Back-to-School Threat: Missed Vaccinations in Children, Teens

Marcia Frellick

June 11, 2021

US children and adolescents may be at higher risk for vaccine-preventable diseases this fall as vaccination levels have not caught up with prepandemic coverage, according to a study published today in Morbidity and Mortality Weekly Report (MMWR) from the Centers for Disease Control and Prevention (CDC).

"Pediatric outbreaks of vaccine-preventable diseases have the potential to derail efforts to reopen schools for the 2021-22 academic year and further delay nationwide efforts to return students to the classroom," write Bhavini Patel Murthy, MD, with the Immunization Services Division, National Center for Immunization and Respiratory Diseases division of the CDC, and colleagues.

The number of children getting routine vaccinations plummeted between March and May 2020 compared with the same months in 2019. Although vaccination rates increased again from June 2020 through September 2020, the rebound was not enough to reach prepandemic levels, according to the study.

At the beginning of the June to September 2020 period, the news was good, the authors write. After most stay-at-home orders were lifted, the number of weekly routine pediatric vaccinations started to approach, and even surpass, baseline prepandemic levels in most of the 10 jurisdictions studied.

"However," the authors write, "across all age groups and across all vaccine types, none of the jurisdictions demonstrated a sustained or prolonged increase in the number of weekly doses administered above prepandemic administration levels, which would have been necessary to catch up children and adolescents who missed routine vaccinations."

To overcome the gap, the authors say clinicians should take the initiative. "Healthcare providers should assess the vaccination status of all pediatric patients, including adolescents, and contact those who are behind schedule to ensure that all children are fully vaccinated."

As COVID-19 vaccinations become more readily available to children, the CDC recommends that providers consider giving COVID-19 shots along with other routinely recommended vaccines.

Martha Perry, MD, associate professor and medical director at the University of North Carolina Children's Primary Care Clinic, told Medscape Medical News that getting the message out about the need to get children and adolescents caught up may require a national messaging campaign similar to that for COVID-19 vaccinations, as well as opening mass vaccination sites rather than families seeking vaccinations from individual providers.

She noted that although schools may offer a checks and balances system for required vaccinations, children who are not yet school age depend on families getting individual appointments.

Size of the Gaps

The MMWR article shows that the shortfall in vaccinations in June to September 2020 compared with those months the year before are striking.

For children younger than 2 years old and aged 2-6 years, diphtheria, tetanus, and acellular pertussis (DtaP) vaccinations declined an average of 9.1% and 6.7%, respectively.

Among children aged 12-23 months and 2-8 years, measles, mumps, and rubella (MMR) vaccinations decreased 8.8% and 11.3%, respectively.

Among children aged 9-12 years and adolescents 13-17 years, human papillomavirus (HPV) vaccinations decreased an average 12.2% and 28.1%, respectively. Among the same age groups, tetanus, diphtheria, and acellular pertussis (Tdap) vaccinations dropped 21.3% and 30.0%, respectively.

Perry said that although all the shortfalls are important, lags in vaccinations for measles and pertussis are particularly alarming in light of outbreaks in recent years.

Additionally, she said, as COVID-19 restrictions are lifting, some of the mitigation strategies, such as mask wearing, that kept other diseases at bay will not be in place, heightening the risk for infection.

The authors chose to measure weekly doses in March to May 2020, and June to September 2020 because many jurisdictions imposed and then lifted stay-at-home orders during these times. They analyzed data from 10 jurisdictions with high-performing information systems (Idaho, Iowa, Louisiana, Michigan, Minnesota, New York City, North Dakota, Oregon, Washington, and Wisconsin).

Adults Missing Vaccinations as Well

Another analysis, commissioned by GSK and conducted by Avalere Health, calculated 8.8 million missed adolescent vaccine doses and 17.2 million missed adult vaccine doses as a result of the pandemic and ongoing government restrictions and public health measures.

That study examined claims for CDC-recommended vaccines across commercial, managed Medicaid, Medicare Advantage, and Medicare fee-for-service Part B for January through November 2020 compared with the same period in 2019. 

It also found that vaccine claims remain well below 2019 levels. Total noninfluenza vaccine claims submissions were down by between 13% to 35% among adolescents and 17% to 40% among adults compared with the same period in 2019.

Perry said it will be critical for schools across the nation to enforce their policies on requiring up-to-date vaccinations even if online attendance is offered.

The workforce needed for this will be challenging, she noted.

"We've lost a lot of workforce in the healthcare field in the pandemic for a variety of reasons and it may be challenging to fill those positions," she said.

She also said the study underlines the importance of each state having a vaccine registry so each provider can determine what vaccinations a child needs.

The study authors and Perry have reported no relevant financial relationships.

MMWR. Published online June 11, 2021. Full text

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick
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