Childhood vaccinations are still recovering from a pandemic dip. What's driving hesitancy, access issues?

ROCHESTER — Recent outbreaks of measles in the U.S., including in the Twin Cities, have highlighted a public health trend that has been in play for the past few years: fewer children who are up to date on immunizations.

Prior to the COVID-19 pandemic, Olmsted County's rate for 2-year-olds who are up to date on the recommended vaccine schedule was above 70%, with 70.5% of those children up to date in 2020. In 2021, though, that figure dipped to 52.2%, and in 2022 and 2023, that rate rebounded to 67.4% and 65.4%, respectively.

Minnesota's overall vaccination rate has followed a similar pattern since COVID-19 emerged; most years, Olmsted County's rate exceeds the state average.

The Centers for Disease Control and Prevention's childhood vaccine schedule recommends that children, between birth and age 2, receive multiple doses of vaccines to prevent infections such as tetanus, chicken pox and measles. Dr. Carolina Larmeu, a pediatrician at Olmsted Medical Center, said these vaccines — and the timing for when they're given — have been extensively studied.

"Not only does it provide optimal immune stimulation," Larmeu said of the schedule, "but we're giving the vaccines at the ages that children will benefit from them the most, when they need protection the most."

Larmeu gave rotavirus as an example. People of all ages can become sick from rotavirus, which causes diarrhea, but babies face higher risks of dehydration and death from that illness, Larmeu said, which is why that vaccine is typically given in the first six months of life.

But while more toddlers, in general, are behind on vaccines compared to pre-COVID, the trend of unvaccinated and undervaccinated children predates the pandemic, said Jennifer Reich, a sociology professor at the University of Colorado Denver and the author of the 2018 book "Calling the Shots: Why Parents Reject Vaccines."

This is because many parents — usually mothers, who often carry the mental load of protecting their child's well-being — view vaccines as "one kind of consumer product in a landscape of many consumer products." This mindset is driven by parents' desire to do what is best for their children, Reich said, and the social messaging that parents "are personally responsible for their children's health outcomes."

"Vaccines are actually, in many ways, marketed as a kind of individual technology," Reich said. "So, unsurprisingly, when something's presented as a choice, people sometimes don't want it."

Vaccines do provide benefits that extend beyond the individual. Herd immunity — when most of a population is inoculated against a disease — protects people who are unable to get vaccinated due to their health status, said Dr. Ann Philbrick, a pharmacist and associate professor and director of community engagement in the University of Minnesota College of Pharmacy.

"Take the measles vaccine," Philbrick said. "That's a live vaccine. So, anybody ... if they're immunosuppressed, they cannot get that vaccine, so those people are really relying on herd immunity in order to protect themselves."

But the messages about vaccines benefiting the community can feel incongruent with parents' experiences, Reich said.

"It's worth acknowledging that, increasingly, communities do less and less for children," Reich said. "So, the idea that children should be supporting community health, but the community is not really supporting children, I think, is important to recognize and to think about how disingenuous it feels."

Before the pandemic, Reich said studies showed that 20% to 30% of American parents rejected some or all vaccines, or were delaying getting them, for their children.

Because parents are often approaching vaccines through the lens of their individual child, Reich said they may consent to some vaccines for their child and not others, or decide for or against a vaccine depending on their child's sex or health status.

An example from Reich: She spoke with a mother who was motivated to vaccinate her daughter against measles because she knew that "infection during pregnancy could cause miscarriage or birth defects," but because her son would not face that particular risk, she felt it was not as important to vaccinate him against measles.

"I had mothers tell me that they didn't think polio vaccines were very important right now because there isn't wild virus polio in the U.S.," Reich said. "But they felt really differently about other vaccines (for diseases) that they thought were more life-threatening, like tetanus and diphtheria."

