Kids are behind on routine immunizations. Covid vaccine hesitancy isn’t helping.

That has pediatricians, school nurses and public health experts worried that preventable and possibly fatal childhood illnesses, once thought to be a thing of the past, could become more common.

“We just want to keep measles, polio, and all the things we vaccinate against out of the political arena,” said Hugo Scornik, a pediatrician and president of the Georgia Chapter of the American Academy of Pediatrics.

He was alarmed by the introduction of several bills in the state legislature in the last year to limit vaccinations, including one that would have ended immunization requirements in schools. Several states considered similar pieces of legislation that would have either removed or whittled away at school vaccination requirements, though none moved forward.

At the beginning of the pandemic, immunization rates for children plummeted. In 2020, the Centers for Disease Control and Prevention saw a 15 percent drop from pre-pandemic levels in states’ orders for Vaccines for Children, the federal program through which about half the children in the country are immunized. In 2021, order levels were about 7 percent lower than pre-pandemic levels, according to the CDC.

In Florida, where the surgeon general announced last month that healthy children may not benefit from Covid vaccines, 2-year-old routine rates for all immunizations in county-run facilities plummeted from 92.1 percent in 2019 to 79.3 percent in 2021.

In Tennessee, nearly 14 percent fewer vaccine doses were given to children under 2 in 2020 and 2021 than before the pandemic.

And in Idaho, the number of kids who received their first dose of the measles, mumps and rubella (MMR) vaccine by age 2 decreased from roughly 21,000 in 2018 and 2019 to 17,000 in 2021.

Immunization advocates say polarized attitudes toward the Covid-19 shot have made holding and promoting school-based immunization events harder as principals and school nurses navigate the fraught territory of building trust within their communities while encouraging vaccination. That’s making it more difficult for kids to get their shots even when their parents want them vaccinated.

Between 2010 and 2020, the last year for which national data is available, immunization rates in children under 3 for hepatitis B, polio, chickenpox and MMR hovered around 90 percent and were largely unchanged, while rates for the pneumonia and rotavirus vaccine increased significantly. Meanwhile, the percentage of children with no shots grew from 0.6 percent to 1 percent. The CDC is expected next week to release new data on national immunization rates for kindergartners in 2020-2021.

Parents who were hesitant to vaccinate their children before the pandemic have now been joined by people who think the government mishandled the crisis, see Covid-19 vaccine mandates as federal overreach, or are exposed to misinformation about childhood vaccinations, said Rupali Limaye, professor of International Health at the Johns Hopkins Bloomberg School of Public Health.

“You get a decline in trust towards your government, and people looking for other sources to inform their decision-making process,” she said. “So they go to social media, [where] misinformation is outpacing evidence-based information.”

Immunization advocates say it was easier to bat down spurious claims that drove pre-pandemic hesitancy, such as that vaccines cause autism. But it’s harder to push back against an argument about personal freedom from government mandates.

“I would have told you in April 2020 that that was going to actually be our moment to turn the anti-vaccine tide,” said Melissa Wervey Arnold, CEO of the Ohio Chapter of the American Academy of Pediatrics. “Unfortunately, instead, the freedom movement took over.”

Only about 45 percent of eligible children in the US have received at least one Covid-19 vaccine dose, according to the CDC.

“Parents are beginning to come in with those same questions they had with the Covid-19 vaccine,” said Nola Jean Ernest, a pediatrician in Enterprise, Ala., and president-elect of the Alabama Chapter of the American Academy of Pediatrics. “’Is it worth it? Do my kids need this vaccine?’ That is the hesitancy that is starting to blossom.”

So far, there hasn’t been a spike in preventable childhood illnesses, but public health experts fear it’s only a matter of time if they aren’t able to meaningfully boost immunization rates. In 2019, the US reported the most measles cases in 27 years, with outbreaks clustered in parts of New York and the Pacific Northwest with low vaccination rates.

Part of the challenge for public health experts looking to anticipate the next outbreak or find vulnerable communities is that the availability of up-to-date vaccination data varies greatly from state to state.

