In the early days of the COVID-19 pandemic, top American pediatricians could see another crisis looming: a swarm of mini-epidemics of childhood diseases returning as families withdrew from regular medical care, including vaccinations.
For months, many in the United States stayed home as scientists worked to understand how COVID-19 spread and who was most at risk of dangerous outcomes. Without much definitive information about the new virus, parents were scared their children might be exposed if they sat in clinic waiting areas or exam rooms. But pediatricians feared that outbreaks of preventable diseases would spiral out of control.
“We do not want to return to a time when parents had to worry their infant could die of meningitis – especially when we have a vaccine to prevent it,” Dr. Sally Goza, president of the American Academy of Pediatrics, said in a May 8 released statement. “The COVID-19 pandemic is giving all of us a real-time education in what this vulnerability feels like.”
The AAP urged parents to keep their appointments, and advised clinicians how to make those visits as safe as possible in guidelines they released in May. Months later, as schools reopen for virtual and in-person learning, some infectious disease experts and pediatricians say the United States is still playing catch up — with flu season on the way.
How we got here
On March 13, President Donald Trump declared COVID-19 a national emergency. Back then, the number of confirmed U.S. deaths still only numbered in the dozens (they number nearly 200,000 today). By May, the American Academy of Pediatrics was sounding the alarm that parents needed to keep their children’s vaccine schedules on track. Already by that month, vaccination rates for childhood diseases like measles had plummeted, the Centers for Disease Control and Prevention reported.
They knew this in part because the federal Vaccines for Children program, which provides half of the nation’s supply of doses for childhood vaccines, reported a drop in orders when compared to January through April a year earlier. During the first six weeks of New York state’s lockdown, pediatric health workers reported a 63-percent drop in child vaccination rates, then-New York City Public Health Commissioner Oxiris Barbot said in late May.
The CDC warned in its May 15 study that, “As social distancing requirements are relaxed, children who are not protected by vaccines will be more vulnerable to” preventable diseases. But by then, some states, such as Georgia, had already begun to reopen.
To ease families’ concerns about catching the coronavirus at their doctor’s office, the AAP urged caregivers to call their pediatricians to check on safety measures before going for a check-up, ask if there were blocks of time set aside for well visits versus sick visits, and if vaccinations and developmental screenings were available in an open-air outdoor setting, such as a parking lot.
In Richmond, Kentucky, pediatrician Alison Moncayo said vaccinations at her practice in the Appalachian foothills dropped off sharply at the beginning of COVID-19: “We had nobody coming in.” By late May, she said, the pace was picking up, but she remained concerned. During a normal, non-pandemic year, she diagnoses a handful of cases of pertussis, or whooping cough, an entirely vaccine-preventable childhood disease that is potentially fatal, particularly for infants. To contain the disease, Moncayo said pediatricians rely on parents to bring their children to be vaccinated on schedule.
“If everybody’s got less shots, it can get another toehold in the community, and these babies aren’t getting protected,” Moncayo said.
This fall, more than 50 million U.S. children are back in school, either virtually or in person, according to the National Center for Educational Statistics, but when it comes to health concerns, most attention has been on mitigating the spread of the coronavirus rather than more common but still serious threats.
The question of how to safely educate children during a pandemic without worsening already harmful disparities has plunged the country into a chasm of debate and consternation. When the AAP released recommendations on how to do so with proper social distancing, hygiene and face masks, those guidelines were based on communities having the ability to test, trace, isolate and ultimately box in the virus — a goal many areas haven’t met. Some public health officials say the Trump administration has not done enough to protect children, teachers and staff and to ensure that schools can open and stay open.
In a normal year, many schools require all children to be up to date on their vaccinations prior to in-person attendance. Noting the troubling lag in normal inoculations even through the summer, the federal government has made some accommodations to make vaccines more accessible and help kids catch up.
On Aug. 19, the Department of Health and Human Services said state-licensed pharmacists could administer childhood vaccines after taking at least 20 hours of training to learn how to properly inject children and identify signs of possible allergic reactions. The move was designed to improve “access to lifesaving vaccines for our children, as we seek to ensure immunization rates remain high during the COVID-19 pandemic,” Health Secretary Alex Azar said in a released statement.
Looking at the CDC data and observations by infectious disease experts, the U.S. remains off track, said Dr. William Schaffner, medical director of the National Foundation for Infectious Diseases. That’s despite months of campaigns to boost awareness and efforts to expand access to childhood vaccinations. He added that several of these vaccine-preventable diseases “used to be spread classically in a school-based environment.”
“We need to catch up and keep up with our immunizations,” Schaffner said.
Why lagging vaccinations are dangerous
For decades, measles haunted American households, infecting an estimated 500,000 people and resulting in 500 deaths each year. Then, in 1963, a vaccine became available to prevent its spread. By 2000, the U.S. declared that measles had been eliminated, meaning more than 12 months had passed since the last measles case was transmitted. But globally, it “remains a leading cause of vaccine-preventable infant mortality,” according to the CDC, leaving open the possibility of measles’ return to the U.S. among those who are not protected.
In September 2018, an unvaccinated child who had visited Israel returned home to New York City. Nine days later, the child developed a rash and was diagnosed with measles. In the months that followed, more than 20,000 people were found to be potentially exposed, including roughly 1,000 infants who were less than a year old.
By July 2019, 649 children were diagnosed with the disease, most of them located in Brooklyn, making up “the largest measles outbreak in the United States since 1992,” according to the New England Journal of Medicine. Most of the children who were infected were not vaccinated.
By September of that year, the city’s measles outbreak was declared over.
To get the number of cases to zero, city public health officials mapped out measles-mumps-rubella vaccinations by ZIP code and conducted more granular analysis by neighborhood to identify gaps in coverage and sources of potential outbreaks. Barbot also said they conducted more intensive outreach campaigns, focusing on religious and community leaders, to ease misgivings about getting children vaccinated. Overall, the 2018-2019 measles outbreak cost New York City $8.4 million.
Less than a year later, that sense of vulnerability was still palpable in the city that had since become ground zero for COVID-19. What particularly concerned Barbot, the city’s former health commissioner and a pediatrician by training, was the decrease in vaccinations and other routine checkups for children 2 years or younger.
The warnings about vaccines are critical to prevent compounding health crises amid a pandemic, but they’re not the only thing some children are missing out on right now. Those first years are critical to child development, and well-child visits are vital in picking up potential issues, such as speech patterns and cognitive abilities, that, when addressed early, can be more effectively managed or even successfully resolved.
“Those numbers have consequences above and beyond COVID, but especially during the time of COVID, we are concerned about the degree to which children are able to access on-going care,” Barbot told the PBS NewsHour.
In the middle of a pandemic that disproportionately hurts Black and brown communities and households with lower incomes and fewer resources to rebound, Dr. Irwin Redlener struggles with the indirect toll COVID-19 has already taken on children, with many “falling behind medically and educationally.”
We don’t have specific data on who is or isn’t getting vaccines and routine care, but if vulnerable children are missing their appointments, they tend to have fewer resources to make up for lost time, and as a result are more likely to endure worse outcomes.
In 1971, Redlener worked as a pediatrician at a federal community health center in Arkansas, in one of the poorest counties in the United States at the time, where he saw children struggle as they grew up in poverty. He “believed we would solve problems of child poverty,” and that he could be part of the solution. Later a co-founder of the Children’s Health Fund, as well as the National Center for Disaster Preparedness, he has devoted most of his life to helping kids.
“Here I am, literally half a century later, still struggling with these same issues,” Redlener said. “I will be gone before these problems are actually fixed. That troubles me greatly.”