It's Time to Start Talking About Back-to-School Vaccinations

Michael D. Miller, MD


July 19, 2022

Most clinicians — particularly pediatricians and public health officials — recognize that routine vaccinations for children have significantly controlled many serious illnesses that, until a few decades ago, were routine in the US. Measles may be the one exception to that progress; because it is so highly contagious, there have been outbreaks in the US as recently as 2019. But through surveillance, contact tracing, catching up on vaccinations, and assuring immune states of healthcare workers, such outbreaks have been controlled.

However, with the pandemic causing reduced in-person clinician visits, many children didn't receive their routine vaccinations. Orders of non–flu vaccines from the CDC's Vaccines for Children Program (VCP), which provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay, decreased 14% in fiscal year (FY) 2020 compared with FY 2019 (October 2018 to September 2019). And in FY 2021, orders were 6% lower than FY 2019. While so far, in FY 2022, orders are 4% lower than the same time period in FY 2019. (Unpublished data provided to me by the CDC.)

Data from state immunization programs for the 2020-21 school year showed a similar drop: a national 1% decline in vaccination rates, with "the proportion of students who were not fully vaccinated and not exempt increased in a majority of states." Two things should be recognized from these two data sets: First, the VCP is number of vaccines ordered, whereas the state data reports percentages of school children who had received their recommended vaccinations (or received an exception, etc.). And second, the VCP focuses on children in lower economic groups who, therefore, might be at greater risk of being uninsured or otherwise at risk of not receiving their vaccinations. Together, these two data sets point to reductions in vaccinations delivered or administered as well as fewer children getting their immunizations — particularly the most vulnerable children.

The reason for the difference in the numbers between the VCP and what states reported may be that enrollment in kindergarten in 2020-2021 was 10% lower than the pre-pandemic school year, according to the April 22 MMWR. In other words, if many children did not start kindergarten, then there would be a larger drop in VCP orders, with a comparatively smaller increase in the percentage of children attending school who had not received their recommended vaccines.

The potential reasons for the drop in kindergarten enrollment could be due to parents deciding to defer starting their kids in school because of the pandemic or "homeschooling" them for the kindergarten basics and planning on starting them right into first grade. Or if their schools were holding kindergarten remotely, they may not have had the personal or technical means for their children to participate. Those factors, along with the relaxed vaccination reporting by many states during the pandemic's public health emergency, are very worrisome because the bottom-line result is that many more children — and communities —  are vulnerable to the consequences of preventable infections.

An additional concern is that though some states (pre-COVID) had more permissive laws and processes concerning nonmedical exceptions for childhood vaccinations prior to school attendance, because of rising anti-vaccine sentiment some states are expanding or loosening exemptions, those more permissive vaccine exemption rules will complicate matters for overburdened teachers, school nurses and administrators, and public health officials — groups already scorched by the burdens of the pandemic. As the April 22 MMWR notes, for the 2020-21 school year, "46% of school nurses reported that school vaccination requirements were a somewhat lower or much lower priority compared with previous years."

Clinician Outreach Is Critical

That is why public health people need to be concerned that if the school year starts and children haven't received their recommended vaccinations, there could be a resurgence of measles, mumps, and rubella (along with other infections), which could spread among children and school staff and be brought home to their families for more community spread. This is a scenario that is now very apparent to everyone from our experience with SARS-CoV-2. And while each of those three illnesses has its own consequences, two are particularly noteworthy.

First, rubella generally doesn't cause serious illness in children who are not immunocompromised; typically a mild fever, sore throat, and a rash. However, in pregnant women, it causes a very high rate of fetal abnormalities or miscarriage, particularly when the mother is infected early in pregnancy.

Second, with measles, contrary to the "claims" made by proponent of the "benefits of natural infections," the measles virus causes a loss of prior immunity gained via vaccinations or infections. This situation is sometimes called "immune amnesia," and was first recognized around 2015. This phenomenon is now beginning to be understood to be at least partially related to a depletion of antibody-producing B cells.

And this risk is not just theoretical. Globally, an estimated 22 million children missed their first dose of measles vaccine, which was an increase of 3 million from 2019. For the United States, this increases the risk for measles outbreaks because past outbreaks have often been caused by travelers from other countries bringing infectious measles to the US.

The take-home (or take-to-the-clinic) message is that now is the time for clinicians and public health officials to be reaching out to parents, school systems, and community leaders. This type of coordinated outreach for vaccinations before the school year starts is being done in Washington, DC. I hope that this is also occurring in other states and localities.

Not only can clinicians raise the issue of catching up on missed vaccines with your patients, but we can also take a leading role in elevating the issue in the public dialogue. Do you know what is happening in your state, community and local schools?

And let us not forget routine immunizations for adults, such as those for pneumonia and influenza. While adults don't face return to school requirements for vaccinations (although many clinical organizations do require a variety of immunizations, or even proof of immune status via blood test), they too should be reminded to get missed vaccinations as well as other preventive services that may have been deferred because of the pandemic.

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About Dr Michael D. Miller
For more than 30 years, Michael D. Miller, MD has been working with large and small companies, government organizations, and patient advocates to improve access and affordability for treatments and innovations. His work has spanned many clinical, scientific, and policy areas, including autoimmune diseases, behavioral health, cancer, cell/gene therapies, diabetes, patents, reimbursements, and vaccines. He graduated from Williams College and Yale Medical School, has served on several nonprofit boards, and has spoken across the country on critical healthcare issues.

Connect with him on Twitter @HealthPolCom and on his website.


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