COVID-19 and Routine Childhood Vaccinations—Identifying Gaps and Informing Solutions

On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. The United States declared a national emergency and, on March 18, 2020, the American Academy of Pediatrics issued guidance advising pediatricians to restrict preventive care visits to younger children requiring immunizations. Pediatric primary care visit volumes precipitously declined. A growing literature is helping to define this impact and raise questions about how best to address the consequences of that lost care.

In this issue of JAMA Pediatrics, DeSilva et al¹ address the critical issue for the pediatric community of declining vaccination rates during the COVID-19 pandemic. The study team used data from the Vaccine Safety Datalink, a collaborative effort between the US Centers for Disease Control and Prevention’s Immunization Safety Office and 8 integrated health care organizations across 6 US states. Using this data set, the study team conducted a retrospective observational study with a pre-post control design, examining both weekly routine childhood vaccination rates and the proportion of children in key age groups with up-to-date (UTD) vaccinations as of February, May, and September 2020. The study team then compared these rates with comparable 2019 time periods. Analyzing the data for approximately 1.4 million children in each year, the study team identified substantially lower rates of weekly vaccine administration across age groups during the early months of the COVID-19 pandemic, followed by an increase to near prepandemic levels from summer into fall 2020. Despite the return to more typical levels of vaccination, the proportion of children with UTD vaccinations was lower among the 7-month, 18-month, and 13-year age groups while remaining stable for the 6- and 18-year age groups.

In all, the data presented by the study team describe a situation that is both reassuring and concerning regarding the impact of the COVID-19 pandemic on childhood vaccinations. Vaccine administration rates in health care systems, after an initial decline, have essentially returned to prepandemic levels. However, as has been observed in other studies, there are lingering effects of the pandemic, as the proportion of children with UTD vaccinations has declined over time.²

The COVID-19 pandemic also has increased health disparities in a range of settings.^3,4 For pediatric vaccination, the study team examined and found wide disparities in the proportion of children with UTD vaccinations by race and ethnicity. These differences preceded the pandemic, and, for some age cohorts, the disparity may have widened. For example, rates of UTD vaccination for the 7- and 18-month age groups varied widely by race, with rates highest in Asian children and lowest in Black children. The differences were not as stark for other age cohorts but were nonetheless present. Worse still, differences in proportion of UTD vaccinations at age 18 months between Black children and children of other races may have increased through the COVID-19 pandemic.

The study had several meaningful strengths and limitations. The Vaccine Safety Datalink uses electronic health record and claims data from each participating site. This approach allows for timely data collection and interpretation and is highly accurate.⁵ The study population is mostly children with commercial and/or stable health insurance receiving care in large health care systems. Even with the addition of Denver Health, which includes children with Medicaid insurance, vaccination coverage trends may be different for other populations, including patients who receive vaccinations through the Vaccines for Children Program. Further, the sample has large numbers of Hispanic children (another strength), although it includes much more modest numbers of non-Hispanic Black children.

This study highlights both the immediate and lagging disruptions in pediatric health care delivery caused by the pandemic as well as potential long-term consequences on pediatric health. The decreased vaccination coverage in young children parallels the declines in other pediatric medical services during the COVID-19 pandemic, including preventive well-child care, screenings, dental visits, and lead testing.⁶ Interventions are needed to promote catch-up vaccination, but how do we best catch up for lost preventive care for children younger than 24 months? Consensus care guidelines could augment preventive care for this cohort, for example, by increasing frequency of well-child care during the next year of life. Although there is no evidence base for this approach, such a change could create not only catch-up opportunities for vaccination for children delayed at age 7 and 18 months, but also provide opportunities to attend to developmental concerns and social needs that have emerged during COVID-19. Practices could also prioritize visits with 13-year-old adolescents who are behind on vaccination.

In examining how vaccination coverage changed during the COVID-19 pandemic, the study by DeSilva et al¹ also highlights persistent suboptimal vaccination rates for children in the US, especially for certain groups and ages. Substantial differences persist even though private insurance and the Vaccines for Children Program cover the cost of vaccinations, underscoring the need for alternate strategies through the pandemic and beyond. DeSilva et al¹ draw particular attention to health care system and community-level interventions as a set of approaches and vaccine requirements and mandates as another. We explore options in those areas.

