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The coronavirus crisis is leading to an immunization crisis

If you’d asked me when our baby was born in November how likely it was that I’d decide to delay his vaccinations against the doctor’s recommendations for several months, I’d have told you there was absolutely no chance.

I report on global health; I know that the diseases vaccination has virtually eradicated in the US still take the lives of far too many children internationally. I know that those diseases can come roaring back in any community where vaccination rates dip. I know that some parents in impoverished parts of the world walk for days on foot in the hope of getting their children vaccinated, and I’m grateful to live in a country where — until a few months ago — I could take access to vaccines for granted.

Our older child, now 3 years old, was vaccinated on schedule. That will not be the case for our second child, born last November.

He got his four-month vaccinations two months late, and we’re not sure when he’ll get his next ones. And we’re not unique. Across the United States, there’s been a huge drop-off in vaccinations as coronavirus social distancing measures make people reluctant to leave the house and visit the doctor. Around the world, critical public health and vaccination programs have been canceled amid the pandemic.

That sets us up for a potential public health disaster down the road. As the immunized share of the population drops, contagious and deadly childhood diseases — many of them already experiencing a resurgence because of anti-vaxxers — could come right back, killing children and adults alike. We’ve lived a long time free from the fear of deadly infectious diseases, and vaccination is a big part of the reason why. But the coronavirus has derailed that progress, and even if a treatment or vaccine for the coronavirus itself is eventually developed, it may take a long time to undo all the complex damage it has done.

In our case, our baby eventually got his shots, albeit several months late. But it was a nerve-wracking ordeal. We live in a house with 10 people, several of them at elevated risk from the coronavirus. The doctor’s office required us to come into the central hospital instead of opening outpatient clinics or making home visits. Our insurance refused to cover getting the shots anywhere else. We felt adrift, without enough information to compare the risks we were being asked to take: How bad was it to delay the baby’s shots? How dangerous was it to go to the hospital? The doctor’s assurances that it would be safe to show up didn’t fully satisfy us — we understood that the risk was low, but our home situation made even low levels of risk a serious concern for us.

Ultimately, it went fine. My partner wore a mask, took the baby into the hospital, got him his shots, and came home. The hospital screened them at the entrance for coronavirus symptoms; everyone was wearing masks; the hallways were deserted. Neither my partner nor the baby got sick.

We’ll have to do this again in a few months; maybe by then the hospital will be set up for something lower-exposure, or maybe we’ll again take our chances. But it doesn’t have to be that way, and there are ideas out there — from support for home visits by doctors to drive-through clinics — that can help make sure that every family can keep up on vaccinations during a disaster.

A fall in vaccinations is well underway — and it might be disastrous

Once you’ve caught a disease, you usually cannot catch it again for a while because your body remembers how to fight it off. Vaccinations try to induce this immune response without getting you sick in the first place. The most common approach is introducing dead or weakened viruses, or key parts of bacteria, to your system. Your immune system will learn how to fight them off, but there’s little risk of getting sick.

In the US, children are vaccinated against hepatitis B, whooping cough, rotavirus, diphtheria, tetanus, measles, polio, and chickenpox, among other diseases. Researchers have estimated that for every year that children receive all of the recommended childhood immunizations, some 20 million illnesses and 40,000 deaths are prevented.

Vaccinations are, put simply, one of the most transformative technologies in human history. In the 1800s, historians estimate that more than a third (and in many places, more like half) of children died before they turned 5. Infectious diseases were the leading killer. Smallpox alone killed hundreds of millions; with a massive worldwide vaccination program, we were able to eradicate it.

Vaccinations have plummeted during the coronavirus crisis, both here and abroad. A May 15 study with authors from the Centers for Disease Control and Prevention (CDC) used order data from the federal Vaccines for Children Program to track exactly how much they declined. As this chart from their study shows, the answer is that they declined very sharply, right around the time of many state shutdowns in mid-March:

Change in dose orders for routine pediatric vaccinations.
CDC

Internationally, too, the pandemic has disrupted vaccination programs. The World Health Organization estimates that more than 100 million children worldwide could be vulnerable to measles as mass vaccination programs have been disrupted. At least 24 countries have paused or postponed their mass immunization programs.

The declines set us up for a public health crisis. If there’s a significant population of unvaccinated children, highly transmissible diseases like measles (which has a so-called R0 estimated between 12 and 18, meaning the average sick person infects 12 to 18 more people) can spread easily.

