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March 14, 2022

How vaccination campaigns for kids worked in the past–and why they're so hard to make effective today.

Daily Briefing

    Writing for The Atlantic, Sarah Zhang analyzes how past and present vaccination campaigns in the United States have attempted to boost child vaccination rates—and why vaccine uptake among children has never been "immediately universal."

    'Vaccine uptake in children has never been immediately universal'

    According to Zhang, "[v]accine uptake in children has never been immediately universal—not for polio, not for measles, chickenpox, HPV, or any other childhood shot." For instance, in September 1957, two years after the polio vaccine became available, just 50% of children had been fully vaccinated against the disease.

    According to a report from the National Foundation for Infantile Paralysis, now known as the March of Dimes, low vaccine uptake among children was not a result of supply issues, or doubts surrounding the vaccine's safety or efficacy. Rather, according to researchers, when the "initial excitement" surrounding the polio vaccine "faded," vaccine proponents had to find ways to reach the remaining unvaccinated Americans—an effort that took nearly two decades before polio was eradicated in the United States.

    Similarly, before the Covid-19 pandemic, it typically took years for vaccines to go from receiving FDA approval to being mandated in schools to achieving high vaccination rates. 

    How to boost vaccination rates among kids

    To boost vaccination rates among children, a successful vaccination campaign must reach the parents who remain indifferent or hesitant, as well as those who might not have the time or easy access to doctors, Zhang writes.

    In previous cases, a combination of persuasion and vaccine mandates has eventually managed to boost vaccination rates—but these tactics have their limits, Zhang writes. "No past vaccine is a perfect analogue for [Covid-19], but each illuminates the challenges of a task as gargantuan as trying to immunize every child in America," she explains.

    For Covid-19 specifically, one issue could stem from the first year of the pandemic, when experts consistently reassured parents that Covid-19 was significantly less deadly for children—a perspective that has since turned Covid-19 vaccination efforts for children into an "uphill climb," Zhang writes.

    "But convincing parents that a disease that is familiar, that they have seen many kids recover from, is in fact worth preventing is not at all unique to [Covid-19]," Zhang writes.

    For instance, in 1963, the first measles vaccine was approved, marking an inflection point in America's vaccination history, changing both the type of disease considered worth vaccinating against and the role of federal and state governments in immunization, according to Elena Conis, a historian of medicine at UC Berkeley.

    During that time, measles was seen as a routine childhood illness—as "inevitable as 'wornout shoes' and scraped knees," according to a doctor Conis quoted. As a result, to persuade parents that their children needed to be vaccinated against measles, health officials in the 1960s launched vaccine campaigns that emphasized rare but severe complications, including ear infections, pneumonia, and swelling in the brain that could cause hearing loss or death. 

    In response to these efforts, parents in "the middle class and upper class were easily persuaded that measles was worth preventing, but those living in poverty spoke of more pressing priorities," Conis noted. "Long lines and short hours in out-of-reach public health clinics did not help."

    The situation created an uneven distribution of the measles vaccine among children until the 1970s, when measles outbreaks hit U.S. cities and public health officials began implementing state-regulated school vaccine mandates. "One of the justifications for making measles vaccines and other vaccines mandatory through school is it does have a kind of equalizing effect," said James Colgrove, a sociomedical-sciences professor at Columbia University.

    By 1980, all 50 states had implemented measles-vaccine mandates. As a result, 96% of American schoolchildren had been vaccinated against measles in 1981.

    "Historically," Conis said, "we've turned to mandates when voluntarism wasn't cutting it. But in recent years, we in some cases didn't wait for that."

    Although vaccine mandates in schools have historically been a key policy in raising U.S. vaccination rates, Conis and other scholars noted that mandates often trigger tension between individual autonomy and the protection of the American public. "We entered this century with a longer list of mandatory vaccines for kids than we ever had before. To me, it's not at all surprising that that saw a rise in vaccine hesitancy and skepticism in the face of this. It's possible we used up a lot of goodwill in doing that," Conis said. 

