A year after adults in the U.S. began getting vaccinated against COVID-19, children ages 5 and up are now eligible for the shot. So far, uptake has been slow — in part because of parents’ concerns over vaccine safety.

On the latest episode of The Dose, pediatrician and American Academy of Pediatrics board member Michelle Fiscus, M.D., and the Commonwealth Fund’s Rachel Nuzum shed light on challenges and opportunities in raising child vaccination rates.

One downstream concern is growing resistance to other childhood vaccines. As Dr. Fiscus says, if “vaccine hesitancy continues to build with the routine childhood vaccines, I am very concerned about the types of outbreaks that we’re going to be fighting over the next years.”

Transcript

SHANOOR SEERVAI: This week marks one year since adults in the U.S. could get vaccinated against COVID-19. Without vaccines, over a million additional Americans would have died of COVID-19, and more than 10 million additional Americans would have been hospitalized for COVID-19 by November 2021, according to researchers at Yale and the Commonwealth Fund.

In recent weeks, the vaccine has been approved for children aged 5 and up. But not all parents are eager for their kids to get the shot. Between fears of a winter surge and the new Omicron variant, the challenge of vaccinating children becomes more complex and more urgent. What will it take to build trust with parents and make the vaccines easily available to kids to protect them, and the more vulnerable adults around them?

I’m Shanoor Seervai, and on today’s episode of The Dose, I’m speaking to Dr. Michelle Fiscus, a pediatrician, a member of the board of the American Academy of Pediatrics, and former medical director for vaccine preventable diseases of the Tennessee Department of Health. In July, she was fired from that position after some state officials disagreed with her efforts to get children vaccinated. I’m also joined by Rachel Nuzum, vice president for the federal and state health policy initiative at the Commonwealth Fund, who has been closely tracking what states can do to increase vaccine uptake.

Dr. Fiscus, Rachel, welcome to the show.

MICHELLE FISCUS: Hi, Shanoor.

RACHEL NUZUM: Thank you.

SHANOOR SEERVAI: So it’s been nearly a year since adults could get vaccinated. Now, children aged 5 to 12 can finally get the shot. Where does child vaccination fit in as the urgency to end this pandemic increases?

MICHELLE FISCUS: Well, it’s very difficult to get to what we think might be a level of herd immunity if we haven’t vaccinated children, if you think about, you know, children make up some 25 percent or so of the U.S. population. And so if you can’t vaccinate 25 percent of the population, what we know about COVID-19 and the SARS-CoV-2 virus is that we probably need vaccination rates around 80 percent, maybe north of that. And so if you’ve left out all the children, it is really impossible to get there. So vaccinating children is pretty critical to our ability to get to a place where we’ve controlled this pandemic.

RACHEL NUZUM: Yeah, it’s a really great question, Shanoor. And it’s one that doesn’t kind of lend itself immediately to common sense. There was a lot of confusion early on about whether or not kids were even susceptible to COVID, whether they could spread it, whether they would have symptoms. And we now know a lot more than we did two years ago, to your point, as Dr. Fiscus noted, we know that kids are about 17 percent of all total cases. And beyond just taking care of kids, we’re not going to be able to really manage the viral spread of the COVID-19 pandemic if we have large swaths of the population that are unvaccinated. And we really think there’s a connection also with how much viral spread is happening with the variants that are able to evolve with the Delta variant and now Omicron, but we really need to get the herd immunity up like Shelley noted.

SHANOOR SEERVAI: And given this, are most parents eager to have their young children vaccinated?

MICHELLE FISCUS: I think it’s hard to say most at this point. And we’ve had vaccine for the 5-to-11 age group for a few weeks now. And we’re only at about 15 percent of that population that’s been vaccinated, which is well behind where we were at this point when we got authorization for the 12-to-17-year population. So now at this point we’ve got just over 50 percent of the 12-to-17 population fully vaccinated in the United States. But the 5-to-11-year-olds are really lagging behind, which just really speaks to that concern about lack of vaccine confidence in some parents who are hanging back for what’s probably a variety of reasons from getting their young children vaccinated.

RACHEL NUZUM: I think the numbers are pretty consistent with what we were expecting when we surveyed parents earlier this summer right before the authorizations came online for children ages 12 and over. We saw roughly 40 percent of parents in the survey that the Commonwealth Fund conducted with the African American Research Collaborative that said that they were very hesitant to vaccinate their children. About 20 percent of them had a lot of questions and weren’t sure, and the remainder said that they had plans to vaccinate as soon as possible. So this is pretty consistent with what showed up in our surveys this summer, and tells us that we’ve got a lot of work to do in reaching the children in the families who are not kind of the early adopters.

