Student vaccinations slowed during covid. Can schools catch them up?
Wendy Hasson, a pediatric intensive care physician in Oregon, knows the tragedy that can befall an unimmunized child. As the nation reeled from the coronavirus pandemic, one of her young patients in Portland missed vaccinations against bacteria that can cause meningitis. The infant grew dangerously ill and nearly died.
"These infections are rare but they can be particularly devastating," said Hasson, medical director of the pediatric ICU at Randall Children's Hospital, remembering that the child sustained permanent brain and kidney damage, and lifelong disabilities. "It's a tragedy because the patient was a completely normal, healthy child previously," she said. Parents are often racked by regret, she said.
Health officials worry about scenarios like that one as students across the nation, now returning to school, have fallen behind on routine school immunizations during the pandemic. Families missed doctor visits and yearly physicals. and some never caught up on shots for diseases such as polio, measles, whooping cough and diphtheria.
The toll of the pandemic is hard to dispute. In Virginia, statewide rates for school-required vaccinations among kindergartners and adolescents fell by 10 percentage points from fall 2019 to fall 2021 - to around 86%, state data shows. Officials attributed the drop to fewer well-child visits, months of virtual learning, fluctuations in kindergarten enrollment and other factors.
Arkansas saw vaccinations for children and adolescents drop more than 12% from 2019 to 2021. And in Washington D.C., more than 30% of students had not met requirements as of mid-August, though city officials think the number is far lower because of complexities in record-keeping. City health officials said they did not have comparative pre-pandemic data "due to changes in reporting methods."
California officials said in August that more than 1 in 8 students in that state was behind on a vaccine required for kindergarten - a shot for measles, mumps and rubella - after the pandemic interruptions of daily life led to missed shots and vaccination delays. The state did not provide directly comparable data but said 1 in 24 kindergartners missed one or more vaccinations in 2019.
Now, as schools open for the fall, the push is on to close the gap. Vaccination centers have been set up in school buildings. Letters and automated phone calls have gone out to parents. Reminders have been posted at bus stops.
"We're cautiously optimistic but we also know there's work to do to make sure that children do get caught up on vaccines, or in some cases they haven't been vaccinated and that they get vaccinated," said Georgina Peacock, director of the Immunization Services Division of the Centers for Disease Control and Prevention.
Nationally, pandemic-years data on school immunizations has lagged. But a sizable decline can be seen in the number of orders placed for a key federal vaccination program and in other data from fall 2020, Peacock said.
Orders for the federal program for families in need - Vaccines For Children - fell 14% in fiscal 2020, compared to a year earlier, officials said. There was a partial rebound in fiscal 2021, but it was still 6% less than the pre-pandemic level. For this year, through May, orders are 4% lower than in 2019.
The CDC's compilation of state and local data for 2020 showed a one-point drop in childhood vaccinations, but Peacock pointed out that even that change represents 35,000 kindergartners. The same year, she said, an additional 400,000 kindergartners did not show up in schools, leaving their vaccination status unclear.
"The pandemic was a very big change and big disruption for our society, and so this type of drop in well-child visits and therefore childhood immunizations hasn't been seen in this way in the past," Peacock said.
States vary in vaccination requirements - and in types of exemptions they allow - but they often include shots to prevent polio, chickenpox, hepatitis B and meningitis, along with diphtheria and tetanus, plus measles, mumps and rubella. In middle school, requirements can include a vaccination to protect against meningitis, and diphtheria and tetanus. Several jurisdictions require vaccinations for HPV, which is linked to cervical cancer.
Coronavirus vaccination is not mandated in most schools - though Washington D.C. requires it for students 12 and older.
National data show 60% of those ages 12 to 17 are fully vaccinated against the coronavirus, as are 30% of children ages 5 to 11. Shots for those younger than 5 were first offered this summer.
The peril of being unvaccinated against significant diseases was clear recently in Rockland County, N.Y., where a 20-year-old man contracted polio, setting off a wave of public health concern about the highly contagious, life-threatening disease that causes permanent paralysis in about 1 of every 200 infections.
Before that, measles outbreaks in 2019 caused similar alarm. More than 85% of cases for the first nine months of that year were associated with pockets of under-immunized people, including Orthodox Jewish communities in New York, according to a CDC report. City officials blamed anti-vaccine groups for spreading misinformation.
Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia and a voting member on the FDA Vaccine Advisory Committee, recalled measles as the most contagious of vaccine-preventable diseases - finally eliminated in 2000 because of school mandates. Decades later, with the coronavirus, mandates are mired in the "culture wars," making the issue far more complex, he said.
Still, Offit said the country is slowly catching up on routine immunizations delayed by the pandemic. "Are we where we were before this?" Offit asked. "Not yet."
Vaccinations for adolescents have taken a big hit, said Judy Klein, president of the nonprofit Unity Consortium, which advocates on the issue. Vaccinations for HPV - recommended but not required in most states - have declined by 11% in fiscal 2022, after drops in 2020 and 2021, she said. "HPV is basically a cancer-fighting vaccine," she said. "It's not something that's going to show up tomorrow; it's going to show up years from now."
In D.C., where schools open Monday, students who show up without all of their shots have 20 school days to come into compliance. Many jurisdictions have similar grace periods. Still, advocates worry that racial disparities in vaccination rates will mean any exclusions would primarily affect Black students.
Thomas Farley, senior deputy director for the Community Health Administration in D.C., said that in recent weeks the agency has sent out 25,000 letters to parents of students missing their shots. Mobile teams have hosted vaccination days at schools with low immunization rates. High schools with health centers are offering shots.
Farley said he thinks few, if any, students will be kept out of school. "Immunization mandates have been used by every state in the nation for decades," he said. "They work. When parents are notified that your child must be vaccinated to go to school, they go and get their children vaccinated." For those who wait until the last day, "there'll be opportunities for them to go within a day, get the child vaccinated, and come back."
Maryland provided data showing that kindergarten vaccinations dropped by 9 to 11 percentage points from the 2019-2020 academic year, when much of the school year was not affected by the pandemic, to the 2020-2021 academic year, a period when students learned remotely most of the time. "That had an impact on immunization reporting," state health officials said.
In Maryland's largest school system, in Montgomery County, the vaccination noncompliance rate had hit 23% last September. After a wave of catch-up efforts, the rate fell to 14% in December, then 11% in spring, said Mark Hodge, senior administrator for school health services in Montgomery. With the start of school a few days away, an update was still being finalized.
Hodge said that amid the turmoil of the pandemic, school nurses and other health personnel in schools were inundated with responsibilities related to covid-19. "There just weren't enough people to do all that was required for covid and do all of the other things too," Hodge said.
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