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Wednesday, February 21, 2024

The Pandemic Tanked Rates of Childhood Vaccination—for Everything

In the 14 months that Covid vaccines have been available, it has felt like they’ve dominated all conversations. What’s in them? How can we get them? Who doesn't want to get them? And—of most relevance right now—when will the youngest children, the last cohort to become eligible, finally be able to receive them?

In that chatter, it’s been easy to forget that they’re not the only shot. Kids and adults routinely take an array of other vaccines, and a vast, complex infrastructure delivers them. But as the wave of the 2021 rollout recedes, shrinking from stadiums full of cars to single chairs at pharmacies, we’re seeing what it once obscured. Millions of people missed other crucial vaccines in the first two years—and counting—of the pandemic.

The drop-off had no single cause. Lockdowns, of course—both families and kids stayed home, and medical offices and school clinics closed for their own protection. But also, health care workers who might have handled well-child visits were reassigned to Covid-shot delivery instead. There were protective equipment shortages. Supply chain disruptions. Misinformation and disinformation that increased suspicion of vaccines. Every social factor that dented the pandemic response had a shadow effect on all the other vaccines that needed to be delivered as well.

Research published since last summer and as recently as last month shows how dramatic the effect has been. In 2020, substantially fewer school-age children and teens got their shots—the combined MMR (measles, mumps, rubella) vaccine, and the ones for diphtheria, tetanus and pertussis, rotavirus and Haemophilus influenzae, among others—according to data from eight health systems that feed into a federal database. Similar drops occurred in 10 states surveyed by the Centers for Disease Control and Prevention and local researchers. The CDC estimated in mid-2021 that US children and teens received almost 12 million fewer vaccine doses during the pandemic, and, according to an analysis by Georgetown University’s Center for Children and Families, Black children and those in low-earning families were the most likely to have missed their shots. In Michigan, researchers found that the slide in routine vaccination also encompassed adults, who missed out on tetanus, shingles, and pneumonia vaccines.

This backsliding was reproduced around the world. “There were really tremendous disruptions to routine vaccination,” says Jonathan Mosser, an assistant professor at the University of Washington’s Institute for Health Metrics and Evaluation. He’s the senior author of a worldwide analysis of childhood vaccinations in 2020, which found that 30 million kids missed doses of diphtheria-pertussis-tetanus vaccines, and 27.2 million missed shots for measles.

Granted, global child vaccination was not perfect before the pandemic; children did miss doses when supplies were thin. But the team’s model estimated that among those 30 million kids missing DTP shots, 8.5 million would have been vaccinated if not for pandemic disruptions; for those missing measles shots, the figure was 8.9 million. The World Health Organization separately estimated that 17 million kids did not receive a single vaccine in 2020, putting them months behind in gaining protection against preventable diseases, since childhood vaccines take multiple doses to confer immunity.

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Covid also interrupted the long worldwide campaign to eradicate polio. (The wild virus still circulates in Afghanistan and Pakistan, and a strain related to the vaccine virus is causing outbreaks across sub-Saharan Africa.) When the world went into lockdown in March 2020, vaccination campaigns were suspended for four months in more than 30 countries. “In the two remaining wild polio-endemic countries of Afghanistan and Pakistan, 50 million children missed out on polio vaccinations for several months,” Carol Pandak, director of the polio campaign at Rotary International, one of the lead sponsors of the eradication effort, told WIRED by email.

Shoring up the public’s immunity and getting childhood vaccination back on track will be a difficult task. “Over time, there's been substantial recovery in many countries, but not enough to capture the children who were missed early in the pandemic. The data are still pretty incomplete for 2021, but there are some early reports that suggest these disruptions have continued,” says Mosser.

That’s partly because there are now more kids—babies born during the pandemic years who need to begin their own vaccination series, even though older children haven’t been covered yet. It’s also because the pandemic’s damage to health care hasn’t yet been repaired. Health care workers have left their jobs, appointments are hard to get, insurance reimbursement hasn’t caught up with families who were knocked off their annual cycle of visits, and the culture war over Covid vaccination is hotter now than it was when the shots were introduced.

