If you’re a pediatrician, chances are you have patients whose parents haven’t given much thought to their kids getting measles. But an outbreak has been underway in central Ohio since October 2022.
As of January 25, 2023, 85 cases of the vaccine-preventable disease had been reported there, resulting in 32 hospitalizations. Thankfully, as of this writing none of the afflicted children, 66% of whom are under the age of 5, have died. But measles is a potentially deadly virus that once ravaged communities across the country, infecting some 4 million people annually and killing about 6,000 people per year in the United States prior to the development of an effective vaccine.
The measles outbreak in Ohio stems from a drop in immunization levels, despite the availability of a safe and effective vaccine against the disease. Released in the 1960s, that vaccine caused infection rates and deaths from measles to plummet, and by the year 2000, measles had been declared eliminated in the United States.
But several years later, concerns about adverse effects of certain ingredients in common childhood vaccines like the MMR (measles, mumps and rubella) combination vaccine led some parents to begin refusing it for their children. Since then, some of these ingredients have been removed from vaccines and recent research shows that many of the concerns raised were not accurate.
It’s not just measles that’s on the rise. The recent rise of social media and its ability to quickly spread misinformation has resulted in more parents having vaccine-related concerns , which has led some to refuse routine pediatric vaccines for their kids. In turn, this has led to an alarming resurgence in outbreaks of not only measles, but also influenza, COVID-19, and respiratory syncytial virus (RSV).
In Ohio, the measles vaccination rate is estimated to be between 80% and 90%, Columbus Public Health commissioner Mysheika W. Roberts, MD, MPH, told The Journal of the American Medical Association in December 2022. More precise data weren’t available, she said, because vaccine reporting to public health authorities in the state isn’t mandatory.
But the problem isn’t just in Ohio; data from the Centers for Disease Control and Prevention (CDC) show that as of late November 2022, worldwide only 81% of children were receiving their first measles vaccine doses and just 71% were receiving their second doses, the lowest global coverage rates since 2008. These rates are well below the 95% vaccination rate needed to curb transmission of the highly contagious disease; since 2016, measles has reappeared in 10 countries where it had previously been eliminated.
The JAMA article also noted that during the COVID-19 pandemic, all “routine childhood vaccinations backslid” according to data released in fall 2022, which showed that between 2019 and 2022 “global vaccination coverage decreased not just for measles but also for diphtheria, tetanus, and pertussis; tuberculosis; Haemophilus influenzae type b; hepatitis B; polio; rubella; and human papillomavirus.”
A July 2022 report from the World Health Organization noted that in 2021 alone, 25 million children worldwide missed out on routine vaccinations, the largest decline in childhood vaccinations in 30 years. That decline was not solely related to COVID-19, which disrupted the delivery of routine health care including childhood vaccinations for millions of youths worldwide and created a highly charged climate of distrust of science in general, the report noted. It was also due to many children living in conflict zones and other fragile environments where access to health care is limited.
Jennifer Schuster, MD, MSCI, a pediatric infectious diseases specialist at Children’s Mercy in Kansas City, Missouri, says those figures match what she’s been seeing in her practice.
“Overall, we have seen fewer children that are what we would consider to be completely up-to-date on vaccination,” she says, “meaning that they’ve received all of the (CDC’s) ACIP (Advisory Committee on Immunization Practices) recommended vaccines for their age.”
While the level of vaccinations varies from child to child, Schuster says that lack of access to routine health care has been a major issue.
“Early in the pandemic, there was a lot of fear of going into medical providers and offices, so people weren’t able to get vaccinations,” she says.
Some parents also had questions or concerns about vaccinations — even ones their children had received previously — as the pandemic put all vaccines and how they’re developed under scrutiny.
“The COVID-19 pandemic and the rollout of the COVID-19 vaccines has led parents to have a lot of really good questions about the role, the efficacy, and the safety of vaccines,” Schuster says. “Many of these are things that we really took for granted in the past, and now parents have access to a lot more information and have a lot of questions.”
