News & Views: Are You Still Vaccinating During the Coronavirus Pandemic?

As many communities are shuttered in an effort to slow the spread of COVID-19, a new, and potentially deadly, situation could be “teeing up.” The Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP) are working to prevent it from becoming a reality. The concern — a cohort of children falling behind on routine immunizations.

The situation

The novel coronavirus pandemic is wreaking havoc on every aspect of daily life, and the situation is even more nuanced when it comes to seeking healthcare:

• Families — In addition to widespread shelter-in-place orders, many families are dealing with home schooling, job losses, food insecurity and, in some cases, loss of healthcare coverage.
• Healthcare providers — Public health clinics and practices, even pharmacies, are dealing with diagnosing and treating COVID-19 infections; addressing supply chain issues; ensuring staff safety and availability; and implementing social distancing, disinfection practices and, in some cases, telehealth appointments.
• Communication measures — Compounding these situations are the necessary communications reminding people to stay home and refrain from any non-essential trips as well as to call ahead before reporting to a healthcare clinic. While these messages are necessary, they are also making many families reconsider obtaining healthcare for non-urgent health concerns.

Unfortunately, taken together, these factors are creating a situation in which many children may be missing well visits and, therefore, routine vaccinations. Given that most vaccine-preventable pathogens still circulate at low levels, and considering the opportunistic nature of pathogens in general, having a large population of unimmunized, or under-immunized, children could mean that as communities begin to return to normal, we experience an increase in outbreaks of vaccine-preventable diseases (VPD).

To get a sense of this very real possibility, take a look at provisional VPD reports to the CDC between January and March 2020*, which show that many of these diseases were circulating:

• Diphtheria – not reported (NR)
• Haemophilus influenzae, invasive disease
  • Children younger than 5 years old: 3 cases (type b); 67 (non-type b); 47 (nontypeable); 19 (unknown)
  • All ages, all serotypes – 1,314 cases
• Hepatitis A – 1,969 cases
• Hepatitis B – 355 cases and 4 cases of perinatal infection
• Human papillomavirus – NR
• Influenza – 125 children died from influenza
• Measles – 10 cases (4 imported and 6 indigenous)
• Meningococcus – 91 cases
• Mumps – 402 cases
• Pertussis – 3,119 cases
• Pneumococcus, invasive disease
  • Children younger than 5 years old – 203 (confirmed) and 10 (probable) cases
  • All ages – 5,196 (confirmed) and 79 (probable) cases
• Polio – 0 cases
• Rotavirus – NR
• Rubella – 2 cases
• Tetanus – 1 case
• Varicella – 850 cases

*CDC data through March 28, 2020

Implementing solutions

In an effort to address this potential, the CDC, AAP and AAFP have developed guidance (See “Resources” section for links) for providers. Specifically, these organizations are recommending a stratified approach to vaccinations during this period:

• For children 2 years and younger — Prioritize vaccinations for this group.
• For children older than 2 years of age, teens and adults — Immunize when benefits outweigh risks, during visits for other reasons, including, if appropriate, during sick visits.

These organizations, as well as other individuals and organizations, have offered the following suggestions for safely implementing the recommendations, particularly related to children less than 2 years of age:

• Stagger scheduling of well and sick visits. In particular, schedule well visits for the morning when the office has the lowest chance of contamination.
• Decrease the number of appointments for each time slot, so that fewer people are in the office at any one time.
• Create separate areas for sick visits and well visits, including separate entrances and exits, if possible.
• Consider working with others in your community to have well visits in a different place than your typical location.
• If practices have more than one location, consider designating one for well visits and one for sick visits.
• Use a combined telehealth/in-person visit, in which the majority of the visit is done via telehealth and the child only needs to come to the office for measurements and immunizations, thereby reducing the amount of time in the office.
• Consider completing physical exams and administering vaccines in the car, if your patient population typically arrives for visits by car.
• Continue checking immunization records of patients who arrive for sick visits. In some cases, people can still be immunized. Review the guidance related to “Precautions” in the Comprehensive Recommendations and Guidelines, General Best Practice Guidelines.  Related to this, when communicating with families, you can share the link for the CDC’s “Vaccines When Your Child Is Sick” webpage.

Other considerations

In addition to implementing procedures that enable young children to be safely vaccinated, providers may also consider the following:

• Continue to communicate with families — Proactively alert families about changes to hours, services or other practical information using your typical communication methods. If you are seeing fewer patients, or if you have staff working remotely, evaluate whether the current situation offers an opportunity to expand to new modes of communication.
• Continue to communicate with local public health officials — Procedures for obtaining vaccine supplies, specific recommendations in regard to provision of vaccines in your area, and disease testing and reporting details may vary based on geographic location.
• Consider providing support information — Particularly if you have a well-trafficked website or social media presence, share information about food pantries, health insurance resources, education-based support services and mental health tips and resources, as all of these are critical during this time. During this time of economic hardship for many, consider sharing information related to benefits like WIC and VFC. Likewise, families may welcome knowing about resources for children, including activities to pass time and how to talk to them about what is happening. Provision of quality information during this critical period may also increase the tendency of patient families to turn to your office in the future.
• Finally, consider sharing information about how to evaluate information and avoid scams. The April 2020 Parents PACK “News and Notes” section offered a variety of resources related to both of these aspects of the current pandemic.

Resources

• CDC’s Information for Pediatric Healthcare Providers
• AAP’s COVID-19 Clinical Guidance Q&A
• AAFP’s COVID-19: Guidance for Family Physicians on Preventive and Non-Urgent Care
• Immunity Community from WithinReach, a community-based collaboration with Washington State
• EZIZ, immunization resources from CA VFC Program