Editor’s note: This story has been updated to include more information about the Sheridan County child who tested positive for measles, as well as the vaccination status of the children of a religious exemption supporter.
As he tracked the growing measles outbreak in Texas, watching with dread as it crossed state lines, Bob Rauner knew there was no time to waste.
Fearful the once common — and life-threatening — virus would reach Nebraska, the physician and Lincoln Public Schools board president began publicly sounding the alarm.
“Nebraska’s vaccination rates mirror those of Texas,” Rauner said during an April school board meeting. “We have similar holes, just like Texas does. It’s likely a matter of time before measles spreads to Nebraska.”
He had reason to be concerned.
On May 27, Nebraska confirmed its first measles case since 2017. Public health officials said the Sheridan County child was appropriately vaccinated for their age, but hadn’t yet received the full series of shots. In addition, the child is immunocompromised, which can lead to breakthrough infections. Federal guidance recommends that children receive their first measles, mumps and rubella (MMR) vaccine between 12 and 15 months and their second between ages 4 and 6. The child had no out-of-state-travel history.
While announcing the case, the Nebraska Department of Health and Human Services noted that the best way to protect against measles is through immunization.
But Nebraska’s childhood vaccination rates are sliding downward even as the threat of measles emerges, according to a new Flatwater Free Press analysis of school data. Driving the decline is an exemption enshrined in state law: religious freedom.
Data indicates religious exemptions — the only nonmedical exemption to school vaccine requirements allowed under state law — have gained popularity in multiple regions across the state. That includes Lancaster County, home to Lincoln, where the percentage of children receiving an exemption roughly doubled in the past five years.
Statewide, parents are opting out of routine vaccines, like the ones targeting measles, chickenpox and pertussis, with increasing regularity. According to a survey conducted by the state at the beginning of the school year, only 11 of Nebraska’s 19 health districts had enough kindergartners who’d had the MMR vaccine to prevent an outbreak.
The trend is not unique to Nebraska, though experts say the state has one of the more lax laws surrounding exemptions for religious reasons.
In interviews with the Flatwater Free Press and to their followers on social media, families who claim the exemptions say their opposition to vaccines stems from deeply held beliefs.
But public health officials warn that an increasingly unvaccinated population could bring dire consequences at a time when state and federal funding cuts threaten to hamstring local vaccination efforts.
The youngest and sickest — infants and medically fragile children who can’t get the vaccine — are primed to lose the most, they said.
“I think the biggest misconception is this is a personal choice,” Rauner said. “It’s a personal choice and a public choice, because when you choose not to vaccinate against some diseases, you are putting other people at risk.”
A growing trend
Allie Bush is a strong believer in religious exemptions for childhood vaccinations. An outspoken vaccine opponent and founder of Nebraskans Against Government Overreach, Bush sees the exemption as a tool to push back against a state mandate she vehemently opposes.
Her two eldest children are vaccinated, following a divorce proceeding with her ex-husband, she said, when a judge required her to do so. Bush has since had another child, who she said will likely be homeschooled. But if she ends up attending public or private school, Bush will claim the religious exemption.
“The sincerely held belief that I have is that any pharmaceutical that’s intended to outdo or enhance God’s design wasn’t in his plan for us and isn’t necessary,” Bush said.
Her family relies on home remedies, homeopathic treatments and “things that weren’t chemically altered in some lab,” she added.
Bush frequently posts on social media about her concerns regarding vaccines. She was among the most vocal opponents of COVID-19 vaccine and mask mandates in Nebraska. And she has been a cheerleader for the medical freedom movement, which has gained fresh national attention after the confirmation of Robert F. Kennedy Jr. to lead the U.S. Department of Health and Human Services.
One explanation for the rise in parents choosing to claim an exemption, Bush said, is increased awareness sparked by the COVID-19 pandemic.
“Most people thought that all vaccines are always required for public school,” she said, “and (exemptions) are not majorly advertised by the schools.”
What is measles?
Measles is a highly contagious respiratory viral disease. It was declared eliminated from the country in 2000, but the U.S. has seen several outbreaks in the last decade.
