Like other pediatricians in Orange County, Eric Ball, of Ladera Ranch, didn’t see many kids during the spring, meaning a lot of his patients didn’t get their vaccines. Because vaccine rates are already low in California, many experts believe that after coronavirus abates and children return to classes, a second health crisis could emerge with the spread of measles, whooping cough and other preventable diseases. (Courtesy of Eric Ball)
Editor’s note: This story was first published by The Orange County Register on July 24, 2020 and written by Claudia Boyd-Barrett.
Since the rise of COVID-19, pediatrician Eric Ball’s job hasn’t been the same.
Before mid-March, when the first round of stay-at-home orders took hold in California, Ball tended to a steady flow of young patients. Their parents brought them to his Ladera Ranch office, Southern California Pediatric Associates, for regular well-child visits and, critically, childhood vaccinations.
No more. Today, even with health fears gripping the community, Ball’s medical office is strangely quiet. As the pandemic has waxed and waned and, now, kicked into a potentially higher new gear, parents have put off or cancelled their kids’ health appointments.
Their thinking, it seems, is that any visit to a health provider only boosts the chances that they or their kids will catch coronavirus. What’s more, as Ball gets on the phone with parents, reassuring them it’s safe to bring their children in, the argument he hears is simple: Since the kids are socially distancing, their vaccines can wait.
Ball says that’s a risky choice — for the kids and, eventually, for the community.
“What I worry about is there are going to be kids who are going to be months or a year behind on their vaccines. And once they reintegrate into society they’ll be susceptible to diseases they shouldn’t be susceptible to,” Ball said.
“I fear that in the fall and winter, especially when children go back to school, we’re not only going to be dealing with COVID outbreaks and flu outbreaks, but outbreaks of vaccine-preventable diseases.”
In April, at the height of the state’s strictest stay-at-home restrictions, childhood vaccination rates in California fell by around 50%, according to state data. The numbers ticked up in May and June, but remained significantly below 2019 levels.
That alarms health professionals, who fear an increase in unvaccinated children could lead to a resurgence of diseases like measles, meningitis, and whooping cough. That concern has only ratcheted up as public spaces have reopened and families — many with kids who aren’t vaccinated — emerge from lockdown to enjoy warm weather.
The recent second surge in COVID-19 cases, especially in Southern California counties, further complicates efforts to spur parents to get their children vaccinated. And experts say whenever in-class instruction resumes at schools — with unimmunized kids sitting shoulder to shoulder — conditions could be ripe for a new, non-COVID health crisis.
“Getting the message out, and turning (kids) away (from school) and saying, ‘Hey you’ve got to get (your shots) done.’ That’s a lot of work,” said Pamela Kahn, health coordinator for the Orange County Department of Education and president of the California School Nurses Organization.
“We don’t want to keep kids out (of school) on a massive level,” Kahn added.
“(But) we don’t want schools to get lax and let kids in who haven’t been immunized.”
Old Problem Gets Worse
California law requires children be up to date on their vaccines before starting school and daycare. But many schools, for reasons ranging from language barriers and economics to parents holding the erroneous belief that vaccines cause autism, have struggled with low vaccination rates.
Even after a jump in vaccination rates from 2010 to 2017, the latest numbers from state health officials showed that just 68.6% of California kids ages 18 months to 4 years old had all of their shots as of 2018. The state’s goal, pre-pandemic, was to reach 80% by 2022.
Now, health officials fear that parents who have lost jobs and health insurance during the pandemic might not know about state programs that cover kids’ vaccinations for free, said Catherine Flores Martin, executive director of the California Immunization Coalition.
They might also incorrectly interpret social distancing orders as a recommendation to avoid the doctor’s office, she added.
Vaccination delays are especially worrisome for babies and toddlers.
Flores Martin said the volume and frequency of vaccines required for the youngest children make it easy to fall behind. And young children, she added, are particularly vulnerable because their immune systems are underdeveloped.
It’s a big reason why many doctor’s offices have doubled down on trying to make sure children under the age of 2 come in for visits.
“It might look like, ‘Oh, it’s only a month or two.’ But for babies, two months behind is a long period to be without protection,” Flores Martin said.
“Once they are close to people, they run the risk of getting something that can be lethal to an infant, like pertussis (whooping cough).”
In April, when California was under stay-at-home orders for the entire month, statewide vaccination rates for children, including babies and toddlers, fell by almost half. In May, vaccinations were running at about 65% of what they were a year earlier and, in June, they’d risen to just 87% of 2019 numbers.
While Flores Martin suggested the trend is encouraging, doctors remain concerned about the swath of children who remain unvaccinated. And now, with lockdown orders issued July 10 for indoor businesses — and the possibility of wider lockdowns kicking in as coronavirus cases surge — doctors worry that parents again might turn away from bringing their kids in for shots.
“My sense is that (doctors) are working hard and making a positive impact on the numbers, but it is still lower than needed,” said Flores Martin.
Locally, initial data shows that some counties are faring better than others.
In Los Angeles, San Bernardino and Riverside counties, the vaccination rate for kids age 2 and younger fell by 50% in April versus a year earlier. In Orange County, the drop was 40%.
And few parents are bringing their kids to the community clinics in San Bernardino and Riverside counties, said Deanna Stover, president of the Community Health Association Inland Southern Region.
