Q&A: Kindergarten vaccination rates continue to decline; exemptions exceed 3% nationally
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Key takeaways:
- DTaP and MMR coverage dipped below 93% during the 2023-2024 school year.
- Fourteen states reported exemption rates above 5%.
Vaccination coverage among kindergarteners in the United States is still declining from pre-pandemic levels, and some states are reporting exemption rates of more than 5%, according to the latest CDC data.
Routine vaccination rates have been decreasing since the COVID-19 pandemic, dipping below 93% this year for the DTaP and the MMR vaccines.
The CDC reported that DTaP coverage dropped from 92.7% during the 2022-2023 school year to 92.3% during the 2023-2024 school year, and MMR coverage fell from 93.1% last year to 92.7% this year.
Forty states and Washington, D.C., reported increases in exemptions, the CDC reported. The proportion of kindergarteners getting exemptions for at least one vaccine rose from 3% last year to 3.3% this year, and 14 states reported exemption rates above 5%.
Healio spoke with Paul A. Offit, MD, director of the vaccine education center and attending physician in the division of infectious diseases at Children’s Hospital of Philadelphia, about why routine vaccination rates are continuing decline and whether they will improve in the future. Also, read to the end to see what Peter J. Hotez, MD, PhD, FASTMH, FAAP, from Baylor College of Medicine, has to say about the CDC’s findings.
Healio: Why has routine vaccination coverage declined since the COVID-19 pandemic?
Offit: If you asked me at the beginning of the pandemic how I thought vaccines would be viewed, I would have imagined they would be viewed as a hero. I mean, in 2020 we had nothing. There was a virus that entered this country in early 2020 that started killing people, hundreds of people a day, and then eventually thousands of people a day, and we did not have vaccines for a year. All we had was to try to avoid human contact. We shut down businesses, we closed schools, we restricted travel and it was a nightmare.
When the vaccines came, I could not wait to get vaccinated! I honestly think it was one of the greatest medical or scientific achievements in my lifetime. I thought this was remarkable, and I imagined America would see it as remarkable, because finally, we had a way to protect ourselves.
But, in our attempts to make sure everybody was protected, we mandated vaccines so you could not go to your favorite bar, restaurant, place of worship or sporting event unless you had your vaccine card, and I think that rubbed a certain percentage of the population the wrong way. By July of 2021, we vaccinated 70% of the U.S. population, and we then hit a wall; 30% of people simply refused to be vaccinated. I think vaccines became sort of a dirty word to some. They associated the word vaccines with vaccine mandates, and they felt that that was an example of a government overreach at a time when there was an enormous effort to back away from the federal government.
Healio: Routine vaccination coverage has been dropping each year since 2020. What do you think would cause coverage to increase again?
Offit: I see two possibilities. The first is education. We get out there and explain that vaccine-preventable diseases can cause a lot of suffering, hospitalization, permanent disabilities and death. I do not think that is likely to be it, though.
I think the more likely scenario is that people will be compelled by these diseases again. It is starting to happen already. We have seen an increase in pertussis cases this year. We have had 200 children die of influenza — that is very high for influenza. Just over the past year, we had a fourfold increase in the number of cases of measles — from 50 last year to 200 this year. If we get to 1,000 cases, we may start to see children once again dying of measles in this country.
We have not just largely eliminated measles. We have eliminated the memory of measles. People do not remember how sick that virus can make you. They think of it as just another viral rash, but it's not that. Half of people with measles will have abnormal chest X rays.
It is the most vulnerable among us who suffer our ignorance, and children are the most vulnerable.
Healio: As vaccination rates drop, exemption rates are continuing to rise. What needs to be done at a policy level to address this?
Offit: School mandates are critical. If we eliminate school mandates, you will see some of these diseases come roaring back because they're transmitted in schools. Mandating vaccines is not a federal issue; it is a state issue.
California is a good example. California had a huge whooping cough outbreak years ago, 2010 or so. Then, in 2014, a measles outbreak occurred at Disneyland, and it spread to other states. At the time, California had only a philosophical exemption. They didn't have religious exemption, so people chose that philosophical exemption. Richard Pan, MD, who was a state senator at the time, set it upon himself to eliminate the philosophical exemption, and he did so in 2015. Then California only had a medical exemption, and with that, immunization rates went up. The only way out of that is to either homeschool your child, which is financially and emotionally burdensome, or to get a doctor to sign a false medical exemption, which, sadly, several doctors were willing to do. But that can cause an increase in immunization.
Interestingly, Mississippi and West Virginia did not have philosophical or religious exemptions, and they had the highest vaccination rates in the United States, even though those are not states known for their public health achievements. If you take away the option, people will get vaccinated. But that does not sit well in this country. Mississippi recently introduced a religious exemption, and suddenly, 2,000 parents decided to exempt their children from vaccination.
Healio: What can pediatricians do in their own practice to improve vaccination coverage?
Offit: I am not a private pediatrician. I work in a hospital, so I don't see these patients as outpatients. But my wife is a private pediatrician, so I watched her go through this. She says what works better for her is to lay it on the line.
She says, “Do not put me in a position where I am going to watch this child walk out of this office not having received one or more vaccines, knowing that there are diseases out there like measles, influenza, whooping cough, pneumococcus or Haemophilus Influenzae type b, knowing that those viruses and bacteria can cause suffering and permanent harm and death. Please do not put me in that position. Please let me love your child.”
I think it is hard for pediatricians to be confrontational, to be emotional, but you are the child's advocate, so be a passionate advocate.
For more information:
Paul A. Offit, MD, can be reached at offit@chop.edu.
References:
- CDC. Measles cases and outbreaks. https://www.cdc.gov/measles/data-research/index.html. Updated Oct. 11, 2024. Accessed Oct. 11, 2024.
- CDC. Pediatric flu deaths reach 200 for the 2023-2024 flu season. https://www.cdc.gov/flu/whats-new/2023-2024-pediatric-deaths-200.html. Published Sept. 27, 2024. Accessed Oct. 11, 2024.
- CDC. Vaccination coverage and exemptions among kindergarteners. https://www.cdc.gov/schoolvaxview/data/index.html?ldkjfdl. Updated Oct. 2, 2024. Accessed Oct. 11, 2024.
- Mississippi Today. State approved 1,800 religious exemptions for schoolchildren as of September. https://mississippitoday.org/2023/10/05/religious-vaccine-exemptions-september/. Published Oct. 5, 2023. Accessed Oct. 11, 2024.
- Senate Bill (SB277) – Public health: Vaccinations. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB277. Published June 30, 2015. Accessed Oct. 11, 2024.
- Winter K, et al. MMWR. 2014;doi: 63(48);1129-1132.
Perspective
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Peter Hotez, MD, PhD, FASTMH, FAAP
I believe these trends reflect a tragic reality that the anti-vaccine activism accelerating during the COVID-19 pandemic (with widespread COVID-19 vaccine refusals) is now spilling over to childhood immunizations. We are seeing similar political and partisan effects between COVID-19 and childhood immunizations, especially in Southern states and elsewhere. If these trends continue, I worry about the U.S. losing its measles elimination status, and, even worse, possibly seeing the return of polio and other conditions. We need to mount a full-on campaign and redouble our efforts for childhood immunizations, educate state legislatures on the critical importance of immunization practices and better support our nation’s pediatricians and pediatric nurse practitioners. I also believe we need improved tools to convey health risks given that today a high percentage of American parents believe the myth that vaccines are less safe than the diseases they are designed to prevent.
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