Symptoms include runny nose, coughing, fever and rash. While anyone can contract measles, children, especially those under the age of 5, are at the greatest risk of developing serious complications. For some, a measles infection can mean pneumonia, lasting brain damage or even death.
The best way to avoid measles infection is through vaccination. The MMR vaccine is 97% effective at preventing measles after two doses.
Experts say that after 2020, when vaccine disinformation swelled online and in communities across the country, more and more families across Nebraska began reconsidering vaccinations.
“COVID, I think, has provided an opportunity for parents and guardians to really ask a lot more questions as far as the vaccines that their children are getting, especially those required for school,” said Kerry Kernen, director of the Lincoln-Lancaster County Health Department.
Of Nebraska’s 19 local health districts, Lincoln-Lancaster has seen one of the most steady climbs in religious exemptions. In the 2020-21 school year, 1.8% of kindergartners across the county received a religious exemption for one or more vaccines. By 2024-25, that number had climbed to 4%.
The impact is especially pronounced when it comes to measles protection. This year, only 89% of kids entering kindergarten in Lancaster County had both doses of the MMR vaccine, down from 94.4% in the 2020-21 school year. That’s well below the 95% that health officials say is necessary to prevent an outbreak.
Spurred by the data, Rauner said Lincoln Public Schools proactively sent out letters to parents explaining what would happen if their unvaccinated child was exposed.
“A young mom who suddenly learns that, ‘Wait, if my kid is exposed and they’re not vaccinated, they have to be out for three weeks, which means I gotta take three weeks off work … Maybe I’m not that hesitant.’ Is it gonna convince everybody? No, but it’s gonna convince some.”
Every LPS school is now at or above the 95% vaccinated threshold for measles, Rauner said, a feat he credits in part to the letters. But an ongoing challenge, he added, is the lack of institutional and social memory around what contracting measles actually means for a child.
“A lot of us don’t remember what it was like (before the MMR vaccine),” he said. “And if our idea of reality is based on what I read on social media, that’s not really what it was like either.””
Little oversight
Ostensibly, families claiming religious exemptions in Nebraska have to be just that — religious. The reality is more complicated.
To qualify for a religious exemption in Nebraska, a family must sign an affidavit before a notary swearing that immunization for one or multiple diseases either:
- Conflicts with the tenets and practices of a recognized religious denomination, of which the student is a member; or
- Conflicts with the student’s personal and sincerely followed religious beliefs.
Oversight of these exemptions ends when the ink dries. There’s no legal process to verify a religious exemption, nor is there a requirement to name the student’s religion.
“It’s open ended, and that’s why it’s really hard to police,” said Dorit Reiss, a professor of law at UC Law San Francisco. “How do you disprove something like that?”
Nebraska’s not alone in allowing these exemptions. Forty-three states and Washington, D.C., allow parents to opt their children out of vaccine requirements for religious reasons. Thirteen of those also allow exemptions for personal or philosophical reasons.
But many of those states require more than Nebraska law does. New Mexico requires parents to provide written affirmation of their religious objections. Nevada requires parents to sign their initials next to statements affirming they understand the risk of contracting and transmitting diseases.
Wyoming, which has a similar exemption form to Nebraska, includes a list of symptoms and effects of each disease a given vaccine prevents. Parents opting out of the MMR vaccine, for example, are counseled that, “Symptoms and effects of measles include pneumonia, seizures, brain damage, and death.”
“The problem is not so much the language in (Nebraska’s) affidavit, but the fact that there’s not really a follow-up,” Reiss said. “If you say, instead of signing a form, the parent has to write a letter explaining why the vaccine is against their religious beliefs and why they want a religious exemption, then you’ll have something to accept and assess.”
Few organized religions outright object to vaccination. While individual Catholics may have concerns about vaccines that use cell lines from an aborted fetus, the church has issued guidance that it is morally acceptable to receive those vaccines if there’s no other option.
The Catholic Diocese of Lincoln requires parents seeking an exemption sign an “acknowledgement of church teaching” that attests to that guidance.
It’s intended to educate families “on the Catholic Church’s teachings related to vaccines, while balancing the exemption rights set forth in state law,” the Rev. Lawrence Stoley, diocesan superintendent of schools, wrote in an emailed statement.