Meeting those questions head on is “one of the key roles of a pediatrician,” Schuster adds. “Our job is to provide good information to families and to be able to have a dialogue and answer those questions for them.”
Helping parents navigate which sources of information are reliable and trustworthy has become a big piece of Schuster’s work, she says.
While addressing concerns is one key way of encouraging uptake of routine childhood vaccinations, actually providing them in places where children are every day is another way to help bridge the gap, says Ellen Nitz, BSN, RN, director of nursing services with the Charleston County School District (CCSD) in Charleston, South Carolina.
“We constantly have children who are delinquent with their vaccinations here in Charleston county, like in all counties in all states,” Nitz explains.
Immunization requirements for attending public schools vary from state to state and even district to district in some cases, so when a family moves to a new district, their child may need one or more vaccinations to comply with local requirements and be allowed to attend in-person instruction.
In 2019, when Nitz became the director of nursing for CCSD — a 48,000-student district that’s spread across 100 square miles of South Carolina’s marshy Lowcountry — she worked with South Carolina’s department of health, called DHEC, to find ways to keep kids up to date on their vaccines.
She wondered about bringing vaccines to these kids where they are most. The 125 school nurses she oversees across the district “see these kids day in and day out. Wouldn’t it be great if we were able to immunize these kids at school?” she asked.
Nitz wrote a grant proposal and in 2020 created a voluntary vaccination program through the CDC’s Vaccines for Children (VFC) program that’s available to all kids in CCSD. It provides pediatric vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) free of charge. This program makes vaccines available in school nurses’ offices throughout the district, so that kids can get vaccinated at school. Parents don’t have to be present for the interaction, which typically takes about 15 minutes per student to reduce the loss of learning time.
Making vaccines available in schools removed some barriers for parents who couldn’t get time off work or those who lacked reliable transportation to take their children to doctor’s appointments. Because the vaccines are provided free of charge and no copayments are required, that also removes financial barriers that had prevented some families from staying current with vaccination schedules. Interpreters who are already in CCSD schools help overcome language barriers. Parents must sign a consent form if they want their child to be vaccinated at school.
Since 2020, the VFC program in CCSD schools has administered more than 2,000 routine childhood vaccines to students who needed them. In 2022, it delivered an additional 1,300 flu vaccines. Through a separate partnership with the Medical University of South Carolina, school nurses have provided more than 11,700 COVID-19 vaccines to staff and students at CCSD schools as they had the proper storage facilities.
Encouraging Uptake Through Communication
Schuster says that encouraging parents to have their children vaccinated can be challenging, but “one of the things that I have learned, especially throughout the COVID-19 pandemic, is that all parents come from the place of wanting the very best for their child. I don’t think I’ve ever met a parent who doesn’t want the very best for their child.”
Depending on the source of the information they’ve been receiving, some parents may have an erroneous or incomplete view of vaccines and how they work, or their safety. But listening to their concerns and providing accurate, evidence-based information can help overcome misconceptions, she says.
“Every parent who is coming to you is different, just like all of the children we see in our practice are different,” Schuster says. “Everybody is coming with their own story and their own questions. There is no one-size-fits-all approach. My approach has been to listen, understand where people are coming from, and then provide the best information that I can to answer their questions.”
Health care providers note that the goal should be to encourage vaccine acceptance, whether it’s the routine course of vaccines that have been available for more than 60 years, or the next COVID-19 vaccines that just became available for those under 5.
“When you have vaccines that can prevent childhood disease,” she says, “we want to make sure that they get to the right people.”
Bridging gaps in access by providing convenient times and locations for kids, staff, and parents helps protect the whole of the school community in ways that other outreach efforts may not have managed to achieve before. And building trust with parents can go a long way toward keeping the kids they love out of the hospital and in the classrooms where they belong.