With outbreaks of communicable and once eradicated diseases on the rise, a focus on vaccination can help keep communities safe.
Back-to-school typically conjures mental images of sales at local retailers pedaling notebooks, pencils, and kids’ clothes. But in the pediatric medicine and public health worlds, back-to-school has another meaning — a time to ensure that all children have the necessary vaccines they need to start the school year on a healthy note.
“This back-to-school season, we can’t forget about the lifesaving, routine immunizations that provide protection against deadly diseases” while also protecting the rest of the community, says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, chair of the American Academy of Family Physicians.
“The community of immunity” is how Iroku-Malize, who is also founding chair and professor of family medicine with the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, describes the power of protection that vaccines can provide when as many people as possible accept them.
In other words, ensuring all children are up to date on their vaccines before heading into the classroom is not just about protecting the children — it’s about protecting all vulnerable members of a community.
This is particularly important as the U.S. Department of Health and Human Services reports that vaccination rates for kindergarteners remain at their lowest level in two decades. As a result, the United States is experiencing an uptick in cases of measles, and the country as a whole is seeing a summer surge of COVID-19.
Which Vaccines Do Children Need?
Vaccine requirements for enrollment in public schools vary from state to state. But Iroku-Malize says there are five “usual suspects” that are required in every state and the District of Columbia for children enrolling in public kindergarten (save for a few noted exceptions):
- DTaP. This shot protects against diphtheria, tetanus, and pertussis. Diphtheria and pertussis, which is also known as whooping cough, are spread from person to person, while tetanus enters through a wound. All three can be very serious and can even be fatal.
- MMR. This shot covers three highly contagious diseases — measles, mumps, and rubella. These diseases spread easily from person to person and cause a range of symptoms with potentially very serious or even deadly consequences.
- Polio. This vaccine, developed in the 1950s, prevents the disabling and potentially deadly disease polio. While polio has been eradicated from the United States, the vaccine is still widely provided to ensure it does not resurge. Polio is still endemic in other parts of the world, and recent stalling of vaccination rates worldwide have led to increased outbreaks abroad and a few cases in the United States related to unvaccinated or under-vaccinated international travelers.
- Varicella. The varicella virus causes chickenpox, a common illness many Gen X and Millennial adults remember having as a child. Chickenpox can be serious, even life-threatening, during pregnancy and in babies, adolescents, adults, and people with weakened immune systems. The varicella vaccine, rolled out in the United States in 1995, can help prevent chickenpox.
- Hepatitis B. This vaccine protects against the liver disease hepatitis B that’s spread via blood and other body fluids. Alabama and South Dakota are the only states that do not require this vaccine for students.
But, that standard list of widely required vaccines aren’t the only tools available to help protect children and the community. Other vaccines that may be required or recommended:
- Influenza. While most states do not require an influenza vaccine for students, seven states do, and most public health officials and pediatricians encourage all students to get an annual flu shot.
- Hepatitis A. More than 20 states plus Washington, D.C., and Maricopa County, Arizona, have hepatitis A vaccine requirements. People who get hepatitis A may feel sick for a few weeks to several months but usually recover completely and do not have lasting liver damage. However, in rare cases, hepatitis A can cause liver failure and even death.
- HPV. The HPV vaccine protects against human papillomavirus, which can cause cervical and other types of cancer later in life. The HPV vaccine is required for students entering seventh grade in Virginia, Rhode Island, and Hawaii. Female students entering grade seven in Washington, D.C., are also required to be inoculated.
- MenACWY. This vaccine protects against meningococcal disease, a dangerous infection that causes swelling of the brain and spinal cord. This vaccine is required for students entering middle or high school in 35 states and Washington, D.C.
- COVID-19. Many doctors and public health officials also strongly encourage all children enrolling in school to receive an updated COVID-19 booster, but no state currently mandates this vaccine as a condition of enrollment.
Aarti Raheja, MD, a pediatrician and clinical assistant professor at University of Michigan Health, urges parents to add elective vaccines to their children’s list of essential back-to-school supplies, noting that these vaccines are “super important to keep kids healthy.”
