Mayor Bill de Blasio urges parents to not fall behind on vaccination schedules, “Getting your child vaccinated is essential work. Getting your child vaccinated is a reason to leave your home.”
As states across the country continue their conversations on reopening schools for the fall, there is the added concern of the spread of vaccine-preventable diseases on top of COVID-19. Since the pandemic first hit back in March, rates of childhood vaccinations have dropped significantly as many parents have been reluctant to schedule their well-child visits out of fear of contracting the virus (1). As a result, children across the country have fallen behind on vaccinations for measles, whooping cough and other potentially life threatening diseases (2).
Vaccination Rates are Plummeting
Thus far, the risk of infection of vaccine-preventable diseases has been mitigated by social distancing and stay-at-home orders. However, as states such as New York begin to reopen, the concern of outbreaks of these diseases grows. In official CDC pandemic guidelines on vaccinations, ensuring immunization services are maintained or reinitiated is described as essential for protecting individuals and communities from outbreaks of vaccine-preventable diseases (3). Given the upcoming flu season and the ongoing pandemic, reducing the burden of respiratory illness is of the utmost importance in protecting the public health of our school communities.
In a recent study conducted by the CDC, the vaccination rates in May 2020 for children under 2 years old in Michigan fell to alarming rates (4). Before the pandemic, roughly two-thirds of infants 5 months or younger were up to date with their vaccinations. This year, the rate fell to 49.7%, less than half of the infant population. This study also pointed to the socio-economic disparities in health care, as Michigan children on Medicaid were even less likely to be up-to-date on their immunizations. This study likely represents trends around the country, as we are already seeing in New York State.
"For children older than two, the city has recorded a 91% drop in the vaccination rate"
In a briefing in late May, New York City Mayor Bill de Blasio announced that vaccination rates among children had plummeted, urging parents to not fall behind on vaccination schedules, “Getting your child vaccinated is essential work. Getting your child vaccinated is a reason to leave your home.” In New York City, vaccinations for children two years old or younger have seen a 42% decrease. For children older than two, the city has recorded a 91% drop in the vaccination rate (5). New York State schools have indicated that they will collect completed child health examination forms (CH205) based on physical examinations and screenings performed within the previous 18 months, which will remain in effect until December 31, 2020 with potential reevaluation as the pandemic evolves (6). While this decision is helpful for parents during a pandemic, some health professionals are concerned that as a result, children’s vaccinations will not be in compliance.
The Impact of Reopening Schools
Recently, I had the opportunity to speak with a New York pediatrician and member of the NYSBHA, Dr. Suanne Kowal-Connelly. When asked about her concerns surrounding the reopening of schools, Dr. Kowal expressed that she understood allowing for older health certificates due to the coronavirus, however she is worried about children not being up-to-date on their vaccinations, “What I can’t deal with is vaccines not being in compliance. I would insist that every student get their vaccines in compliance, just the way we always do.” Dr. Kowal reminded me that New York City has very recently experienced the consequences of unvaccinated communities.
In 2018, an outbreak of measles in Brooklyn began when one unvaccinated child returned home from Israel with measles, resulting in 649 confirmed cases of measles that lasted a total of 10 months (7). In this case, 85.8% of the patients with a known vaccination history were unvaccinated and serious complications included 37 cases of pneumonia and 49 patients hospitalized. Given COVID-19’s targeting of the respiratory system, one can imagine the impact that a measles outbreak would have this upcoming school year, “You don’t want your child to end up with some vaccine-preventable disease in the midst of a pandemic” (Dr. Kowal).
Potential Concerns Around Vaccinations During COVID-19
It is now more important than ever that school-aged children stay on course with their immunization schedules, not only for their own health and safety, but for the health and safety of their peers, school staff, and families. For diseases like measles, public health officials estimate that community vaccination rate from 93% to 95% is necessary to prevent a widespread outbreak (1). The current vaccination rates are far below the standard for herd immunity, mostly due to the concerns surrounding social distancing and going in for doctors appointments during COVID-19.
“A lot of different workflows are in place to make sure that families can access their provider safely and get the wellcare and vaccines they need, and I don’t see any advantage to letting that slide because of COVID.” -Dr. Suanne Kowal-Connellly
In response to this fear, Dr. Kowal wants families to know that health institutions are putting all necessary protocols in place so that patients can come in safely. Whether that be through ensuring social distancing, having PPE available, and separating out well and sick visit times, “A lot of different workflows are in place to make sure that families can access their provider safely and get the wellcare and vaccines they need, and I don’t see any advantage to letting that slide because of COVID.”
