• Surveys Take Population-Level Look at Vaccines

    Results Highlight Challenges, Opportunities for Improvement

    Dec. 20, 2023, Michael Devitt Recent survey data from three patient populations — infants and children 24 months or younger, kindergarteners and adults — bring perspective to the state of vaccines and immunizations in the United States as 2023 comes to a close. The research, published in three reports, illustrates the challenges family physicians are likely to encounter as respiratory illness season continues and clinicians prepare for National Immunization Awareness Month next summer.

    “We can increase vaccination rates by efficiently and persistently making strong, presumptive recommendations for vaccinations at every type of patient encounter,” said Paul Hunter, M.D., a professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health in Madison. “We have the trust and influence to expand confidence in vaccines among our patients, clinical staff, colleagues, public officials and social networks. These three studies can help us focus our efforts.” 

    The Academy has stressed the importance of universal immunizations for everyone, and accrued a wealth of resources to help members raise vaccine confidence and counter misinformation on vaccine safety and effectiveness.

    Mixed Results, Disparities at 24 Months

    The first report, published in the CDC’s Morbidity and Mortality Weekly Report, used National Immunization Survey-Child data to compare vaccine coverage at 24 months among two birth cohorts: 2017-2018 and 2019-2020. Although overall childhood vaccination rates were similar, there were some notable differences, with increases in

    • coverage of the birth dose of hepatitis B vaccine (+3.3%),
    • receipt of two or more doses of hepatitis A vaccine by age 35 months (+1.9%) and
    • receipt of the rotavirus vaccine by age 8 months (+0.9%),

    and decreases in receipt of

    • the combined seven-vaccine series (-0.9%),
    • the full series of Haemophilus influenzae type b conjugate vaccine (-0.6%) and
    • four or more doses of diphtheria, tetanus toxoids and acellular pertussis vaccine (-0.6%).

    Story Highlights

    Race and ethnicity analyses revealed several ongoing disparities in vaccine coverage. Compared with white children, Black, Hispanic/Latino and American Indian/Alaska Native children all had lower coverage at 24 months with

    • four or more doses of DTaP vaccine or pneumococcal conjugate vaccine,
    • rotavirus vaccine,
    • two or more doses of influenza vaccine and
    • the combined seven-vaccine series.

    “Overall coverage with recommended childhood vaccinations remains high; however, persistent disparities in coverage among children in racial and ethnic minority groups, as well as those who are not privately insured, who live in rural areas, and who live below the poverty level must be addressed to ensure that all children are protected from vaccine-preventable diseases,” the authors wrote. “More extensive use of the Vaccines for Children program, interventions to improve vaccine confidence, enhanced flexibility in scheduling vaccination appointments and expanded options for the place of vaccination will aid in making the U.S. immunization program more accessible and equitable for all.”

    Less Coverage, More Exemptions for Kindergarteners

    The second report, also published in MMWR, examined vaccination and vaccine exemption rates among U.S. kindergarteners during the 2022-2023 school year. Compared with the previous school year, coverage decreased in

    • 25 states for the varicella vaccine,
    • 28 states for the poliovirus vaccine,
    • 29 states for the measles, mumps and rubella vaccine and
    • 31 states for the DTaP vaccine.

    Nationally, coverage for all four vaccines for the 2022-2023 school year stood at 92.9%, similar to the previous year but substantially below the 95% coverage rate for the 2019-2020 school year, the last when children were vaccinated before the emergence of COVID-19.

    Meanwhile the overall percentage of children with a vaccine exemption increased to 3%, the highest rate reported since the CDC began tracking vaccine exemptions more than a decade ago. Exemptions increased in 40 states and the District of Columbia, and more than 90% of reported exemptions nationwide were not for medical reasons.

    According to the National Conference of State Legislatures, 45 states and the District of Columbia grant religious exemptions to people who have such objections to immunizations, and 15 states allow philosophical objections for children whose parents object to immunizations based on personal, moral or other beliefs. Whereas there have been few changes in vaccine exemption laws, other evidence implicates the COVID-19 pandemic for negatively impacting parental attitudes toward childhood vaccines in general.

    “Whether because of an increase in hesitancy or barriers to vaccination, the COVID-19 pandemic affected childhood routine vaccination,” the authors wrote. “Enforcement of school vaccination requirements, school-based vaccination clinics, reminder and recall systems, and follow-up with undervaccinated students have already been shown to be effective in increasing vaccination coverage. A better understanding of the reasons behind nonmedical exemptions increasing in 40 states and D.C., and their impact, could help develop policies that would complement those interventions, to bring higher vaccination coverage and protection against vaccine-preventable diseases within reach of more states.”

    Misinformation Rises, Confidence Falls Among Adults

    The third report, published by the Annenberg Public Policy Center, analyzed results of a recent wave of the Annenberg Survey on Attitudes of Public Health, which was first empaneled in April 2021 and conducted periodically since to track public perception on vaccines, COVID-19, influenza, Respiratory syncytial virus and other important health issues. The survey of more than 1,500 U.S. adults found that misinformation on vaccines continues to grow, while vaccine confidence continues to shrink. Among the findings:

    • 71% of adults think vaccines approved for use in the United States are safe, the lowest percentage since the question was first asked. At the same time, 16% think approved vaccines are not safe, the highest percentage since the question was first asked.
    • 16% think increased vaccinations are the reason so many children have autism, up from 10% in April 2021. In a separate question, 12% of adults think vaccines are full of toxins and harmful substances such as antifreeze.
    • Compared with a series of questions from August 2022, fewer participants now believe in the safety or effectiveness of vaccines for human papillomavirus, MMR, influenza, COVID-19, shingles and pneumococcal disease. Many of the declines were statistically significant.

    “There are warning signs in these data that we ignore at our peril,” said Kathleen Hall Jamieson, Ph.D., director of the Annenberg Public Policy Center at the University of Pennsylvania in Philadelphia, and director of the survey. “Growing numbers now distrust health-protecting, life-saving vaccines.”

    Family Physician Perspective

    Hunter, a previous AAFP Vaccine Science Fellow, cautioned that more parents and guardians are requesting vaccine exemptions. While this can be challenging, plenty of opportunities exist — whether in the exam room, on social media or through public policy — for family physicians to explain the benefits of vaccines to the public.

    “We need to learn skills to be efficient and effective at delivering these messages so we can keep up the effort for years to come,” he said.

    Hunter attributed decreased vaccine confidence and increased beliefs in misinformation to “nefarious actors” who use “weaponized rhetoric” to prey on people’s fears while seeking financial gain, personal notoriety or power.

    “Pointing out the intent of creators of misinformation and listening to the underlying concerns of lonely, fearful people are key to combating misinformation about science in general and vaccinations in particular,” Hunter said. “Collectively we can identify these creators and use our time to engage with people who have been taken advantage of.”

    Taking a strong, presumptive approach about getting vaccinated, Hunter added, can make a difference with patients and parents. Hunter also suggests

    • listening to the patient’s primary concerns without interruption if they initially decline vaccinations,
    • offering concise responses,
    • asking for permission to provide information that counters their concerns and
    • documenting a plan to recommend vaccines again at the next visit.

    Hunter recommended several Academy resources for members who want more information, including a free online CME course on improving COVID-19 vaccination rates in infants and young children and guidance documents on having conversations about routine vaccinations for children and adults. He also encouraged family physicians to access Immunize.org resources on vaccine confidence and vaccine hesitancy, and original content from CDC and AAP.