The arrival of the coronavirus exacerbates a problem that has grown in recent years. Already, vaccination rates have been declining as misinformation about vaccine risks has led many parents to opt out of immunizing their children. The anti-vaxx movement, bolstered by misinformation and social media, has convinced more and more families to delay vaccinations, leading to disease outbreaks in communities that had previously eliminated the disease. The plummet in vaccinations due to the pandemic will make the problem far worse — especially if many of those children never catch up.

Over the last several months as the pandemic’s effects hit the US in earnest, many doctor’s offices were focused only on shots for newborns, assuming that pushing off boosters for older children wouldn’t be a big deal. But as it is becoming apparent that normalcy might be a year or more away, they’re being forced to rethink that. The CDC study found that declines in vaccination rates were much higher for vaccines for older children, likely because of the focus on younger children. But while most vaccines for older kids can be put off a few months, they can’t be put off indefinitely without risking widespread infectious disease outbreaks as social distancing lessens.

“US children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” the study concludes.

To vaccinate children in a pandemic, we need a more flexible health system

What can be done to make sure children get the vaccinations they need during the pandemic?

“Parental concerns about potentially exposing their children to COVID-19 during well-child visits might contribute to the declines observed,” the May 15 study argues. “To the extent that this is the case, reminding parents of the vital need to protect their children against serious vaccine-preventable diseases, even as the COVID-19 pandemic continues, is critical.”

My experience with trying to get our baby vaccinated suggests that the problem is less that parents don’t understand the vital need to protect their children and more that they need options during a pandemic crisis. In our case, we needed to bring our child in for his four-month wellness check, but we had a few questions for the doctor: Could we go into a clinic instead of to the central hospital campus, a complex of buildings that would also be treating our city’s coronavirus patients? Could a nurse come and meet us at our car and give the baby his shots through the car window, without us carrying him into the hospital? What about a home visit?

Every time, the answer was no — the hospital hadn’t set up procedures for such alternatives. They said they might do so at some point, but in the meantime insisted the hospital was safe. But at that stage in the virus’s spread, and living with some at-risk roommates, we really didn’t feel comfortable with taking the risk.

We spent a while looking into our other options. Our insurance would only cover the baby’s vaccination at the hospital. We could find providers not covered by our insurance who’d be at least willing to vaccinate him in an outpatient clinic instead of at a hospital — for $500. In the end, we took him to the hospital, but I can’t blame parents who chose to stay at home, hoping that a safer solution would eventually present itself.

Many individual doctor’s offices are making heroic efforts — including drive-up vaccine clinics and home visits — to fill the gap. But many others aren’t, hamstrung by insurance rules or budget cuts (many pediatricians and their staff have been laid off as the coronavirus crisis makes doctor’s appointments rarer) or the rapidity with which the coronavirus situation and local laws have been changing in the past few months.

So that’s one area we can focus on: Pediatrician offices can offer home visits and drive-through vaccination clinics, and if they can’t afford to do that, the government should step in to get them the funding to make it possible. To be sure, home visits are expensive and can put doctors at risk themselves, and drive-through clinics aren’t a good replacement for a full wellness check under ordinary circumstances. But in extraordinary circumstances, more options mean more flexibility for families.

Also, perhaps more important, we could scale up testing so that when we have to take our baby back for his next round of shots we can be confident that the doctors seeing him get tested regularly for the coronavirus. We could also cover vaccinations for all kids regardless of their health insurance situation, recognizing that many people might need to use out-of-network providers to access vaccinations.

In developing countries, public health organizations face difficult choices between risking the spread of the coronavirus or guaranteeing millions of preventable child deaths. Better data on how the coronavirus spreads will help them identify low-risk ways to resume lifesaving operations.

Ultimately, of course, the way to solve these problems is to successfully address the coronavirus crisis — either with widespread testing, contact tracing, and isolation, as countries like South Korea and Taiwan have done, or with an effective treatment or vaccine, though such a solution is years away.

Regularly scheduled immunizations are too important, though, to wait for victory over the coronavirus. We should not be asking parents to figure out coronavirus risks themselves, or accept the risk of exposing their families to one disease for the sake of preventing others.

And even under ordinary circumstances, giving parents and doctors flexibility has major advantages. Home visits and drive-through clinics don’t just reduce coronavirus risk, they also help parents who don’t have child care, parents who can’t easily get off work for doctor’s appointments, and parents who don’t have a good way to get to the nearest doctor’s office. Covering vaccinations regardless of a child’s health insurance helps uninsured kids, of which there are millions.

Over and over, the coronavirus pandemic has laid bare the flaws in systems that were already a problem. Vaccination in the US was already under threat, putting us in a position where any further dips in vaccinations put us at great risk. It’s now more urgent than ever that we fix it.

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