Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN

Declining vaccination rates throughout the COVID-19 pandemic

During 2021, an estimated 25 million infants missed scheduled doses of routinely recommended childhood vaccines. These data represent 2 million more infants than those who missed doses in 2020 and 6 million more than in 2019. The World Health Organization (WHO) declared these findings as the most significant prolonged decrease in childhood immunizations in nearly 30 years.

 In a recent systematic review, findings from 21 of 26 eligible global studies demonstrated declining immunization rates in children and adolescents during the COVID-19 pandemic.

The Centers for Disease Control and Prevention (CDC) reported that data for the US vaccine coverage for the 2020-2021 school year was 94% for all required vaccines, one percentage point lower than the previous school year.

 In addition, responses to a 2022 cross-sectional online parent survey revealed that approximately one-third of parents reported that their child had missed at least 1 vaccination and more than 40% reported that their youngest child had missed a routine medical visit during the pandemic.

It is still unclear whether these reductions in the number of vaccines for infants, children, and adolescents are related to stay-at-home recommendations and mandates (including closures of schools and many child day care centers) during the early phases of the pandemic or are more closely aligned with parental vaccine hesitancy and/or refusal. As COVID-19 vaccines received emergency use authorization, first for adults followed by staged age recommendations that now include all children 6 months and older, pediatric care providers increasingly encountered individuals and communities whose vaccine stance ranged from hesitancy (delayed decision-making regarding vaccination) to refusal (deciding to decline 1 or more recommended vaccinations).

As COVID-19 restrictions are modified and/or removed, resulting in more in-person school and extracurricular activities, many children are presenting to pediatric primary care settings for their annual physical exams that were delayed during the pandemic. Providers must not only recommend age-appropriate vaccines at the present health care visit but also ensure systematic evaluation for catch-up opportunities for previously missed immunizations. The CDC provides helpful guidelines to customize a catch-up immunization schedule for children and adolescents who start routine immunization late or who are more than 1 month behind. These guidelines include recommendations such as determining appropriate intervals for catch-up vaccines, assessing for medical conditions, and reviewing contraindications and precautions.

Although scheduling challenges are the most common logistical barrier precluding timely vaccination, other less tangible psychosocial barriers are emerging and being amplified. Misperceptions about vaccine safety are thriving among promulgations of unscientific theories and the rapid spread of information that is not credible, most often on social media websites. In addition, parents are raising concerns about a crowded vaccination schedule in which they feel their child is receiving too many vaccines at any one time and/or over a brief time. Many parents are requesting custom, alternative schedules that are not evidence-based, often after reading emotionally charged stories of extremely rare adverse reactions that are elevated by an abundance of negative media coverage.

Counteracting this misinformation is not a simple task but requires considerable thought and new methods of communicating with parents. Gone are the days when pediatric primary care providers served as a family’s singular source of trusted information. In today’s reality, parents have an overwhelming plethora of information at their fingertips with little preparation or resources to carefully consider the reliability of each source. As one of the greatest achievements in modern medicine, vaccines are a victim of their own success. Newly trained pediatric care professionals rarely see the devastating effects of vaccine-preventable illnesses such as diphtheria or Haemophilus inf luenzae. However, New York just confirmed the first case of polio in the United States in nearly a decade,

 and worldwide cases of measles increased by 79% in the first 2 months of 2022 compared with 2021.

 The reemergence of vaccine-preventable diseases demonstrate the potential for rapid transmissibility and the sudden upending of community safety and security.

In general, providers should make a practice of requesting permission to approach parents’ hesitancy regarding vaccination. Concerns should be acknowledged with validation and empathy for accompanying parental emotions. Providers must carefully consider body language implications and convey an unhurried demeanor. They should sit at eye level with the parents and avoid charting, writing, or looking at a computer screen during the conversation. It is best practice for providers to focus on an individualized risk-benefit assessment (vs general aggregates) while carefully evaluating the parents’ readiness to change their feelings and beliefs related to vaccine hesitancy and /or refusal.

Common pitfalls while communicating with parents include missing cues in conversation, overusing inaccessible medical jargon, overstating vaccine safety, taking a confrontational approach with implied ultimatums or subtle shaming, and condescendingly discrediting information sources presented by parents.

 It is best that providers not respond directly to potential misin-formation by delving into the minutiae of disreputable sources, instead stating specific facts that provide correct information addressing the harms that can happen if discredited health advice is followed.