Malini DeSilva, a physician and policy researcher at the Health Partners Institute in Minnesota, led the examination that showed vaccinations had slid in eight health care systems, which was published in October. It found that by September 2020, only 74 percent of 7-month-olds were up to date on their shots, compared with 81 percent a year earlier. For 18-month-olds, the figure had fallen from 61 to 57 percent. While those might seem like small differences, she points out that vaccination schedules, especially in the first two years of life, are rigid. Missing even one is like knocking over the first domino in a row—and can leave a child not just underprotected against illnesses, but ineligible for school.

“When our report came out, we heard from public school systems that they were having issues, because there were so many kids that were not up to date for immunizations in that kindergarten and first-grade group,” she says. “The school systems were struggling with trying to provide things like school vaccine clinics and other things, to help make [enrollment] happen.”

There may never before have been a time, in the US at least, when childhood vaccination was so comprehensively—if accidentally—undermined. In the US, kids’ vaccines are recommended by the Centers for Disease Control and Prevention and medical specialty societies, but required by states, usually for school enrollment. Those requirements have always been somewhat porous. Though all 50 states, plus the territories, require kids to be up to date on shots before attending school, 44 of them allow religious exemptions and 15 permit loosely defined “philosophical” objections.

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Experts have warned for years that those exemptions collectively drive holes in herd immunity and risk sparking epidemics. Outbreaks in states that allow exemptions have proven them correct. As just one example, more than 300 people in California, six other states, Canada, and Mexico developed measles in 2015 after an unvaccinated child caught it from another tourist at Disneyland. That outbreak led California to tighten the loopholes in its school requirements—and probably paved the way for the state to be one of just a handful that will require Covid vaccination for school kids when the next academic year begins.

More states have gone the other way, ruling out any Covid mandates for schools—and beyond that, the politically motivated furor over the Covid vaccine has triggered unnerving reconsiderations of all child vaccines. Last summer, the Tennessee Department of Health fired its top vaccination official for reminding local health departments that teens can be vaccinated without their parents’ consent. Last fall, a Florida state senator threatened to review school requirements for vaccines other than Covid. The Georgia General Assembly is currently considering a bill, cosponsored by 17 Republican state senators, that would prevent any government entity, including public schools, from requiring any vaccinations.

Two weeks ago, the independent UK-based polling firm YouGov found that, among a sample of 1,500 US adults, 71 percent support requiring children to be vaccinated against measles, mumps, and rubella, and 55 percent against other infectious diseases (excluding Covid). In an analysis, the pseudonymous science blogger Mike the Mad Biologist—in real life an infectious-disease microbiologist—points out that those percentages aren’t high enough to create herd immunity, especially against measles, which requires vaccination rates of at least 95 percent.

“There's a lot at stake,” says Jen Kates, a health policy expert and vice president at the nonprofit Kaiser Family Foundation. “Prior to Covid, there were pockets of communities where parents did not want their kids to have to get a school-mandated vaccine, and they would work to get exemptions. But if well-established mandated routine vaccination will be threatened, that would be concerning, because those school mandates are responsible for keeping vaccination rates high among kids and preventing outbreaks.”

It’s against this backdrop of delayed vaccines and increased public scrutiny that the Food and Drug Administration briefly considered authorizing Pfizer’s Covid vaccine for kids ages 4 and under without full trial results—that is, on the basis of data for two doses, not three. (The agency had already asked Pfizer to extend the trial to study the effects of a third dose, but considered moving ahead on partial data to let vaccinations begin anyway.) That plan was abandoned, but it alarmed researchers and may have seeded more doubt among worried parents.

The best outcome, of course, would be for parents and politicians to realize that all vaccinations protect children, and return to supporting all shots wholeheartedly. The next best may be to hope that those objecting to vaccination can make a distinction between the routine shots they have always allowed their children to receive and the new one that has triggered their doubts.

“People's views are often very vaccine-specific,” says Angela Shen, a vaccine-policy expert and visiting research scientist at Children’s Hospital of Philadelphia, who led the Michigan study and conducts focus groups on vaccine confidence. “What folks are telling me about the Covid vaccine is that the way they feel about it is often not the same thing as what they feel for routine vaccines, for themselves or their children. It’s like a hamburger: You might love the onion but hate the pickles.”


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