This could partially explain why Olmsted County kindergartners are vaccinated at different rates for different vaccines. During the 2023-24 school year, 95.1% of the county's kindergartners were fully vaccinated against hepatitis B, but 92.5% were up-to-date with the MMR vaccine (measles, mumps and rubella). The MMR vaccine also has the highest rate, just by a hair, of non-medical exemptions granted for kindergartners.

In these considerations that parents make in choosing (or not choosing) vaccination for their child, they are searching for information — Reich said it is easy to say that these parents are ignorant or anti-science, but that is often not the case.

"I think it's a mistake to dismiss parent concerns as simply misinformation because they're often trying to make sense of a huge amount of information in a world that feels mostly unsafe for children these days," Reich said. "They're trying to make decisions of things that they feel are controllable, and vaccines might be one of those things."

Politics and partisanship weren't prevalent factors in vaccine decision-making, Reich said, until COVID.

"The way the Trump Administration communicated about vaccines ... it started to become aligned with political ideologies in a way that had not existed before," Reich said.

Common concerns around vaccines include the fear that a child's immune system could be overwhelmed by receiving multiple shots at once ("It's really not too much for the body to handle," Philbrick said) and that today's vaccines are made using human fetal cells (this is untrue, Reich said).

A question that Larmeu said she often hears from hesitant parents about the MMR vaccine, in particular: Does it cause autism? That belief, Larmeu said, stems from a research paper that was later found to have falsified data, and the doctor behind the discredited research had his medical license revoked.

In those cases, Larmeu said, she talks with those parents about the discredited data and what research has been done on the MMR vaccine since then.

"There have been several studies, with thousands and thousands of patients," Larmeu said, "(that have) proven that there is not a link between MMR and autism."

In these conversations between parents and providers, Philbrick said it is important for the provider to listen to and acknowledge these concerns.

"Back up any recommendation you have with facts," Philbrick said. "It might be, 'I was concerned, too, so this is what I did to make sure that I was an expert on this and that I would make the right choices ... for myself.'"

If a parent does opt out of a vaccine for their child, revisiting that conversation at a later date is important, too, Philbrick said.

"Maybe today you're not going to change their mind," Philbrick said. "But every little piece of information that you can give a parent or patient about vaccines and being consistent in that message is going to help move them just a bit further to making an educated decision about the vaccine."

Both Philbrick and Larmeu recommend that parents with questions should reach out to a trusted medical provider, such as their pediatrician or pharmacist. Larmeu also pointed to healthychildren.org, an online resource for vaccines and child health topics.

Beyond individual families, Reich said community-level interventions can be helpful in addressing another reason why vaccination rates are down: access to health care. A shortage of primary care providers and pediatricians can make getting timely appointments for a child more difficult.

"During COVID, we saw huge successes with things like vaccines distributed through pop-up clinics at elementary schools and community centers," Reich said.

Locally, Olmsted County Public Health Services held extra immunization clinics through the summer, with scheduled and walk-in options, said Leah Espinda-Brandt, disease prevention and control nurse manager at OCPHS.

"As of the end of August this year, the number of clients that were served here at Public Health's vaccination clinics has already surpassed the numbers we did in 2023," Espinda-Brandt said. "More people are coming in to get vaccinated, so that's great news."

The public health department also collaborates with Mayo Clinic and Olmsted Medical Center, Espinda-Brandt said, to talk about new interventions for getting children vaccinated and to avoid overlap, like two providers holding vaccine drives on the same day.

Pharmacists are also playing a bigger role in vaccine administration since the pandemic, Philbrick said. While pharmacists have been able to give flu shots for several years, the national Public Readiness and Emergency Preparedness (PREP) Act passed amid the pandemic gave pharmacists, pharmacy technicians and pharmacy interns permission to provide flu and COVID shots to patients as young as 3 years old and any vaccination for people age 6 and up.

These extended permissions will become permanent in Minnesota beginning Jan. 1, 2025.

"That really expands the ability to give vaccines in a pharmacy setting," Philbrick said.