 It is essential for providers to avoid an argumentative approach. They should begin a conversation by finding any space of common ground or agreement. In addition, providers should focus on prioritizing the most urgent health threats and specific parental concerns and questions rather than generalizing assumptions of concerns across patient demographics.

When communicating with parents about vaccine hesitancy or refusal, the provider should take an approach that assumes vaccination by making a presumptive announcement rather than a questioning approach.

Now that your child is 12 years old, 3 vaccines are on the schedule to be administered today. 

Today we will vaccinate against meningococcal disease serogroups A, C, W, and Y, HPV cancers, tetanus, and whooping cough.

Are you OK with the vaccines recommended today?

What vaccines would you like to receive today?

Motivational interviewing is an evidence-based, patient-centered, goal-oriented, collaborative decision-making communication technique that is effective in creating behavioral change.

 It involves 4 specific principles, as illustrated below.

It sounds like you have some concerns. Tell me what you already know about ___.

What information can I provide that might be helpful to you?

What questions do you still have after doing your own research?

I’m glad to hear about the consideration you’ve given to ___ . 

It’s obvious you really care about your child’s health and you’ve given this a lot of thought.

I hear you saying you are concerned about ___.

My understanding of your concerns is that ___.

Now that we’ve discussed this, how does that affect your decision?

What benefits do you see from vaccination and what concerns do you still have?

Recall and reminder systems are an evidence-based, time-tested effective strategy to ensure on-time coverage with full vaccination recommendations. Efficacy is similar across methodologies, including phone calls, text messages, electronic medical record (EMR)-based communication, or regular mail. Providers may find it beneficial to include a statement on the practice website sharing their vaccine philosophy, recommendations for adherence to the CDC-recommended schedule, and resources for parents with vaccine concerns. The website can include vaccine resources with hyperlinks for parents to access prior to the visit. Parents should write down any questions they have and bring them to the visit. Some practices may consider asking parents to leave the practice and find another provider, especially when the provider-parent decisions differ significantly. The American Academy of Pediatrics advises that dismissing patients from a practice is not a decision to be taken lightly but is an op-tion in circumstances in which all other recommended avenues have been exhausted.

Providers must ensure that the collective practice is involved and invested in increasing immunization rates. All practice personnel have a role in improving practice performance, sometimes referred to as a front desk to back door approach. Front desk personnel should be trained in preparing patients for the potential for vaccines at every visit. EMR integration can also flag underimmunized records with prompted scripting for parents in scheduling an appointment. Providers should implement a layered protection approach. Nurses and other health personnel administering vaccines should all be fully informed and equipped to give parents office-approved resources and answer basic questions. Providers should have adequate time in their schedule to answer parent questions. Billing personnel should be aware of financial implications, including Medicaid coverage. The practice should participate in the Vaccines for Children program, which provides vaccines at no cost to families in need of support.

Regarding vaccination, providers should have clear, consistent, and concise messaging, delivered with empathetic concern. Communication between the provider and parents is a critical factor in removing barriers to vaccine administration and should be clear and reassuring for parents who are vaccine hesitant or who refuse vaccines. Parents should be encouraged to adhere to the vaccination schedule approved by the CDC and recommended by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners, as well as other reputable professional organizations. Providers and office-based personnel who believe that every child deserves the best protection from life-threatening, vaccine-preventable diseases have established the foundations for a provider-parent relationship that supports the health and well-being of all who walk through the practice doors.

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2. Seyed Alinaghi S, Karimi A, Mojdeganlou H, et al. Impact of COVID-19 pandemic on routine vaccination coverage of children and adolescents: asystematic review. 

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5. Catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind: recommendations for ages 18 years or younger, United States, 2022. CDC. Updated February 17, 2022. Accessed September 13, 2022. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html

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9. Measles cases are spiking globally: here’s what you need to know about the outbreaks and the impact it’s having on children. UNICEF. May 4, 2022. Accessed September 13, 2022. https://www.unicef.org/stories/measles-cases-spiking-globally

10. Refusal to vaccinate. AAP. Updated July 28, 2021. Accessed September 13, 2022. https://www.aap.org/en/patient-care/immunizations/implementing-immunization-administration-in-your-practice/refusal-to-vaccinate/

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In this article, declining trends in vaccination across the United States are discussed, along with how providers can reduce vaccine hesitancy.

Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN

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