Pediatric health care settings can embrace several key approaches. The importance of leveraging sick visit vaccination in catching up children who were missed is now more important than ever.⁷ Pediatric practices have been so innovative during the COVID-19 pandemic, including delivering care via telemedicine, shifting workflows and office designs to promote social distancing, and embracing population health techniques to re-engage families in preventive care services. This study by DeSilva et al¹ shows that the shift to promote vaccination in the context of sick visits will be increasingly important. Further, given the accompanying declines in preventive care with increases in chronic conditions such as obesity³ and depression⁴ during the pandemic, converting these sick visits to preventive visits, when possible, may also be important.

Pediatric health care settings can also reach out to patients and families directly to notify them of needed vaccinations. There is substantial, rigorous evidence of the effectiveness of reminder-recall systems for pediatric vaccinations.⁸ Despite the range of approaches with proven benefit (for example, mailings, telephone calls, and text messaging), these systems are not widely integrated into pediatric primary care settings.⁹ Text messaging may especially help patient populations with worse outcomes, such as patients who have public insurance.¹⁰ However, better support and guidance are needed to easily and seamlessly incorporate these systems into practice. For example, professional organizations might identify preferred vendors able to readily implement these programs for health care systems or practices without this capacity. Complementing text messaging approaches, health care systems have increased use of electronic health record patient portals, a trend accelerated during the COVID-19 pandemic. Although there are concerns regarding adoption of portals among underserved populations, emerging evidence suggests portal-based vaccine reminders can lead to small but significant gains in vaccination.¹¹

At the community level, pediatric health care systems can partner with alternative settings to promote vaccination. Pediatricians and pediatric clinicians will remain front and center in these efforts. When asked about their key sources of health care advice, parents consistently cite their child’s physician as the most trusted source of information about vaccinations.¹² No other group is likely as well positioned as pediatric clinicians to address rising parental hesitancy about routine childhood vaccines¹³ or support present and future COVID-19 vaccination efforts for children.¹² However, alternative settings can be particularly useful for reaching hard-to-reach children and adolescents, especially the now vaccine-delayed age groups identified in this study. Health care systems could develop and implement interventions to support vaccination coverage in schools, childcare centers, and other settings with regular contact with children. School-based vaccinations are used to administer a broad range of vaccinations in other countries, and, in the US, such programs have been effective in vaccinating large numbers of children and adolescents during various vaccine-preventable disease outbreaks.¹⁴ To encourage health care system collaboration and promote vaccination efforts in these alternative settings, financial incentives from insurers to primary care practices could encourage the outcome of vaccination without requiring the setting to be the primary care practice.

Finally, policy changes to expand vaccination requirements may help close gaps that have emerged during the COVID-19 pandemic. Legal requirements for vaccination can be an effective and powerful tool if implemented with attention to detail and with regard to the context. Requiring vaccination for certain populations in the US dates to the Revolutionary War, with a long history of legal support for mandates in various settings. There is strong evidence that mandates support and maintain high immunization coverage in K-12 schools, colleges and universities, and health care facilities.¹⁵ The majority of the population, including parents, support various forms of compulsory vaccinations.¹⁶ As trusted sources of health care advice, pediatricians can both advocate and guide support for vaccine mandates, sidestepping political and ideological considerations while instead focusing on the underlying evidence of effectiveness.

The COVID-19 pandemic’s lost care may have long-term consequences unless pediatric health care systems and child health advocates are proactive in engaging families to take advantage of every opportunity to catch up. Health care system changes, such as reminding and offering vaccination in a variety of settings, and policy changes, such as vaccine mandates, will be essential in providing the impetus for families to re-engage with care and achieve timely and complete vaccination of children and adolescents.

Corresponding Author: Brian P. Jenssen, MD, MSHP, 2716 South St, 10-322, Philadelphia, PA 19146 (jenssenb@chop.edu).

Published Online: October 7, 2021. doi:10.1001/jamapediatrics.2021.4248

Conflict of Interest Disclosures: Dr Fiks is co-inventor of Care Assistant software, which has a module that supports immunization; reports that their research team received a grant from New Jersey’s Manufacturers Insurance for work unrelated to this manuscript; and honorarium and travel expenses from Prime outside the submitted work. No other disclosures were reported.