Harborview Medical Center pediatrician Dr. Beth Dawson-Hahn has become accustomed to diagnosing children over Zoom. Sometimes, a child’s checkup is limited to a short telehealth call with parents.
As a result, lots of boxes have gone unchecked, especially at the peak of the pandemic — routine vaccines against common illnesses such as chickenpox, but also shots to prevent more serious viral infections, like measles, mumps and rubella. Unless parents were willing to bring their kids in for a visit, many went without the vaccines.
Now, public health officials and clinicians are scrambling to catch up. The number of vaccines given to kids 18 and under in Washington has dropped by hundreds of thousands, compared to prepandemic levels, new state and federal data show. In April 2020, there was a decrease of 70% to 80% in doses administered to children 4-17 compared with the average from the past five years.
And this coming school year, families are required to provide a copy of medically verified immunization records — or a valid exemption — for their children to attend school.
If they don’t have the records by the first day of school, they can’t attend in person.
“The data from Washington state mirror the data that we’re seeing nationally, which is routine vaccinations are down in all age groups and for pretty much every vaccine — except, obviously, COVID,” said Dr. Dimitri Christakis, a pediatrician and director of the Center for Child Health, Behavior and Development at Seattle Children’s. “It’s a problem, it needs to be rectified, and it’s one more way in which children have been an afterthought.”
The new state rules technically kicked in last year. But because school buildings were largely closed then, this year will be the first that schools will require medically verified immunization records or a special exemption — and can exclude kids from school if they don’t have the proper records showing a lengthy list of vaccines: chickenpox, polio, hepatitis B, the combined tetanus, diphtheria, pertussis vaccine, and the combined measles, mumps and rubella shot.
Most children receive the mandated vaccines before they reach school age, but some vaccines require boosters as children grow. Students don’t have to get a COVID-19 vaccine — it’s only authorized on an emergency basis and hasn’t received full approval from the U.S. Food and Drug Administration. But adolescents and teens who are eligible can now get that shot and other routine vaccines at the same time — a change from earlier CDC recommendations that the COVID-19 vaccine be administered alone.
According to the new data, vaccinations remained far below average in every age group until the last few months. In December, the number of vaccines administered to kids ages 11 and 12 — when children tend to get immunized for meningitis and human papillomavirus, and get a tetanus booster shot — leapt above statewide averages , and have stayed above average in the months since.
In general, pediatric vaccine distribution tends to peak in August as families race to get appointments before school starts. In an average year in August, Washington providers administer about 250,000 pediatric vaccines. But in August 2020, vaccines fell to about 175,000.
Officials didn’t provide regional or city-specific data, but it’s possible that the overall decline is spread unevenly across the state.
In Seattle, the pandemic hardly made a dent in vaccine compliance: Seattle Public School officials say about 97% of the district’s students are up to date on their vaccinations as of June 6. A little more than 1,000 students aren’t in compliance, far fewer than just two years ago, when more than 7,000 students were out-of-date before the start of school.
Districtwide, out of the 1,000 or so students who are out of compliance, about 212 attend "tier 1" schools, which is a school-district equity rating for schools where there may be more underserved students of color, students who are unhoused or those who are immigrants or English learners.
The district’s data shows that, in general, tier 1 schools have lower vaccine compliance. This is true even among a subset of schools with school-based health centers, where students can get vaccines for free.
But the district made a big push, especially at the end of this school year, to get students up to date, officials say. At Seattle World School, the city’s school with the lowest vaccine compliance, about 58% of students were in compliance on June 6 — but 69.5% were by June 20. School nurses and other health center staff called or emailed families directly, encouraged them to visit school health centers, ran vaccine clinics — and in some cases, traveled to students’ homes, workplaces or places of worship.
“All year we’ve been working on immunization compliance,” said Samara Hoag, manager for health services at SPS. “But at the end of the year, we sent out messages to the (school) nurses individually and as a group, (saying) ‘Keep pushing, keep pushing.’ ”
The new state vaccine requirement comes at the same time that schools are juggling safety logistics for another pandemic school year. Department of Health officials say students and teachers will still be required to wear masks, wash hands and stick to a host of other health and safety protocols when they come back to school in the fall — guidance that could change if the federal Centers for Disease Control and Prevention adjusts national guidelines.
State health department officials say they’re reminding school districts about the new vaccine policy now, in hopes that districts will have a long lead time to notify families whose records are out of date.
Officials say they’re also trying to get a handle on what factors, in addition to a mass migration to telehealth, explain the persistent lag in vaccination. For example, they’re investigating whether vaccine hesitancy tied to COVID-19 has spilled over to hesitancy to get other vaccines, like those required to attend school, said Lacy Fehrenbach, the deputy secretary of health for COVID-19 response at the state health department.
“We have been trying to do a bit of mapping to see, is there a correlation between communities in Washington with low childhood vaccination rates compared to what we’re seeing with COVID? That work is still underway,” she said.
Officials are also monitoring COVID-19 vaccine rates in children. As of June 22, about 17% of kids 12-15 were completely vaccinated; 33.9% of 16- and 17-year-olds were also completely vaccinated.
Dawson-Hahn, at Harborview, said families are more receptive to bringing their children in for routine vaccines now that COVID-19 vaccine rates are high, at least among adults, and infections are low.
“Now everyone is trying to do routine care they were holding off on, so I imagine in some clinics there is a delay [in getting an appointment],” she said. But, she added, “Most pediatric practices are trying to give vaccines somehow, knowing they are behind.”