• Worth a Shot: Home Visits Keep Kids Up to Date in Pandemic

    There have been so many unexpected tragedies during this pandemic, I have lost count. Things I didn't even know I needed to worry about are suddenly on my list of concerns.

    I have watched with growing concern as coronavirus has brought not only the risk and fear of COVID-19 infection, but of a resurgence of vaccine-preventable diseases.

    As COVID-19 has spread to every corner of the world, the infrastructure of poor countries has been pushed to the brink in their struggles to keep the virus at bay. One of the strategies implemented to do this, preventing large groups from coming together in close contact for prolonged periods of time, is now threatening vaccination rates. An unintentional outcome of social distancing has been the spread of illness and death from vaccine-preventable diseases. This spring, after the World Health Organization and the United Nations Children's Fund warned that the pandemic could spread through inoculation programs where large groups of children and mothers gather in lines for extended periods of time, many countries suspended their programs.

    In some countries that kept immunization programs going, cargo flights with vaccine supplies were halted by the pandemic, and health workers who normally run the programs were diverted to other roles.

    Diphtheria has now reemerged in Pakistan, Bangladesh and Nepal. Cholera has emerged in South Sudan, Cameroon, Mozambique, Yemen and Bangladesh, and a mutated strain of poliovirus has been reported in more than 30 countries. The WHO and other international public health groups are urging countries to carefully resume vaccination while they are dealing with the coronavirus. However, vaccine supplies are still difficult to obtain, and health care workers are spread thin. Countries already having difficulty responding to COVID-19 could be overwhelmed by outbreaks of other diseases such as measles, which has flared around the globe in places like Bangladesh, Brazil, Cambodia, the Central African Republic, Iraq, Kazakhstan, Nepal, Nigeria and Uzbekistan. Eighteen of the 29 countries that have suspended measles vaccination campaigns due to the pandemic are reporting outbreaks.

    I have read these reports with a heavy heart, but those stories feel far away. The risk posed by dipping immunization coverage is right here at home, too, and something that we as family medicine physicians need to be aware of and ready to confront. Those of us in areas where new COVID-19 cases hit a lull probably saw office visit numbers increase, but if history has taught us anything, it's that we may be fighting a surge in the fall. In that scenario, in-person office visits will plummet, and we will need to be ready for what we are going to do to make sure that our pediatric populations, in particular, do not fall through the cracks and get behind on immunizations. As a physician with a large pediatric patient population, vaccines have long been a soapbox issue for me. I have conversations with parents regarding the importance of vaccines every day in my clinic -- and now sometimes in patients' homes.

    I recently did a home visit for a 2-month-old I had delivered. I saw her at home for her initial newborn visit as well. Home visits were something that have been a part of my practice since the beginning, but only for those recently discharged from the hospital, hospice patients or those with mobility issues. I never considered pediatric home visits before COVID-19, but I talked with parents about their fears related to bringing their children to a medical facility even with the safeguards we have in place (or bringing them into the community, period).

    Pediatric home visits, including immunizations when needed, are now part of my practice. We are a rural practice and have patients who drive an hour or more to get here from surrounding counties, so home visits are not possible for everyone, but in those cases we have improvised by having weight checks and immunizations done at local health departments, with a rescheduling of the in-person well-child check or doing a telehealth visit.

    Addressing the likely disruption of routine vaccinations is crucial, and I expect my practice will have to adjust even more in the coming months.

    I have already discussed with staff the need to come up with protocols for drive-up/parking lot vaccination and increasing home visit capacity. Immunizations are vital to public health and the safety of our patient population, and the disruption of routine immunizations could reverse the incredible progress of widespread vaccination not only in our country but around the world.

    The rates of vaccinations for children have dropped significantly due to concern and reluctance to bring children to doctors' offices for fear of contracting the novel coronavirus. This means children are falling behind on routine vaccinations. According to a CDC report that analyzed the vaccination coverage of children in Michigan, immunization rates plummeted in May. Less than half of children 5 months or younger were up to date on recommended vaccines during that month, compared to roughly two-thirds of infants who were on schedule during May of the previous four years. This is likely representative of trends throughout the country.

    Dealing with COVID-19 is enough. We don't need to also contend with vaccine-preventable illness on top of it. We need to reach out to our patients and ensure that we catch any children -- or adults, for that matter -- who are behind on vaccinations to get caught up now. Think outside the box, offering home visits for vaccinations if you can or parking lot vaccine opportunities where parents and patients do not have to get out of the car.

    We are also going to have to have strategies going forward to keep our patients from falling further behind on preventive health services such as vaccinations. I am encouraging my patients who are coming due on DEXA exams, colonoscopies or mammograms to get these tests, if possible, right now while there is a low rate of infection in my area.

    Preventive health is at our core as family physicians, and something we must be diligent about in the coming months. We need to utilize our EMRs to find the missed opportunities and call patients to make them up, work in as many well visits as we can during as long as we have low rates of infection in our communities and start to educate our patients on the extreme importance of flu shots this year, as well as how to stay safe.

    It is a challenging time, but many things we rely on as family physicians will be there with or without COVID-19, including the trust and reliance our patients and our communities have for us regarding recommendations on preventive care and trustworthy information.

    Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.


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