Pandemic fueled confusion, decline in routine pediatric vaccinations

Two studies published last year in Clinical Pediatrics described how COVID-19 lockdowns led to a lack of routine vaccinations for infants and young children early in the pandemic.

The AAP expressed concern about this issue early on, and researchers found that vaccinations “decreased dramatically” in the first 8 months of 2020 compared with the same period in 2019.

In the first new study, clinicians at Einstein Medical Center in Philadelphia described the early lockdown’s effects on their practices in a low-income community in North Philadelphia and a network of seven affiliated pediatric community practices in Northeast Philadelphia and the surrounding suburbs.

“After the city’s stay-at-home order was issued on March 17, 2020, the practices limited in-person well-child visits,” they wrote. “At the academic practice, in-person well visits were limited to infants aged 15 months or younger starting on March 23, expanded to children aged younger than 10 years on April 27, and to children of all ages on May 3. However, the number of clinicians available to conduct well visits did not return to full capacity until June 1.”

In a cohort of 1,093 children of varied backgrounds, they found that DTaP third doses and first doses of the MMR vaccine series declined from February to April 2021, from 59.3% to 41.5% for DTaP and 55.6% to 33% for MMR. Whereas rates of DTaP vaccination began to rebound in May and reached a peak in September, MMR vaccinations sustained an even bigger drop to in May, rebounding in August and peaking in October.

Additionally, the authors found that more than two-thirds of the cohort were on Medicaid, and that those using private insurance were more likely to complete their vaccination series.

“From mid-March to mid-April 2020, the Vaccine for Children program received orders for 2.5 million fewer doses of routine vaccines and 250,000 fewer doses of measles vaccine, compared with the same period in 2019,” they wrote.

In the second study, researchers at Children’s National Hospital and George Washington University in Washington, D.C., discussed their own experiences with early lockdowns.

“In our academic outpatient centers, monthly average of in-person visits, sick and preventive, dropped by almost half between March and August 2020 compared with the prior 6 months,” they wrote. “In addition to the health risks innately imposed by COVID-19 infection, the decline in preventive visits put infants at additional risk of vaccine-preventable infections, missed identification of delayed development, and decreased ability to foster family-child mental health, all of which are mainstays of preventive care.”

In a retrospective review of electronic medical records during that period, they found that the most common barrier to receiving vaccinations was concern about being exposed to COVID-19 and “the belief that avoiding preventive visits was required by the stay-at-home order.”

“Among those who used public transportation (metro or bus), there was a statistically significantly increased concern of exposure to COVID-19 during travel (83.3% vs. 33.3%, P = .006), although the number of participants was small (n = 12),” they wrote. “An additional concern cited was difficulty obtaining child care for other children at home because hospital/clinic policy encouraged visits with only the patient and one adult, in compliance with COVID-19 guidelines. Parents also reported forgetting about the appointment or having same-day scheduling constraints. Insurance lapses or switching providers were not frequently identified as barriers.”

Some parents also believed a misconception that only emergency services were available during lockdown, not preventive services, whereas others said they could not arrange child care for their other children.

The researchers concluded that communication should be more highly considered due to confusion and mixed messaging that led to the lack of follow-up vaccinations during that period.

“Throughout the pandemic, policies at our institution emphasized and encouraged in-person well-child visits at 2, 4, 6, and 12 months but deprioritized in-person visits for other ages,” they wrote. “This caused confusion, especially when older siblings were limited to telehealth preventive visits. Improved communication between parents, especially members of a higher risk community, and the providers of medical services is important to improve compliance with well visits at critical ages. Further studies should examine who parents trust for communication about their child’s preventive health care because the American Academy of Pediatrics, local health departments, the general health system, and nonclinical staff all provided information.”

References:

Abuali M, et al. Clin Pediatr. 2022;doi: 10.1177/00099228211044840.

Weisz J, et al. Clin Pediatr. 2021;doi:10.1177/00099228211050476.