Like many parents, Karina Cooksey was looking forward to sending her 8-year-old son Simon back to school this fall. Now she’s wondering if he’ll have to attend third grade at home in Plain City, Utah, after all. Because Simon has a genetic disease that destroys his immune system, she’s less worried about him getting COVID-19. She’s more terrified he’ll be exposed to measles.
Children across the country have fallen behind schedule for critical immunizations, such as measles, while they were quarantined at home, according to recent reports from the U.S. Centers for Disease Control and Prevention. Global vaccination efforts also have suffered devastating setbacks. A report released last month co-authored by the World Health Organization shows that “moderate-to-severe disruptions” or a total suspension of vaccination services in 68 countries have affected 80 million children under the age of one.
Now, as states decide whether to open up daycare centers and schools this fall, parents like Cooksey are weighing whether unvaccinated children pose a risk to children like her son with weakened immune systems. This drop in vaccination rates poses a threat not only to immuno-compromised kids, but also to people—regardless of age—who have been previously vaccinated because some immunizations wane over time.
“I’m highly concerned about kids not getting their shots,” Cooksey says. “When most of the population gets vaccinated, we achieve herd immunity for vulnerable people.”
School officials nationwide are preparing to help parents stay on track with their children’s vaccinations or quickly get caught up on missed doses, especially in areas hit hard by COVID-19, such as Boston, Detroit, and Los Angeles.
“Thanks to the help from local and state health departments, we are taking steps to help ensure that all students are up to date by the start of the school year,” Chrystal Wilson, assistant superintendent for the Detroit Public Schools Community District, wrote in an email to National Geographic. “A draft school reopening plan was just released for feedback from staff and families. As those plans are being finalized, the health of our students and staff will be a priority. This includes ensuring that students are protected against vaccine-preventable diseases.”
This urgency stems from thousands of children in the U.S. having weakened immune systems, which means their health depends on “herd” or “community immunity.” One nationwide survey from the CDC estimated 4.2 million kids under the age of 18 are immunosuppressed. Simon has a rare condition known as X-linked hyper IgM syndrome, which prevents his body from producing antibodies against infectious disease. As a result, he can’t receive the attenuated viruses that make up the MMR vaccine, which protects against measles, mumps, and rubella. If people around him are not vaccinated, Simon is left exposed.
The Cooksey family has good reason to be worried about diseases like the measles. In 2019, there were 1,282 measles cases in 31 states, the highest U.S. tally in 27 years. To bring the resurgence under control, a growing number of states have passed laws in the last year to tighten vaccination requirements for schools and daycare centers by removing exemptions for personal and religious beliefs.
Then the novel coronavirus hit.
“It was a perfect storm,” says Sally Goza, a pediatrician in Fayetteville, Georgia, and president of the American Academy of Pediatrics. “Parents were told to stay home and were scared to take their kids to the doctor. There was a real precipitous drop in visits. It’s a national issue.”
According to Goza, pediatricians typically see fewer sick children in springtime, as flu and cold season recedes. That suggests the majority of the skipped visits were most likely “well child” checkups, during which kids routinely receive immunizations in preparation for summer camps and school. In New York City, the U.S. epicenter of COVID-19, vaccinations plummeted 63 percent—and 91 percent for kids over two—from March 23 to May 9, compared to the same time last year.
Last month, the CDC released data looking at the impact of COVID-19 on national pediatric vaccination trends and found that orders of all publicly purchased non-flu vaccines—including hepatitis, meningitis, polio, and rotavirus—were sharply down in April.
Doses of the MMR shot in eight U.S. health care organizations serving public and privately insured patients dropped to less than a quarter of the usual amount among children over 2 years after President Donald Trump declared a national emergency over COVID-19 on March 13. The drop was smaller in younger children, but a separate case study in Michigan found that 50 percent of children under 5 months had kept up with their immunizations, compared to 68 percent in non-pandemic times.
“We focused on children under two because they are vulnerable and these are milestone ages where they get shots to protect them against vaccine-preventable diseases,” says Angela Shen, co-author of the Michigan study and a research scientist at Children’s Hospital of Philadelphia. “Once the kids fall off their schedule, it’s really hard to catch up.”
