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Inside Efforts to Stem Childhood Disease Outbreaks

By Elaine K. Howley
April 28, 2023
Kindergarten children playing with toys.

“Vaccines are one of the world’s greatest public health accomplishments. Vaccines save millions of lives,” she says. “We have to keep our eye on that North Star because that’s what it’s about — protecting our children and our communities.”

— Lisa Gwynn, DO, MBA, MSPH, FAAP, associate professor of clinical pediatrics and public health sciences at the University of Miami Miller School of Medicine.

On February 23, 2023, the City of Columbus Public Health in Ohio hit an important milestone — it had finally surpassed 42 days (two incubation periods) since the last onset of a case of measles. The outbreak that had sickened 85 children and landed 36 of them in the hospital since late October 2022 was on the decline.

The outbreak occurred in part because measles, mumps, and rubella (MMR) vaccination levels in Ohio had fallen below the national target of 95%. According to data from the Centers for Disease Control and Prevention (CDC), just 88.3% of kindergarteners in Ohio completed the two-dose course of the MMR vaccine for the 2021-2022 school year.

The reasons for this decline are largely related to misinformation.

“Here in Columbus we have community members who still believe, even though it’s been debunked, that the MMR vaccine is associated with autism,” says Columbus Public Health Commissioner Mysheika W. Roberts, MD, MPH.

That has led some parents to intentionally wait to get the MMR vaccine until they are required to do so for their child to begin attending school at about age 6.

“That’s a delay of five years,” Roberts says; children typically get their first dose of the MMR vaccine between 12 and 15 months of age.

Some children don’t get the shots at all, qualifying instead for exemptions on religious or philosophical grounds. These exemptions allow the child to attend school, but don’t protect them from potential infection or prevent infected children from spreading the disease.

As vaccination rates decline, diseases that had previously been all but eliminated are starting to appear in communities across the United States. The CDC reports that in 2019, 1,274 individual cases of measles were confirmed in 31 states, the highest number of U.S. cases reported since 1992. While public health initiatives designed to control the outbreak of COVID-19 helped drop that number to just 12 cases in 2020, since restrictions have eased, measles cases are again rising — 121 cases were reported in 2022.

In response to these increases, communities from Florida to Washington State are stepping up efforts to get more children vaccinated.

Reaching Seattle’s Immigrant Communities

The reasons for missed vaccinations can vary across the country.

In Seattle, for example, public health officials have noticed a decline in vaccinations particularly among immigrant communities.

Samara Hoag, MN, RN, NCSN, manager of health services for Seattle Public Schools (SPS), oversees school nursing at 104 sites across the district. Her work includes checking that all children are in compliance with state vaccination requirements to attend in-person instruction. She says currently, “our overall district compliance is 97.92% but immunization compliance is not uniform across all schools.”

In analyzing the population data from each school, Hoag has determined that schools with greater percentages of low-income and immigrant students tend to have lower vaccination rates. This is due in part to factors that make it difficult for some people to get vaccines, such as inconvenient doctor office locations or a lack of transportation. For others, there may be challenges with having a regular pediatrician near where families live, so they can’t easily stay on top of their child’s vaccine schedule. Language barriers between providers and patients can also be a major obstacle for some.   

One challenge is determining which vaccines a child has already received, Hoag says. No universal, centralized vaccine database exists in the United States, and state registries can’t easily share data about an individual on the other side of a state border. Overseas health records likewise may provide piecemeal information. Some health care providers in the United States may have difficulty interpreting foreign health records.

What’s more, many countries around the world use a day/month/year notation for dates rather than the month/day/year arrangement that’s most common in the United States. Calendars also differ. Ethiopia, for example, uses the Ge’ez calendar for all official documentation, which is quite different from the Gregorian calendar most of the rest of the world uses.

All of these nuances can make it difficult to sort out whether a child is up to date on vaccines.

That’s where three of Seattle’s public school nurses come in. Ladan Mohamed, RN, BASW, is a Somali American who speaks Somali; Selamawit Tedla, LPN, is an Ethiopian American who speaks Amharic; and Sheila Guarin-Juta, LPN, is a Filipino American who speaks Tagalog. They offer specialized expertise in translating vaccine cards and making sure new students in their communities are in compliance with state requirements and able to attend school.

Some students who are recent immigrants are unable to access their records, presenting additional challenges.

“When I came [to the United States] there was no record of any of my vaccines,” Guarin-Juta  recalls, and says that she had to get duplicate shots in Canada before she could come into the United States and enroll in school at age 17.

When faced with the need to get shots, whether for the first time or to catch up, parents’ vaccine hesitancy can also stand in the way. Mohamed notes that in the Somali community, fears about the MMR vaccine leading to autism and stories about other adverse reactions are major obstacles she helps families overcome.

“There’s a distrust of the health system,” she says, with some parents questioning why their children need so many vaccines.

“It’s also [due to] language barriers and cultural beliefs,” she adds, noting that vaccines that contain gelatin — which is made from pigs — may not be acceptable for some devout Muslims for whom consuming pork products is not allowed. However, a number of Muslim religious authorities have ruled that the pork gelatin used in vaccines is considered medicine and not food

Tedla adds that in the Ethiopian community, confusion about the vaccines can lead to hesitancy. Some also are reluctant to receive another vaccination when they’ve already been vaccinated in their home country but can’t prove they had the shot. Individuals who have underlying medical conditions can also be reluctant to take the vaccine sometimes, Tedla says, because they’re afraid of possible side effects.