Dr. Brenda Figueroa, a pediatrician with Borrego Health, which has clinics in San Diego, San Bernardino and Riverside counties, estimated she’s seen 30 fewer children each day over the past three months at her offices in El Cajon compared to before the pandemic.
That adds up to almost 3,000 children missing care, despite the clinic implementing screening and social distancing procedures, and offering an option to get vaccinations outside.
“There was, and there is still, a lot of fear and skepticism about bringing children to their appointments,” said Figueroa.
Fear of Disease
Stephanie Velasco, a mother of eight from Pacoima, has hesitated to bring her kids to the doctor’s office during the pandemic.
In June, when she got a call from Northeast Valley Health Corporation’s clinic in San Fernando, reminding her to bring in her 2-month old daughter for shots, the first question Velasco asked was: “Is it safe?”
Velasco envisioned a waiting room filled with sick children coughing and sneezing, as it was before the pandemic.
Instead, she said the waiting room was empty when she arrived. A staff member took temperatures at the door. And everyone, including the doctor, wore a mask.
The experience gave Velasco the confidence to return a couple of weeks later with her 4-year-old son who needed shots for preschool.
“I was still a little nervous about it,” she admitted.
The problem goes beyond nerves. In some communities, clinics have closed temporarily, cut hours, or laid off staff due to the pandemic and the drop in demand for services.
Stover said more than 20 of the 105 primary care clinics her organization represents in Riverside and San Bernardino counties remain closed. Among those, she added, are some school-based health centers and mobile health clinics, which can provide vaccinations for children whose parents lack time or transportation to visit a regular clinic.
Many clinics have shifted to tele-health appointments. But immunizations can’t be done over a phone or computer. Parents whose regular pediatrician’s office is closed have to seek care at the nearest open clinic, which can be further away, said Stover.
Some parents, especially those who are low income, may not have access to transportation to get them there. And even if they do, they may not feel comfortable going to an unfamiliar clinic, Stover said.
For some diseases, the risk of delaying immunization is minimal, experts said. Polio, for example, has been eradicated from the United States for more than 30 years.
But sporadic outbreaks of other diseases, such as measles, chickenpox, mumps and whooping cough, still occur.
In 2019, there were 73 confirmed measles cases statewide and more than 5,000 cases of whooping cough, including nearly 2,000 in Los Angeles County.
Measles can lead to pneumonia and encephalitis, among other side-effects, with children younger than 5 and adults older than 20 most likely to suffer complications. Whooping cough can lead to pneumonia, seizures, brain damage and death, with young children — particularly babies younger than 1 — being the most vulnerable to complications.
Some of the same social distancing rules being used to slow the spread of COVID-19 could help prevent or slow the spread of diseases that typically can be warded off with vaccines.
But Figueroa, among others, wonders how feasible it will be to expect young children to follow social distancing rules once they’re back at daycare and school. She said it’s been a challenge to get kids and teens visiting her clinic to simply wear a mask.
“Half of them, when I walk in, they have their mask on their chin. They don’t want to wear it,” she said.
“So it’s going to be very difficult at school. How are they going to enforce that the kids practice all the guidelines?”
The next couple months could be critical for getting children caught up on their vaccines.
Communication is Key
Statewide, The California Immunization Coalition is working on a “back to school” immunization campaign, a push that Flores Martin said is also being taken up by the school nurses organization, American Academy of Pediatrics, and California Department of Public Health.
California Department of Public Health spokesman Ronald Owens said officials have also conducted webinars and sent out letters to health care providers promoting routine immunization during the pandemic.
Hana Brake, communications coordinator for the Orange Unified School District, said administrators there are reaching out to local hospitals, asking them to provide mobile immunization stations for students.
And in Riverside County, public health authorities have issued email blasts to patients who receive care at county clinics, reminding them about the importance of getting kids vaccinated, said Riverside University Health System Public Information Officer Jose Arballo.
Clinics are also designing creative strategies to encourage patients to come in. Some offer drive-through immunization clinics, or set up tents where children can get immunized without stepping into an enclosed building. Many have rearranged their office spaces and appointment hours to keep well children and sick children separated.
Some providers are contacting patients via social media, text messages and phone.
At Northeast Valley Health Corporation in the San Fernando and Santa Clarita valleys, workers send out daily messages to parents of different age cohorts, urging those parents to set up appointments. Those messages also link to a video featuring Director of Pediatrics Dr. Gina Johnson reminding them to get their kids vaccinated.
“Once we’re able to communicate with them, many (parents) are much more happy to come in,” said Johnson.
“Generally, just our word that it’s safe is enough for them to say, ‘OK.’”
Still, some providers worry that the pandemic-era drop in vaccinations could result in the opposite problem as the school year approaches. A sudden surge in demand, they say, could be difficult to manage, especially given the need to maintain social distancing inside clinics.
Flores Martin advised parents to call their child’s doctor to schedule postponed vaccinations, since not all clinics are proactively contacting families. Providers, too, need to do their part by reaching out to patients, she said.
“Some of these vaccines that parents take for granted have really impacted and diminished or eliminated these (vaccine-preventable) illnesses in little ones,” she said.
“We want to make sure these illnesses don’t come back and complicate things even more.”
Claudia Boyd-Barrett reports for The Center for Health Reporting at USC’s Schaeffer Center for Health Policy and Economics. This story was supported by a grant from First 5 LA.