Heather Gagliano, operations and education director for the Idaho Immunization Coalition, said data lags make it difficult to prove the scale of the problem.

“In my years with immunizations, I have seen people who have always been concerned,” Gagliano said. “But it was really very few. I am concerned that it is becoming much more mainstream in that conversation where dis- and misinformation somehow is being accepted as the truth more so than it has before.”

Data on exemption requests — another window into how many families are choosing not to vaccinate their children — is also slow. But the information that exists shows a small but increasing number of families opting out of vaccination in some states.

In North Dakota, religious, moral and philosophical exemption requests increased from 3.6 percent during the 2019-2020 school year to 4.46 percent for the current school year.

In South Carolina, which only grants religious, not personal belief, exemptions, the number of exempt students has steadily increased over the last five years, from 1.2 percent in the 2017-2018 school year to 2 percent this year.

A spokesperson for South Carolina’s health department declined to comment specifically on the reasons for the shifting vaccination patterns, but said, “there are a lot of factors and trends involved.” But Amanda Santamaria, director of nursing services for Dorchester School District Two in Summerville, SC, and president of the South Carolina Association of School Nurses, believes parents are now scrutinizing vaccines in new ways.

“It’s made people look at vaccines in general for students and for children under a finer microscope,” Santamaria said.

Pediatric providers believe more information is circulating about how to circumvent vaccination requirements through exemptions, contributing to the lower-than-usual immunization rates.

“Before, it was very rare for a religious exemption,” said Kimberlee Wyche-Etheridge, senior vice president of health equity and diversity initiatives at the Association of State and Territorial Health Officials and a pediatrician in Nashville. “Now, there seems to be that option on the table.”

In places like Colorado, Louisiana, Mississippi and New York, state health officials and pediatricians say they aren’t seeing a noticeable difference in parents’ attitudes toward immunization or in their available data.

There’s always been a small group of parents that resists childhood vaccinations, but if doctors can get parents into the office and answer their questions, they can usually convince them to get their children immunized, said Eric France, a pediatrician and chief medical officer for the Colorado Department of Public Health and Environment.

But in many parts of the country, the pandemic has influenced parents’ views on vaccinations in ways that states shouldn’t ignore, warned Patsy Stinchfield, a pediatric nurse who practiced in infectious disease as a vaccine specialist at Children’s Minnesota, a non-profit pediatric hospital, and president-elect of the National Foundation for Infectious Diseases. In Minnesota, more than a third of 2-year-olds were not up to date with their vaccines in 2021.

“It’s worth all states, both in the private and public sectors, paying extreme close attention to it as well as extreme energy towards this problem, because it won’t just fix itself,” she said.

Once it became clear that kids were falling behind on vaccines, the CDC, as well as other national organizations like AAP, launched campaigns to encourage parents to catch up, said Georgina Peacock, acting director of the CDC Immunization Services Division.

During the pandemic, the CDC provided grants to community organizations across the country to improve Americans’ confidence in vaccines. The agency also hired and trained vaccine demand strategists, health equity officers, and adult immunization coordinators to help state health departments promote Covid-19 vaccines, and, increasingly, routine immunizations.

But immunization advocates are concerned that without more work to combat general vaccine hesitancy, the anti-vaccination movement will grow stronger.

Some vaccine proponents are finding it increasingly difficult to conduct outreach. Santamaria, in South Carolina, said her school district has promoted school-based vaccine clinics as a program offered by the district — rather than by individual schools — to shield principals and school nurses from anti vaccine backlash.

Erica Harp, lead nurse for Great Falls Public Schools in Great Falls, Montana, said she is cautious with her immunization advocacy these days.

“Vaccination used to be something that the school nurse was always advocating and speaking towards, and I hope we can continue to do that,” Harp said. “You’re always concerned about how you’re being perceived in the community … Our schools are not required to have school nurses. You’re always trying to make sure you’re protecting your job, almost.”

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