At the beginning of the Covid-19 pandemic, Eileen Costello, the chief of ambulatory pediatrics at Boston Medical Center, had been forced to reduce patient visits by 90%. Even so, she tried to keep all appointments with kids to get their routine vaccinations for diseases such as measles, mumps, and whooping cough.
“We moved heaven and earth to book the kids in person who were due for a vaccine,” said Costello, who is also a clinical professor at Boston University School of Medicine. “But it became evident that parents weren’t going to come. They were too afraid.”
So Costello got creative: With a van donated by a local ambulance company, she and her colleagues put together a mobile vaccination vehicle, with a gurney as an exam table and an improvised freezer system featuring frozen water bottles to keep the vaccines cold. All week, the van brings pediatricians, often a child’s typical doctor, to patient neighborhoods; as a safety net hospital with most pediatric patients on public insurance, the van often heads to underserved areas in and around Boston.
As routine vaccinations of children in the U.S. plummeted during the pandemic, efforts like BMC’s have sprung up around the country to help close the gap.
A CDC study in May that examined data from two different federal vaccination programs between January and April 2020 found that childhood immunizations dropped sharply from mid-March to late April when Covid-19 was deemed a pandemic and the U.S. declared a national emergency. During that period, providers ordered 2.5 million fewer doses of regular childhood vaccines — not including those for influenza — and 250,000 fewer doses of vaccines containing measles protection, compared to the same period the previous year. On the state level, childhood vaccine doses in Massachusetts declined by 68% in the first two weeks of April, according to the Massachusetts Department of Public Health, and from Michigan to Ohio to Wisconsin, fewer vaccines were administered.
“I just got really worried very early,” said Costello. “We’re going to have a huge cohort of undervaccinated kids.”
In Wisconsin, pediatrician Nathan Fleming and his colleagues at Lake Country Pediatrics in Oconomowoc transformed a small wheelchair-accessible school bus into a mobile exam room back in April. The rural clinic usually does home visits, but early in the pandemic, they knew so little about how Covid-19 spread, Fleming said, and they needed to find a way to safely continue childhood vaccinations. After each visit, the bus is cleaned in the same way one would clean a scientific laboratory, opening the windows, and filtering all the air in the ventilation system.
“We can keep the bus really clean, really safe for families,” said Fleming. “And that way parents weren’t skipping those primary care well child checks where you would normally get immunized against measles or whooping cough or chickenpox.”
Both Costello and Fleming said their programs have been remarkably successful. BMC uses the van for both pediatric and flu vaccinations, and as a result, gave 300 more flu shots in 2020 than in 2019. Costello also said she thinks the hospital gave just as many, if not more, childhood vaccinations during the pandemic because of the program. Lake Country Pediatrics has also had childhood vaccination numbers hold steady and even go up during the pandemic, and Fleming credits the mobile vaccination program.
Another approach being tested out is drive-thru vaccinations. Jill Amsberry, a pediatrician in St. Cloud, Minn., suggested early in the pandemic that her clinic start offering curbside vaccinations. As many as 30 patients per day would come through, and Amsberry said parents were enthusiastic not only because of the convenience, but because many kids seemed less averse to the shots than usual with less time to anticipate them.
Like the mobile programs, Amsberry said that her clinic’s campaign, which was stopped in early November due to cold weather, allowed childhood vaccination rates to remain steady through the pandemic. Her practice also expanded the curbside vaccinations to flu shots and even to other clinics under the same health care system in the area.
Even without these programs, all three pediatricians emphasized that going into the office to get a vaccination is very safe. To limit the spread of Covid-19, doctors’ offices are taking precautions such as separating sick and well kids to utilizing telemedicine as the checkup portion of a visit, with a child coming in only briefly so that a nurse can give immunizations.
With all these measures, getting a vaccination is likely “less of a risk than going to the grocery store,” said Angela Beeler, chief of the division of pediatrics of the UMass Memorial Medical Center.
But Beeler said that some parents are still hesitant. Like many medical centers across the country, her pediatrics division doesn’t have programs that do mobile or outdoor routine childhood vaccinations, although it did run an outdoor flu shot clinic.
If the trend of missed vaccinations continues, pediatricians worry that the U.S. could experience outbreaks of vaccine-preventable diseases to deal with after, or even on top of, the Covid-19 pandemic. In their first few years of life, the CDC recommends that children receive vaccines to prevent at least 13 diseases, from measles to tetanus, and some vaccines require multiple shots spaced out over several weeks or months.
According to the CDC, a recent analysis of vaccine orders through the federal Vaccines for Children program revealed that although weekly orders of vaccines are now roughly on par with last year’s, the total number of vaccines ordered is still down overall, having not yet recovered from the dropoff in the early part of the pandemic.
A recent analysis by Epic Health Research Network, which has not been peer-reviewed, found that among providers in 23 states who use Epic’s electronic medical record system, overall vaccinations in 2020 were down from predicted levels across all age groups. The most well-vaccinated children were under 6 months, with 95% of the expected number getting their recommended shots, but the rate decreased with age: 92% for those 6-17 months; 88% for those 18 months old to 6 years old; and 83% for those 7-18 years old. Although the numbers are fairly high, many diseases require an extremely high rate of vaccination to preserve herd immunity. Measles requires 95% of children to be vaccinated, said Costello, while whooping cough does not have a reliable herd immunity threshold at all, according to the CDC.
Ultimately, Fleming said he hopes that the flexibility and creativity that spurred the mobile vaccination unit carries on past the pandemic.
“I really hope that we continue to see, not just here at Lake Country but across the country, an investment in innovation,” said Fleming. “We’re making it easier for families to be healthy.”
Great initiative by the pediatricians, but pediatricians doing routine child vaccinations is huge overkill. In a lot of countries these routine vaccinations are done by nurses in public health units (with good health record systems). Seems the US can use some serious simplification and streamlining in these routine procedures.
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