    "Once you go down the mandate road, you're sort of making the persuasion road a little rockier," said Julie Downs, a psychologist and behavioral scientist at Carnegie Mellon University. "So maybe we do want to go down the persuasion road with kids a little bit before we get to the mandate mode." 

    Ultimately, "[t]he viability of school mandates will also depend on how well the vaccines perform, especially in the long term," Zhang writes.

    Notably, Covid-19 vaccines have been available to children under 16 for just a few months. During this time, roughly 26% of children ages 5 to 11 and 57% of teens ages 12 to 17 have gotten both shots. 

    "These rates, which are so far below that of adults that they suggest many vaccinated parents aren't vaccinating their kids yet, have already prompted much hand-wringing for being too low," Zhang writes. However, "in historical terms, we are still very, very early into our efforts to vaccinate against [Covid-19]." (Zhang, The Atlantic, 3/10)

     

    Advisory Board's take

    3 key steps to help vaccinate children in your community

    Over the last two years as I’ve been tracking the development of Covid-19 vaccines, emergency use authorizations, and rising national vaccination rates, one thing has been clear: scientific innovations are only effective if we get them to the people who need them. However, bringing innovations to people is complex. It requires a balance between strong scientific communication campaigns, consistent messaging (especially amidst changing information and guidance), targeted efforts to truly understand and address diverse community perspectives, regulatory actions, and strong leadership.

    This article from the Atlantic illuminates another critical lesson: predicting the future of scientific innovations and public health also requires us to look to the past.

    We must understand the intersection science, medicine, history, and the ripple effects these intersections have on public perspectives of innovations (and subsequent adoption.) As Zheng highlights, we can learn a lot—but not all—about today’s Covid-19 vaccine uptake in children by looking to the past, for example by examining the slow uptake of children’s’ measles vaccines. In some cases, history might repeat itself, but we can also leverage lessons learned to advance progress today—for example, how to strike the right balance between persuasion and mandates. 

    As Zheng noted, vaccine uptake in children might be an “uphill climb.” But there are 3 things that all health care leaders can be doing right now to increase vaccination rates amongst children:

    1. Understand how perspectives on vaccines can vary across and within communities. “Parents” and “children” are not monolithic groups. As Zheng pointed out, initial distribution of the measles vaccines was uneven as communities had differing perspectives on measles and its significance. Health care leaders should continue to partner with local community leaders who have direct insight into parent perspectives—such as pediatricians, religious leaders, and educators—to surface concerns from the frontlines and expand their reach.

    2. Continue to offer vaccine solutions that meet community needs. As Zheng highlighted, much success of children’s Covid-19 vaccinations will depend on the ability to convince parents. But convincing is in both the messaging and the execution. To make children’s vaccines as easy as possible, health care leaders should continue to create and staff child’s vaccination clinics with flexible hours and convenient locations. Parents shouldn’t have to take off work to get vaccinated and kids shouldn’t have to miss school to get their shots.

    3. Don’t pass on opportunities to educate children directly about Covid-19 vaccines. While parents have the final say over their child's vaccination decision, it's still important to place value in the questions, concerns, and thoughts that children may have. Kids can and should learn about Covid-19, the vaccines, and what it all means for them. Health care leaders can lead efforts to educate kids and empower them with knowledge and information about the vaccines. Some organizations, like the Smithsonian Science Education Center, have even launched instructional materials designed for use in and out of school to encourage young people to become trusted sources of information about Covid-19 in their communities.

    Parting thoughts

    These are just three of the many steps health care leaders can take on the mission to vaccinate kids and protect them from Covid-19. Above all, leaders should embrace a commitment to honest and clear communication, even if that means changing previously held stances. When the science shows changing results, that should be communicated clearly and robustly. And when the science affirms our guidelines; we can double down. When we hold stances that ultimately are proven "wrong" or were misguided, we should embrace the humility it takes to admit that and change course. This is as important as ever, with trust in our public health system at an all-time low. Each of us can play an essential role in building back trust in science and medicine.

    Andrew Mohama contributed to this article.

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