For example, to be protected from pertussis, commonly known as whooping cough, the CDC recommends babies receive a vaccine dose at two, four, six, and 15 months. “The reason we’re concerned is that they likely missed or will miss a number of shots,” Shen says. Likewise, kids receive two MMR vaccine doses, one as a toddler and one just before kindergarten. Measles, when left uncontrolled, can cause pneumonia, swelling of the brain, brain damage, blindness, or hearing loss. In 2018, there were 140,000 measles deaths globally of mostly young children.
Everyone has a stake in maintaining community immunity, says Mark Sawyer of Rady Children’s Hospital-San Diego. No vaccine is 100 percent effective—it’s 97 percent for two measles shots, but just 93 percent for one. That means even children with conscientious parents and some adults shouldn’t take immunity for granted.
“Every year there’s always a subset of immunized people who will get sick,” Sawyer says. “That’s why we need a certain level of population immunity to keep us protected.”
Medical professionals and school officials are particularly nervous about whether children will be up to date by the time schools reopen. To reach herd immunity for measles, for example, more than 90 percent of the population must be vaccinated.
“We can’t get below that,” says pediatrician Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia. “Some immuno-compromised kids depend on those around them. If we live in a society, we have an obligation to them.”
In Los Angeles, approximately 85,000 kindergarteners, seventh-grade students, and new enrollees receive vaccinations each year prior to admittance, and the school district plans to keep these state-mandated requirements. The Los Angeles Unified School District said all students will need to have these required vaccinations if school facilities reopen in the fall. The district plans to coordinate with medical services and healthcare providers to ensure access to vaccinations doesn’t dip because of California’s “safer-at-home” orders.
School administrators in Detroit—Michigan’s COVID-19 epicenter—are working on a similar approach. They plan to use a state registry to flag students who are out of compliance.
“During the summer months we will also be hosting immunization drives that will be coordinated with our enrollment fairs,” says Wilson of Detroit Public Schools. “Many of our schools also have school-based health centers that provide immunizations. … This will allow families that have trouble accessing a health provider, whether for insurance or other reasons, to take advantage of the services offered.”
Boston, meanwhile, has dealt with numerous COVID-19 cases, but it has not yet seen a drop in student vaccination rates, according to a statement from Boston Public Schools: “We plan to continue adhering to the current Massachusetts law that prevents students from attending school without all of the mandated immunizations, aside from a few exemptions.”
Kimbrelle Lewis, principal of the Cordova Elementary Optional School in Tennessee and president-elect of the National Association of Elementary School Principals, says that the unusual circumstances of the pandemic might be grounds for a grace period—as long as parents can prove they’re trying to get caught up with their children’s shots.
“We want to follow state guidelines for immunization requirements, but we also understand there are times when there are exceptions,” says Lewis, adding that many school districts allow for extensions for extenuating circumstances.
Getting caught up
Globally, vaccination rates are declining for a variety of reasons, according to the report compiled by the WHO; UNICEF: and Gavi, the Vaccine Alliance. That includes overwhelmed health care systems and supply bottlenecks, as well as patients under lockdown who are afraid of going outside, says UNICEF immunization chief Robin Nandy. Healthcare workers are also worried about delivering immunization en masse without adequate personal protective equipment.
“The longer the disruption lasts, we’re facing a greater risk of outbreaks,” he says. “For some countries it could be a double whammy. They could have an outbreak of measles at the same time they’re trying to recover from COVID-19. That’s our major concern now.”
Global agencies are asking countries to weigh the risks of resuming vaccination campaigns. Some places may need to wait until COVID-19 cases begin to subside, but Nandy hopes they will then respond with intensified efforts to “find those children who are unvaccinated and get them vaccinated.”
Pediatricians are working to send patients the message that it’s safe to come back to their offices. They’re separating sick and well children into different areas or asking families to wait in their cars until doctors are ready to see them. Last month, the American Academy of Pediatrics launched a social media campaign dubbed “Call Your Pediatrician” for doctors, and it has a consumer version in the works.
Some pediatricians, including Karen Burgess at the University of Alabama College of Community Health Sciences in Tuscaloosa have been using the downtime to comb through medical records and call parents to let them know when their children are due to come in.
“I wanted to communicate the message,” Burgess says, “that the last thing we want to deal with right now is other serious illnesses that otherwise could have been prevented if we’d stayed on top of vaccines.”