By Carol A. Kemper, MD, FACP
Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center
SOURCE: Seither R, Laury J, Mugerwa-Kasujja A, et al. Vaccination coverage with selected vaccines and exemption rates among children in kindergarten - United States, 2020-21 school year. MMWR Morb Mortal Wkly Rep 2022;71:561-568.
The COVID-19 pandemic caused disruption in healthcare delivery for everyone. Schools continue to struggle to meet the Healthy People 2030 Nationwide target of ≥ 95% coverage for measles, mumps, rubella (MMR) vaccination in kindergarteners, and COVID-19 did not help. Remarkably, the nationwide vaccine rate for children entering kindergarten in the 2020-2021 school year was decreased by only 1% for all vaccines compared with the previous year. Overall, 2.2% of kindergartners provided an exemption from at least one or more vaccines, but an additional number of children were not current on their vaccines and enrolled in either a formal or informal “grace period” or provisional period of “catch-up” or were lacking documentation of vaccine coverage. Hence, national coverage for MMR fell to 93.9% for the two-dose MMR vaccine, ranging from 78.9% in the District of Columbia to ≥ 98.9% in Mississippi. MMR coverage > 95% was reported for only 16 of 47 states plus the District of Columbia (33%), and fell below 90% in seven states and the District of Columbia. Varicella vaccine coverage was slightly lower at 93.6%, although 17 states reported ≥ 95% coverage with this vaccine.
The proportion of kindergarteners claiming exemption (2.2%) in the 2020-2021 school year was similar to the proportion in 2019-2020 (pre-COVID). Nationally, for the 2020-2021 school year, medical exemptions accounted for only 0.2% of the exemptions, while non-medical exemptions (religious or personal belief) constituted 1.9% of all exemptions, which was decreased from the previous school year in 37 states. However, the number of children assigned/enrolled into a formal or informal “grace period” or provisional enrollment pending vaccination increased in 18 of 28 states providing this information to 3.9%, ranging from 0.1% for Hawaii to 10% for Arkansas. In addition, there were a number of children simply not providing documentation. Overall, the number of children out of compliance with regulations increased from 0.2% in Florida to a maximum of 16.6% in Indiana. The authors noted that if all non-exempt children lacking documentation/enrolled in the grace period could get vaccinated, all but two states would reach the ≥ 95% MMR goal.
Not only did COVID-19 disrupt access to medical care during the 2020-2021 school year, but many states had relaxed vaccine requirements for remote learners, parents were not required to provide vaccine documentation to schools, and there was less time for school staff to collect and document vaccinations. Ultimately, documentation of vaccine status became a lower priority for many school staff and school nurses, who were short staffed and challenged with tracking COVID-19 cases.
Now that kids are back in school, it is imperative for schools to demand appropriate vaccination of kids in a timely fashion to prevent disease outbreaks in their community. Unlike COVID-19 vaccination, where breakthrough infections are common, some childhood vaccines are necessary for disease prevention, such as polio, which has just re-appeared in an unvaccinated individual in New York. Further, pockets of unvaccinated children have been directly linked to increases in pertussis and measles in communities. For example, when California experienced a gradual decrease in vaccine rates in 2000-2010, especially in more affluent areas, the result was the largest outbreak of whooping cough in California in seven decades, stretching from 2010 to 2014. In 2014, the California Department of Public Health reported a peak number of 11,203 cases of pertussis, 456 of which required hospitalization (26% in intensive care); 278 cases were small infants younger than 4 months of age, three of whom died. This outbreak of pertussis in California communities — or perhaps just the mere fact of keeping exposed children out of school for 25 days on home isolation — went a long way to changing many parents’ minds in our area. Suddenly, pertussis was a real disease, not just something you read about. In addition, the California legislature decided to remove the personal exemption clause for childhood vaccination in 2015, applicable to the 2016 school year, although anti-vaccine activists have railed against this change. As a result, reported cases of pertussis in California fell to 700 cases in 2020 and only 193 cases in 2021; the last pertussis death in a child 4 years of age or younger occurred in California in 2019.
It is important to remind parents that vaccination not only protects their child, it is for the good of the community — it protects all of us, especially the weak, the very young, and the elderly.
The COVID-19 pandemic caused disruption in healthcare delivery for everyone. Schools continue to struggle to meet the Healthy People 2030 Nationwide target of ≥ 95% coverage for measles, mumps, rubella (MMR) vaccination in kindergarteners, and COVID-19 did not help. Remarkably, the nationwide vaccine rate for children entering kindergarten in the 2020-2021 school year was decreased by only 1% for all vaccines compared with the previous year.
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