Even if a given religion doesn’t explicitly condemn vaccines, its adherents may still harbor anti-vaccine sentiment.
A 2023 Pew Research study found that white evangelicals in the U.S. have become increasingly antagonistic toward school vaccination requirements; 40% of respondents said parents shouldn’t be required to vaccinate their children, compared to 20% in 2019. Further data from Pew shows that over the last two decades, an increasing number of Nebraska’s faithful have begun identifying as evangelical.
Bush, who identifies as Christian, doesn’t believe someone needs to be religious in order to claim a religious exemption. While some states offer personal or philosophical exemptions in addition to religious ones, she doesn’t see the need for them in Nebraska, because the religious exemption acts functionally the same.
“There’s no specific religion that has to be adhered to in order to utilize the religious exemption … It’s purely a parent’s own decision,” she said. “They just have to go get it notarized in the state of Nebraska.”
Building trust amid funding crunch
For public health officials, the looming crisis hammers home the need to regain and maintain community trust.
In the Panhandle Public Health District, where the Sheridan County case was reported, health officials were proactively preparing. Data shows the district had the second-lowest kindergarten MMR vaccination rate this school year, at 90% — second only to Lancaster.
The district rolled out a flyer with a local family who chose to get vaccinated, and they hosted virtual educational sessions for health care providers, said Jessica Davies, the district’s health director, prior to the news of the state’s first measles case. Health district nurses are always available to answer questions about vaccination.
“We are ready,” Davies said in early May. “We’re actively monitoring locally and nationally. Our epidemiology team, they’re completely prepared for a thorough disease investigation.”
Effective prevention
Having those conversations with parents is important, said Kari Simonsen, pediatrician-in-chief of Children’s Nebraska. It’s vital, she said, to enter those chats without judgment.
“I do think that families have concerns that come from a variety of places,” she said. “And all those concerns are valid, and we want to be there to help them uncover what those are and work through it in a way that makes sense for the family, rather than to say, ‘Oh, all this information that you heard, it was a myth.’”
In early April, Gov. Jim Pillen and State Epidemiologist Dr. Sydney Stein added their voices to the chorus encouraging childhood vaccination.
“This one is a no-brainer. This vaccine works, and it protects our kids,” Pillen said during a press conference.
But vaccination efforts could grow even more challenging thanks to funding cuts at the federal and state levels.
Health districts are in line to lose millions in state support over the biennium under a budget bill signed by Pillen earlier this month.
The cuts will negatively impact the work by people like Jennifer Booker.
As the vaccine coordinator for the North Central District Health Department, Booker is responsible for making vaccines accessible across the nine-county region. Given its 14,000-mile expanse, the task is easier said than done.
North Central staff offer mobile vaccination clinics in Ainsworth, Valentine, Niobrara and Bloomfield. They manage a booth at the KBRX Farm & Home Show, where they invite onlookers to participate in a Plinko style game and test their vaccine knowledge. And they offer a walk-in vaccine clinic at their main office in O’Neill each Thursday.
Already, North Central staff are looking at their travel routes for ways to reduce mileage and grappling with the possibility that they may need to reduce the number of mobile clinics.
“With less funding, we will have less access points,” said Heidi Kuklis, executive director of the North Central District Health Department. “We run a very efficient vaccine program, but it does take money to get it done.”
Meanwhile, measles cases continue to rise nationally. As of May 23, the Centers for Disease Control and Prevention reported 1,046 cases in the U.S. Of those, 96% were unvaccinated. Three people have died.
Data shows that Nebraska has a band of stronger vaccine protection on its southern border, which Rauner said may act as a buffer against cases in Colorado, Kansas and Missouri. But it’s incumbent on officials at every level to encourage vaccination efforts, and ensure that one case doesn’t become many.
“When rubber hits the road,” he said, “you don’t want babies dying.”
How we analyzed childhood vaccination rates
The Flatwater Free Press submitted an open records request to the Nebraska Department of Health and Human Services seeking annual school immunization data collected for kindergartners and seventh graders across the state.
The department released immunization data by public health district, including specific data for each required vaccination and corresponding exemptions. The vaccination rates were calculated by dividing the total of vaccinated kindergartners or seventh graders by the total number of students entering kindergarten or seventh grade.
