A nightmare for pediatricians became a reality earlier this month: Polio, which was previously thought to be eliminated in the U.S., paralyzed an unvaccinated adult, and the virus was found in the wastewater in New York City and outlying counties.
This case of polio was particularly worrisome for three reasons. First, the person had not recently traveled, indicating that he got infected with the virus in the U.S., not overseas. Second, the strain of polio that infected him (type 2) causes paralysis in about 1 in 2,000 infections, suggesting there have been hundreds and possibly thousands of persons recently infected with the virus in New York. Third, genetic analysis indicated that the strain of polio is one that evolved from an oral polio vaccine — which uses a weakened live virus — and is identical to the strain that has caused community transmission in London and Israel, indicating this is problem in multiple countries that were previously considered polio-free.
New York City, where we work, has an estimated 1.7 million children, all of whom have the opportunity to be vaccinated at a pediatrician’s office given the presence of safety net hospitals where every child can seek care and vaccination, regardless of insurance or immigration status. Seventy years ago, parents lined up to have their children vaccinated against a disease that each year left thousands of people disabled or unable to breathe. Today, with images of children in iron-lung machines relegated to history, up to 40% of 5-year-olds are not fully vaccinated against polio in some New York City neighborhoods, leaving thousands now at risk of paralysis and death.
How did our country’s commitment to a health intervention so exquisitely safe and life-saving slip this far to leave children vulnerable?
Pediatrician’s offices are the infrastructure the U.S. relies on for vaccinating children. This strategy has largely been successful, with only 0.5-1.5% of children never being vaccinated, a lower percentage than most regions of the world. Families trust their pediatricians for health information.
While pediatricians’ offices are the critical site for turning vaccines into vaccinations, laws serve as a critical check that this system is working as intended. The best predictor of high rates of childhood vaccination in the U.S. is strong enforcement of vaccine requirements for children to enroll in school and childcare. Yet vaccine hesitancy and refusal, due to misinformation or religious and medical exemptions, have whittled away high rates of routine vaccination. This foundation crumbled even further when the Covid-19 pandemic disrupted well-child visits to pediatrician’s offices both domestically and globally.
Despite the reliance on the pediatrician workforce for administering childhood vaccines, pediatricians receive limited required training or resources for evidence-based approaches to providing vaccine information and effective vaccine administration. They are largely unprepared to handle the increasing volume and declining veracity of vaccine-related information that parents hear or see.
We believe there is an urgent need for policies and practices to strengthen vaccine delivery through pediatricians. Here are three ways to get there.
First, the Centers for Disease Control and Prevention and states must fund staffing and partnerships between local health departments and pediatricians’ offices for identifying children not up to date on their vaccines. With the proper resources, health departments can query immunization registry data and electronic medical records and notify parents of children who need to be vaccinated. Local government-backed childhood vaccination support is even more highly necessary in this time of health care staffing shortages.
Second, pediatricians should add achieving high rates of routine vaccines to their practices’ quality improvement processes, following models created for flu vaccines during the seasonal roll out. Regulatory boards, such as the American Board of Pediatrics, and hospital rankings, such as U.S. News & World Report’s, should include standard childhood vaccine rate metrics; doing so will stimulate quality improvement efforts to increase vaccination rates within independent pediatric offices and large health care systems. Training resources with certified coaches should be widely available for pediatricians and their staff, both in practice and in training, to address vaccine hesitancy.
Third, state Medicaid programs should offer substantial incentive payments to pediatricians who achieve high rates of vaccination, and should encourage private payers to do the same. Preventing even one case of polio paralysis that leaves a child disabled for a lifetime will almost certainly make these interventions cost beneficial from the perspective of government and health systems.
Where the polio virus is circulating due to low vaccination rates, outbreaks of measles and other vaccine-preventable infections are not far behind. Fighting the recirculation of polio is a war the U.S. knows how to win, but only if it can equip the frontline — pediatricians — with the tools they need to counter vaccine misinformation, hesitancy, and complacency.
Sallie Permar is pediatrician-in-chief at NewYork-Presbyterian Komansky Children’s Hospital and chair of the Department of Pediatrics at Weill Cornell Medicine. She reports having consulted for Merck, Moderna, Dynavax, Hoopika, and Pfizer in regard to their cytomegalovirus vaccine programs. Jay K. Varma is an internal medicine physician and infectious diseases epidemiologist, a professor of population health sciences at Weill Cornell Medicine, and director of its Center for Pandemic Prevention and Response.
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