SHANOOR SEERVAI: And so what are these concerns that people have? It’s important to address them.

MICHELLE FISCUS: The same concerns, really, that we heard since the beginning of the vaccination efforts, you know, parents who are concerned that maybe the vaccine was rolled out too quickly or wasn’t tested rigorously enough. And we hear a lot, especially around social media, on what might be the long-term effects of vaccines. While the vaccines were developed quickly, they went through the same kind of robust clinical trials that we see with other vaccines that we’ve used in the childhood schedule. But what we’re really seeing are parents who would otherwise vaccinate their children with routinely recommended vaccines who are not rushing to go and get their kids vaccinated with this one.

SHANOOR SEERVAI: So if we think about the snapshot of vaccines, child vaccines for COVID, and we compare that to, say, vaccination rates for measles, what’s the difference there?

MICHELLE FISCUS: There’s a huge difference. So generally, we like to see measles vaccination rates around 95 percent or so because measles is the most contagious infectious disease pathogen that we know of. And when you start to see immunization rates drop below about 95 percent, you start to crack the door open to allowing measles to get in and cause infections in people who are susceptible. So in general, across the United States, vaccination rates against measles are quite high. We generally have thresholds where we would like to be at least 90 percent of kindergarteners that are vaccinated fully against measles. And then, as I said, in comparison, we’re sitting at about 15 percent of the 5-to-11 population that’s been vaccinated with even one dose because they’ve only really had time to get one dose of a COVID-19 vaccine. So we have a long, long way to go to close those gaps.

RACHEL NUZUM: And that really ranges from in some states like Massachusetts to a high of 20 percent, down to 1 percent in states like Texas. So we just have to be really conscious of this variation between states. And we also know there’s a tremendous amount of variation within states that from county to county we can really see different rates of vaccination. And that all has to be taken into consideration as we think about how to target children and their families, which messages we might want to be using and need to be using to really reach them.

SHANOOR SEERVAI: And I mean, it’s early, Rachel, but are there some trends that you can observe about subgroups, either by geography or race, where our child vaccination rates particularly low?

RACHEL NUZUM: Well, like I mentioned, we’ve got a number of states who have particularly low childhood vaccination rates. One of the things that we know makes a big difference especially we just talked about how important it is to parents to be able to have a trusted health care provider, like a pediatrician or a primary care provider, to talk through their concerns and get their questions answered. We have millions of children — actually the highest number of children who are uninsured right now — than we’ve had historically. After a low in 2016, those numbers have increased in terms of uninsured children. And those are the states that I’m particularly concerned about how we reach the children who are not connected to the health care system. We know that they’re more likely to be Black or Latino, we know they’re more likely to be low income, and just have many fewer resources to connect into the health care system. So those are the communities in the families that I’m particularly concerned about, as we look across the states and look at the trends on vaccinations.

SHANOOR SEERVAI: So we’ve talked about states that aren’t doing well. But what about states that are doing well? Are there places where the rollout is good and potentially replicable?

RACHEL NUZUM: There are definitely states that are taking a lot of the lessons that they learned from the adult rollout and kind of building on that and learning from that. As I mentioned, there are some states like Massachusetts that are up around 20 percent. One thing that’s really important to note is that there’s a tremendous data lag. So the time difference between when a vaccine goes in the arm of a child, to when that gets reported to the state, to when the state reports up to the federal government, and then the data is validated and released — I don’t think any state will tell you they have this figured out or wants to be held up as the shining beacon example. When our highest state is at 20 percent, that tells us that we’re all just getting started. So it’s a little too early for kind of best practices because every state is really trying to figure this out, and the policy environment changing as we go. But those are some pieces that we really learned how important those were over the past year of navigating this with adults.

SHANOOR SEERVAI: Okay, so let’s talk about logistics, then. Tell me more about where pediatric offices fit into the rollout?

MICHELLE FISCUS: There was a study that looked at where people would prefer to get vaccinated. And overwhelmingly the preference is to get vaccinated by your own health care provider. And these were adults that were surveyed. Also, in surveys of parents, they have indicated that they’re really most comfortable having their children vaccinated at the same place they get all of their other routine vaccinations. And so it’s critical that pediatricians play a role in this. And in many cases they have been all along because so many pediatricians provide vaccines to the parents and other adults that come to their practice, whether that’s flu vaccines, or tetanus boosters for new parents, or pertussis vaccines for grandparents of new babies.