The Case Against Exemptions
While many vaccines are required for children to attend public school, there are increasing requests for exemptions. Some children may qualify for exemptions for health or religious or philosophical reasons — permitting children to enroll without having had one or more of these important, routine childhood vaccines.
But when the rates of vaccination drop, that opens the door to outbreaks of vaccine-preventable diseases. Recent upticks in measles cases are attributable to a corresponding drop in vaccination rates. For example, during the 2022-23 school year, the national vaccination coverage rate for the MMR vaccine slipped to 93.1%, down from a target 95% that was last achieved during the 2019-20 school year.
Some communities had even lower coverage rates, which increased chances of outbreaks, leading to 58 cases of measles being reported in 20 jurisdictions in the United States in 2023.
The problem continues to worsen; as of July 11, 2024, 167 measles cases have been reported by 24 jurisdictions. Thirteen outbreaks (defined as three or more related cases) have been reported so far in 2024. By comparison, in 2023, just four outbreaks were reported.
Clearly, every fraction of a percentage point translates to real risk for individuals and communities.
Therefore, Raheja urges parents to forgo elective exemptions if at all possible to protect children who can’t receive certain vaccines for health reasons. “Vaccines really save lives and we’re really trying to focus on community benefit.”
Staying on schedule with routine vaccinations is also important, because delaying these inoculations puts individuals and vulnerable community members at risk for vaccine-preventable diseases. However, during the worst of the COVID-19 pandemic, many people were unable to keep up with routine doctor’s visits, and some children fell behind on inoculations.
There’s no time like the present to catch up, Raheja says. “Go to your doctor as soon as you can to catch up on those vaccines.”
Overcoming Vaccine Hesitancy
Despite the abundance of data showing that required vaccines are safe and effective, some parents are still hesitant. The best way to overcome that challenge, Iroku-Malize says, is by “continually utilizing the ongoing comprehensive relationship with our patients and their families so that we can allay their fears.”
Simply talking about the importance of getting a child all their routine vaccinations on schedule can help ease a parent’s concerns. “I come to these conversations with a level of respect and understanding,” she notes. “There’s no shaming involved. I listen actively to their concerns,” and then address them one-by-one, she says.
Raheja agrees that addressing concerns needs to be handled in a “non-confrontational manner” especially because, often, the reason for the hesitance is rooted in love and concern for the child’s well-being.
“A lot of their concerns are really focused on vaccine safety,” she says, so, reassuring parents that these vaccines are safe can often help them make the leap to acceptance.
“I explain that having your child immunized or having a family member vaccinated helps keep the kids in school and allows them to stay connected to friends and classmates and continue activities. That improves their quality of life and allows them to have that social and emotional development,” Iroku-Malize explains.
It also can help keep them out of the hospital and reduce their chances of developing any of the lifelong complications that can arise from many of the infectious diseases that vaccines can prevent.
Raheja also likes to use a communication approach called presumptive delivery strategy. “It’s just assuming that parents will vaccinate,” she explains.
“Instead of saying, ‘Do you want your child to get their vaccines today?’” she flips the question into a statement, saying: “‘Your child will be getting their MMR and varicella vaccines today.’ Changing that terminology around works quite well,” she says, especially when everyone in the clinic is using that same approach so the message is reinforced by every staff member encountered during the visit.
Raheja also shares that she and her children are all vaccinated, reinforcing that vaccinating is the right thing to do for everyone.
The Bottom Line
Iroku-Malize says there are three key things for parents to know:
- Safe and effective vaccines are available now for children going back to school, and parents should call their pediatrician or schedule a clinic visit for their child to ensure they are up to date with all local requirements before heading into the classroom. Updated COVID-19 and influenza vaccines will be available this fall.
- Vaccines are lifesaving, providing critical protection against potentially deadly diseases.
- A primary care physician can help make sure every child has what they need to head back to school protected and ready to learn and grow this fall.
“Ensuring that kids stay up to date with vaccines is really important as we head into the back-to-school time,” Iroku-Malize says.