Another concern among Public Health officials is the decrease in vaccine orders by health care providers. The CDC examined two data sources from the same period in 2019 and 2020 to assess the impact of the pandemic on pediatric vaccination in the United States: Vaccines for Children Program (VFC) provider order data and Vaccine Safety Datalink (VSD) vaccine administration data (8). What they found was a decline in vaccine orders the week following the national emergency declaration.
The figure above comes from the aforementioned CDC study and shows how vaccination ordering experienced a steep decline in mid-March. However, it is important to note that vaccination orders began to steadily increase in late-March for children under 2 years of age. This points to early success of strategies implemented by VSD health care organizations to promote childhood vaccinations during the pandemic, including outreach to patients overdue for vaccinations and changing office workflows to minimize contact between patients.
Dr. Kowal adds that in cases where vaccinations are unavailable due to increases in demands, pediatricians can write a letter to the school indicating that the student has been seen and as soon as vaccine stocks are made available they will be able to receive their vaccination. While this is not an ideal solution, it helps to hold parents and schools accountable for keeping students up-to-date on vaccinations, “I’m not saying that suffices, but it at least helps to keep the child in school and get you through that period” (Dr. Kowal). In many ways, schools and families will have to remain flexible when it comes to student health for the upcoming school year, and SBHCs can help ensure that while there is flexibility, New York schools are staying vigilant when it comes to vaccine-preventable diseases.
SBHCs can help bridge the educational gap when it comes to understanding how vaccines work, not only during the pandemic but after as well.
The Role of SBHCs in Immunization
In response to the growing concerns around social distancing in healthcare settings, various solutions to the decline in vaccination rates have been implemented including vaccine clinics in outdoor parking lots, vaccination mobile clinics, and home visits for children with special needs (2) In response to parent concerns about visiting the doctor, Dr. Sean T. O'Leary, a member of the AAP Committee on Infectious Diseases, emphasizes “Medical offices are among the safest places you can be right now given the really extensive measures they’ve taken to prevent the spread of COVID-19 both to themselves and their patients. Parents shouldn’t be afraid to go to their doctor" (9). Dr. Kowal definitively echoes Dr. O’Leary, “If they can get their kids to school, then they can get them to a healthcare provider. We should make sure they do it.”
One of the main services offered by SBHCs is immunizations. However, following the outbreak of COVID-19, many SBHCs were temporarily shuttered due to school closures. In most New York counties, these health centers have since opened. However, in New York City, a region home to nearly two-thirds of the state's SBHCs, health clinics have remained closed. Mayor Bill de Blasio has yet to give a reasoning for keeping these clinics closed nor a timeline for when they might reopen. Given the importance of SBHCs in serving harder-to-reach populations, the long closures of NYC’s SBHCs leads to concerns of ensuring all students are up-to-date on vaccinations as schools prepare to open for the fall. Director of the NYSBHA, Sarah Murphy, recently commented on the closures, stating “the last thing we need is to add measles on top of the pandemic” (10). It is therefore important that SBHCs are reopened across the state as soon as possible to begin outreach to parents whose children may have fallen behind on their immunization schedules during the lockdown.
The reality outside of the context of COVID-19 is that many parents are skeptical in general when it comes to vaccines, largely due to misinformation. Dr. Kowal firmly believes that educating parents on vaccinations is a feasible solution to these anxieties, “If we could just educate large masses of people better, maybe that would help allay some of the fears, because the fears are based on something people just don’t understand most of the time.” Due to SBHCs accessibility to both students and the parents of students, SBHCs can help bridge the educational gap when it comes to understanding how vaccines work, not only during the pandemic but after as well. Herd immunity will be especially important in putting an end to this pandemic, and SBHCs can start the work of educating parents now in an effort to help the process of COVID-19 vaccinations down the line.
NYC Health and Hospitals Vaccination Sites
New York State Recommended Vaccine Schedules
Dr. Kowal’s Blog Series on What Parents Need to Know About COVID-19
For resources related to SBHCs and Immunizations, visit the NYSBHA’s new Resources on Immunizations page.