Many pediatricians already had COVID-19 vaccines in their offices even before the pediatric vaccines became available. But we can’t gloss over the fact that not every child has a medical home or access to a pediatrician. And so that’s really where those community health centers, maybe local pharmacies, those school-based clinics, are so important to be able to be in the neighborhoods where children are and to have vaccines available when children are present during the school day, at places where children are after school or on weekends, Boys and Girls Clubs, YMCAs — we really need the whole immunization neighborhood involved in getting children vaccinated, and hopefully their caregivers when they bring them.

SHANOOR SEERVAI: I did want to talk a little bit about schools because, you know, I was wondering if we’re going to see the same sort of mandates in schools as we are seeing with employers for the adult population. And then, if there is a mandate at the school level, will they also be administering vaccines in all schools?

MICHELLE FISCUS: I think you’re going to see a lot of variation with this. We already have several states that have passed laws that they will not permit COVID-19 vaccine mandates. Then you have a few places that have already put mandates in place like California, Illinois, some other either jurisdictions within states, or states. But that’s a real minority of areas. What I’m particularly concerned about is that this politicization of COVID-19 vaccines is beginning to creep over into mandates around other vaccines in schools. And so we’re starting to see legislation start to bubble up that what’s in more philosophical or ethical or just, you know, “I don’t want to” vaccine exemptions into regular school vaccinations. And so I think this is going to be a really delicate situation going forward in considering COVID-19 vaccine mandates, especially before there’s full FDA approval for children 5 to 17, which hopefully will be coming before too much longer. But you know, in a lot of states, this is not only an issue for COVID-19 vaccines but really has become kind of tenuous around just the regular immunization requirements that we’ve had in place for schools for decades.

RACHEL NUZUM: I was just going to add, I think variation is going to continue to be the headline on this, with the states passing legislation or introducing legislation to kind of prohibit public health measures or prohibit school districts or local jurisdictions from requiring mandates. We’ve seen this, you know, around mask-wearing. A lot of different kind of public health interventions have been called into question. And then New York City announced, you know, a mandate for, which I think is the first in the nation, for customers in restaurant dining and entertainment venues like movie theaters and live theater. So that’s really at the other end of the continuum to really say, and acknowledge that, you know, getting everyone vaccinated as a clear component of kind of economic recovery, right? You see some states and jurisdictions taking that position, while at the same time there are many others who have really gone the other direction and are questioning the authority of the state or the federal government to require public health intervention.

SHANOOR SEERVAI: And we already know, you know, the virus doesn’t know borders, it doesn’t stop at one state and pick up in another. So, sort of what I’m hearing you say is that the hardest work is ahead of us.

MICHELLE FISCUS: Yeah, I think that’s right. And you know, I mean, even looking back over the last year of vaccination, things have sort of been in fits and starts. You start with a vaccine, everybody who wants to get it is excited, and you don’t have enough, and the lines are long, and people can’t find doses. And then something happens like the Johnson & Johnson pause where, for a couple of weeks, they told us not to use the Johnson & Johnson vaccine because of concerns of blood clots. And so then you see this huge falloff in interest in getting vaccinated because, you know, everybody kind of gets worried again, and then you have Delta. And so then that spurs people forward to go get vaccinated because now we have this new virus variant that is more infectious and potentially more dangerous. And then people start to kind of think less about that. And then you have the kids and then you have Omicron. And so even strategies that work well today may not work well or resonate with people a month or two from now. And we saw that early on in the rollout. We had states like West Virginia and Tennessee that were, you know, way out in front in the beginning, that a few months into the pandemic response had fallen to the back of the states in the country. It is a constantly moving, challenging, retack-redirect kind of response to try to manage.

SHANOOR SEERVAI: So we’ve talked a lot about the challenges, and many have been anticipated. But are there any surprises in the rollout so far? Any good news?

RACHEL NUZUM: One thing I think we can see is that we’re learning from the rollout of adults and kind of taking some of those lessons and then making them appropriate for kids. As the adults were coming online for being vaccinated, we really didn’t have primary care providers at the table, despite the fact that in our surveys we saw over and over again that folks were most comfortable going to their primary care provider. And that was a finding that held true, regardless of your race, regardless of ethnicity, regardless of political party, people really wanted to go to a trusted provider. We did not have the capacity to really utilize our primary care providers when the vaccination campaign started. The vaccines weren’t packaged in the right way. There were a lot of storage issues. We didn’t have the financial incentives. We didn’t have a lot of things in the system that enabled us to do that. With kids, you’re seeing a very different plan. And it’s very focused on taking the vaccinations to the pediatricians, to their primary care practices. We figured out how to package them, we’ve figured out a lot of the storage issues. And this is all been happening in a really incredibly short amount of time. So I think it is really good news that we’re learning as we go. And we’re putting some of those adjustments and policies into place.