In all of these instances, it takes a lot of effort, education, and collaboration with families from these nurses to overcome these obstacles, Mohamed says.

While SPS is working hard to reach all of its students, the state of Washington as a whole has a lower K-12 immunization completion rate than the national average; in Washington, the rate was 91.7% for the 2021-2022 school year. But recent legislation is helping the state’s department of health catch up.

In 2019, the state implemented House Bill 1638, which prohibits philosophical or personal objections from being used to exempt a child from the MMR vaccine. This helped increase the MMR vaccination rate to 94.4% in the 2020-2021 school year, up from 90.8% during the 2019-2020 school year.

Delaying Shots in Affluent Miami Communities 

In Miami, immunization rates for the standard childhood vaccination rates also have been dropping, but for different reasons.

The CDC reports that Florida’s kindergarten MMR vaccination completion rate was 91.7% in the 2021-2022 school year, down from a high of 94.6% during the 2006-2007 school year. The 2021-2022 figures are the lowest since the 2010-2011 school year when 91.3% of students had completed all doses of required vaccines.

While a decline of 3% might not seem like much, in whole numbers, thousands of children are affected. For example, in Florida, the CDC reports that there were 229,432 kindergarten-aged children during the 2021-2022 school year. A 91.7% coverage rate means that about 210, 390 kids had been vaccinated, but roughly 19,040 children weren’t up to date on their needed MMR vaccines. Had that same total kindergarten population of 229,432 children achieved the higher 94.6% coverage rate, the pool of unprotected children drops to 12,390. The risk of onward infection also drops; measles is one of the most readily contagious pathogens on Earth and when vaccine coverage rates fall below 95%, the threat of community spread of this potentially deadly and often cases of this debilitating illness increase significantly. 

Ironically, those areas of the city with higher educational and income levels are seeing the biggest declines in immunization. Parents in these areas “are getting this [false] information that separating the doses out is better, and that’s putting a much larger strain on our health system because we’re trying to squeeze everybody in and we only have a limited number of appointments,” says Lisa Gwynn, DO, MBA, MSPH, FAAP, associate professor of clinical pediatrics and public health sciences at the University of Miami Miller School of Medicine.

In contrast, Gwynn says families in underserved, economically challenged communities where health insurance is more difficult to come by are less likely to push back on any vaccine she recommends. This is especially true for immigrant families that have recently arrived, she says.

“They want whatever is needed for their child to get into school and they want their child to be protected,” she says.

Encouraging Vaccines Acceptance: What Works?

Getting shots in arms requires a tailored, patient-centered approach.

In Ohio, addressing the outbreak involved a concerted effort to identify new cases and conduct contact tracing for known contacts of those infected. It also led to outreach efforts to encourage vaccination uptake.

Roberts says that the decline of the outbreak only came about through “a lot of hard work and partnership with our children’s hospital here locally and working with our provider population across the metro area,” she says. “We were really aggressive in encouraging providers and parents to vaccinate and take any opportunity where you encounter a child who’s eligible for the vaccine to give them the vaccine.”

She adds some people responded really well to home visits.

“Some family members were more comfortable with us coming to them in their home environment to give them the vaccine” she says, “than they were coming into our office to get the vaccine.”

Because of the success of the MMR vaccine outreach, Roberts says the department plans to expand in-home vaccination offerings.

“We did it during the height of the pandemic for homebound individuals who wanted the COVID-19 vaccine,” she says, “but now we’re going to be offering not only COVID-19 and MMR vaccines, but all the other childhood vaccines at home if people want that, even if they’re not homebound.”

To prevent future outbreaks in Seattle, Hoag says school nurses like Mohamed, Tedla, and Guarin-Juta connect with members of their community in their native language to help them get caught up and stay current with vaccine schedules.

In addition, bringing school-based health centers into schools has also improved access. Hoag explains that SPS has 29 such health centers, which are separate from the school nurse’s office; they’re staffed by a nurse practitioner and can offer vaccines, school physicals, reproductive health care, and other primary care services to students on campus. She says bringing these community providers to school-located clinics and developing those partnerships is a great way to address gaps in vaccine coverage.

In Miami, Gwynn says working with parents who have concerns or might be hesitating to get their children vaccinated means building trust and starting the conversation about vaccination as early as possible — even before the child is born, if possible.

She says pediatricians are learning new motivational interviewing techniques to overcome the “different opinions, misinformation, and disinformation” that interfere for some folks.

“When you have a public health system like ours in Florida where they’re not recommending certain vaccines and going against what’s recommended by the Academy of Pediatrics and every other medical or organizational body, it’s challenging,” she adds.

Don’t Hesitate, Vaccinate!

Across the board, Roberts says that when faced with parents who are reluctant to have their children vaccinated, providers “really need to take the time to understand what they’re hesitant about, and do your best to educate them on what we know about vaccines.”

With the MMR vaccine in particular, the vaccine has “been around for years. It’s very safe. It’s highly effective. We know it does not contribute to autism,” Roberts explains.

And finding a way to assuage fears related to that can boost vaccine acceptance.

“The last thing you want to do is force the vaccine on somebody. Really, it takes some time to have that conversation with them,” she says.

No matter how difficult it can be, Gwynn says keeping the end goal in mind helps.

“Vaccines are one of the world’s greatest public health accomplishments. Vaccines save millions of lives,” she says. “We have to keep our eye on that North Star because that’s what it’s about — protecting our children and our communities.”