s largest communities are seeing higher rates among unvaccinated kindergartners than a decade ago. In Burleigh, Cass, Grand Forks and Ward counties, last year’s kindergarten “personal belief” exemption rates are among the three highest years of “personal belief” exemptions recorded in the last decade.

The problem also is true across the border. In Polk County, “non-medical” exemptions, as Minnesota calls them, were up to more than 2 percent in the 2017-18 school year for five vaccines tracked by the state. But in the 2009-10 school year, only one of those vaccines had more than 2 percent “conscientious objections,” as the state once categorized them. In Hennepin County, some vaccines have seen non-medical exemptions crack 3 percent.

Grand Forks has earned plaudits for high vaccination rates. Nine elementary schools in the city — including one on Grand Forks Air Force Base — made the statewide “immunization honor roll” for the 2018-19 school year, which recognizes schools that have 95 percent of kindergartners fully vaccinated. And some experts point out that, as schools work harder to keep students from going without records of a vaccine or an exemption, one side effect is that the exemption rate might tick upwards.

But not all Grand Forks elementary schools appeared on that honor roll, and the problem remains a vexing one for public health officials. Dr. Paul Carson, a professor in North Dakota State University’s Public Health Department, said leaders are contending with both a fading collective memory of, and falling urgency around, potential disease outbreaks — whose deadly effects increasingly feel like part of a bygone era. What’s more, health leaders are having to battle unfounded speculation that vaccines are linked to issues like autism.

But according to the federal Department of Health and Human Services, only about 1 or 2 people in a million experience “severe allergic reactions” to vaccines, which means that in rare cases, those students might need a medical waiver.

And Carson points out that not vaccinating children can have dire consequences. Measles is a vaccine-preventable disease that he said can have deadly effects, but whose prevalence threatens to grow as attitudes toward vaccines grow more lax.

"To see us losing ground on a completely preventable disease for fears that aren’t legitimate is very frustrating,” Carson said.

Carson points to Grand Forks Public Schools as a model for taking charge of the problem — spurred by the urgency that comes from dealing with an outbreak.

“Having lived through the TB epidemic in Grand Forks, they saw what a communicable disease could do in their school,” he said.

And he says he’s been heartened by recent developments in the state. He was co-author of a paper, published in June 2016, that explored why vaccination rates were rising. In late 2015, the paper explains, the state attorney general’s office gave schools a warning: get kids immunized, or get their waivers collected — or risk losing money.

“This presentation called attention to the ability of the North Dakota Department of Public Instruction … to withhold funds from schools that were allowing children who were non-compliant with immunization requirements to attend school,” the report states.

State Health Department data shows that, in the 2016-17 and 2017-18 school years, there were marked drops in the number of kindergartners with no vaccination record on file in major North Dakota counties. That also can mean more kids recorded getting exemptions, experts say, instead of going unrecorded.

The question remains whether the state could do more to help drive down the number of non-religious, non-medical waivers. Compared to some states, it’s quite easy for North Dakotans to get a “personal belief” waiver — it’s just a quick set of paperwork and a parent signature. California, for example, ended “personal belief exemptions” several years ago and quickly saw an uptick in vaccinated children (though a spike in medical exemptions followed, too).

In Minnesota, it’s still possible to get a non-medical exemption, though exemptions do require a notary’s signature, according to the state health department website.

Experts say stringent laws help local districts hit “herd immunity” — the threshold at which a disease’s spread is significantly limited by vaccines.

So are tighter regulations needed in North Dakota?

One possibility experts have raised is that parents might get a “nonmedical” vaccination exemption only after getting a signature from a healthcare provider, or that health leaders might make the exemption forms available only on request — making the process a bit harder, and perhaps decreasing parents who simply sign a form to avoid the trouble of a doctor’s visit.

North Dakota Superintendent of Public Instruction Kirsten Baesler deferred to the Legislature on what to do with future kindergartners’ personal exemptions. She said school districts have only begun pursuing vaccination documentation more aggressively within the last several years, meaning it could be one to three years before there are identifiable trends upon which the Legislature might act.

In the meantime, Thompson will keep doing everything he can to keep kids in Grand Forks safe.

“If a parent wants to be excluded, that’s absolutely their right in the state of North Dakota,” Thompson said. “We just try to educate on our side about what is the downside — not only to the health of their child, but to the health of other students in that particular school who could have situations, medically, that would cause potentially life-threatening situations.”

EDITOR'S NOTE: This story has been updated to correct a reference Dr. Paul Carson made to the risks of vaccine-preventable diseases. Carson referred to measles in an interview — not tuberculosis, as initially published, which is not typically prevented via vaccine.