One of the things that we heard, loud and clear from primary care providers and from pediatricians, was that there was a real barrier at the practice level because they were not able to be reimbursed for consultations and conversations with parents and families if it didn’t result in a vaccine being administered. And the Biden administration just rolled out some policies to specify that in Medicaid, that visit, even if it’s a consultation only, will be covered and that will be covered at 100 percent. So those policy changes make a really big difference for the practices, but also for reaching the families and the children that we’re trying to reach.

MICHELLE FISCUS: When I talk to pediatricians, you know what Rachel brought up, that when you think about what a pediatrician or another primary care provider has to do to be able to bring vaccines into their office and administer them: you have to potentially have new or different storage equipment, you have to monitor those vaccines, you may have to put all kinds of different procedures in place, you may have to have extended hours, you may have to hire people just to do vaccinations depending on what the response rate is. And you know, remember, you have to vaccinate all of these people twice. Where I see tons of hope is just talking to kids and seeing posts on social media of parents or pediatricians who are posting pictures of kids. And you know, as a pediatrician, there’s there are a few things that are in my heart more than preventing preventable diseases in children. And it’s really easy to get discouraged that, hey, we don’t have 85 percent of the 5-to-11 population vaccinated yet. But it’s great to see growing numbers of kids that are.

SHANOOR SEERVAI: And so let’s look ahead with that in mind, as schools are closing for winter break. What is your best-case scenario for what things will look like when kids go back to school in January?

MICHELLE FISCUS: Best-case scenario, we take these couple of weeks to get vaccination appointments scheduled, we know one vaccine is better than no vaccine, and that we’ve still got people masking and distancing and washing their hands and being careful about how they’re gathering so we don’t have a massive surge in January. I hope we won’t have a surge after the holidays. I am not optimistic about that. But, you know, that is what we would all like to see.

SHANOOR SEERVAI: And then this is something you’ve sort of pointed to throughout the conversation, which is that parents’ COVID vaccine hesitancy on behalf of their children is raising broader public health questions. If we see more and more parents leaning toward a universal antivax attitude, then what would be the broader public health consequences further down the road?

MICHELLE FISCUS: You think about the things that we prevent in not only children, but because children gather and tend to be spreaders of the diseases they have. You think about whooping cough, which is still in our communities, and we have a vaccine that can greatly reduce that. But you know, that’s a disease that can kill infants. We don’t see chicken pox very often. We see a whole lot less flu than we would see if people weren’t getting vaccinated; we would see a whole lot less of it if more people got vaccinated. And then we don’t hear about cases of measles. Measles has been eliminated from the United States, even though we had a few outbreaks over the years. But even just one case of measles can catch like wildfire. In Tennessee a couple of years ago we had an individual who returned from a country where measles was endemic, and was infectious and exposed 542 people in a period of about 72 hours. It was terrifying because, you know, it’s so easy for a virus like that to take hold.

And so if we start to see these immunization rates decrease — because people become more hesitant because they haven’t seen these diseases, they don’t know what they can do — we’re going to be in for a world of hurt. Something like measles usually kills about one out of a thousand kids that it infects. Compare that to COVID, which kills one out of something like 280,000 children. Not to minimize the impact of COVID on kids, but measles is really, really serious. And if we get lax about this, if that vaccine hesitancy continues to build with the routine childhood vaccines, I am very concerned about the types of outbreaks that we’re going to be fighting over the next years.

RACHEL NUZUM: Shanoor, I just wanted to add, you know, as we see headlines about plenty of supply of vaccinations, I think it is really easy to forget that there are still communities and families that don’t have access to the vaccine. And we also have to remember that COVID and the push for COVID vaccinations is not happening in a bubble. When we have roughly half of Black respondents indicating that they’ve had adverse interactions with the medical system or half of our Latino respondents indicating that they’ve experienced systemic racism in the medical system, we’ve got to listen to that and really take that into account as we come up with our messages and tailor our outreach strategies because these are real components that build on each other.

SHANOOR SEERVAI: Such an important point, Rachel.

Dr. Michelle Fiscus, Rachel Nuzum, thank you so much for joining me today.

MICHELLE FISCUS: Thanks, Shanoor.

RACHEL NUZUM: Thanks, Shanoor. It’s great to be here.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Additional music by Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.

Show Notes

Bio: Michelle Fiscus, M.D., FAAP

Bio: Rachel Nuzum, M.P.H.