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Back-to-School Virus Watch: Children Are at Risk for More Than Just COVID-19


Researchers have found that the COVID-19 pandemic has caused potentially millions of children to miss routine vaccines. During a time of back-to-school excitement and reversals of transmission prevention efforts in some states, children may be at risk of facing a slew of non-COVID-19 viral outbreaks.

As children head back to school and as COVID-19 cases rapidly increase worldwide, fears surrounding the health and safety of schoolchildren in the United States have resurfaced, in large part because of major disruptions in routine vaccinations resulting from the pandemic.

Although COVID-19 vaccines are not available for children under 12 years old, routine vaccinations, such as those for the flu, measles, rubella, and diphtheria, are. However, the pandemic’s effect on the health care sector has resulted in millions of children without their routine vaccinations, potentially opening the door for outbreaks of other diseases to occur, especially in areas of the country that have chosen to open schools without face mask, vaccination for adolescents and adults, or social distancing requirements.

To fully comprehend the sheer mass of the number of children who have missed routine vaccinations, a modeling study funded by the Bill & Melinda Gates Foundation and published in the Lancet examined the global disruptions in vaccine coverage associated with the COVID-19 pandemic.

The Scale of Vaccine Disruptions

The investigators of the study assessed administrative data and reports from electronic health records from January 2020 to December 2020 to develop an estimation of the pandemic’s impact on childhood routine vaccinations. The study focused on the missed vaccinations for measles, diphtheria, tetanus, and pertussis, specifically the missed third dose of the diphtheria-tetanus-pertussis (DTP3) vaccine and the first dose of a measles-containing vaccine (MCV1).

The model also included mobility data as a predictor of the effects of COVID-19 on the amount of movement and interaction between people. This data allowed for the investigators to assess the pace of disruptions and recovery of vaccinations.

The results showed that the estimated vaccine coverage was 76.7% (95% CI, 74.3-78.6) for DTP3 and 78.9% (95%CI, 74.8-81.9) for MCV1 globally in 2020, which represented relative reductions of 7.7% and 7.9%, respectively. The investigators estimated that as many as 30.0 million children missed doses of DTP3, 8.5 million of whom were likely attributed to the COVID-19 pandemic. Additionally, 27.2 million children missed doses of MCV1, 8.9 million of whom could be connected with the pandemic.

Missed vaccinations peaked from April through May of 2020, and although recovery has been gradual but steady, new variants, such as the easily transmissible Delta variant and the newly emerged Lambda variant, in addition to the dwindling of COVID-19 precaution measures could stop or reverse this trend.

“In the absence of concerted routine immunisation catch-up and expansion efforts, especially as populations return to pre-pandemic interactions, the world will face heightened risks of vaccine-preventable diseases in 2021 and beyond,” the investigators wrote.

COVID-19 Causes for Disruption

A big reason so many children missed routine vaccinations stemmed from the widespread closure of doctors’ offices and initial fear that health care spaces could lead to transmission of COVID-19, leading many parents to cancel or postpone vaccination appointments in 2020, according to Jonathan Mosser, MD, MPH, the lead author of the study and an assistant professor of health metrics sciences at the Institute for Health Metrics and Evaluation at the University of Washington, in an interview with The American Journal of Managed Care® (AJMC®).

“The pandemic has, for many of us, required us to really think about the risks and benefits of doing lots of different things, including seeking medical care, and weighing those against the risks of exposure to COVID-19. We also know that the pandemic has generally added even more barriers to access for medical services for many people,” said Mosser.

Mosser also explained that the boom of telehealth services during the pandemic has also interrupted the ease at which children are offered vaccines for measles and influenza, preventing providers from administering vaccines in-person during routine check-ups.

Additionally, the uptick in vaccine misinformation surrounding the COVID-19 vaccines developed by Pfizer, Moderna, and Johnson & Johnson has led to increases in misinformation for other vaccines, a concern that was noted by Mosser and Karl Minges, PhD, MPH, the interim dean of the School of Health Sciences at the University of New Haven, who has been actively studying the public health risks related to the pandemic and return-to-school efforts during the crisis.

“Once COVID-19 becomes less mainstream and less of a problem that's facing the broader swath of the United States, we still might see low levels of vaccine utilization for a long time pervasively for all types of vaccines because of the misinformation that's really been distilled from the COVID-19 vaccines,” predicted Minges in an interview with AJMC®.

Disparities and Equalities

Another major takeaway from the study was the stark vaccination disparities between different regions of the world. High-income nations, including the United States, experienced the smallest disruptions compared with lower- and middle-income nations.

During 2020, the pandemic resulted in 10% to 20% reductions for DTP3 and MCV1 doses in northern African and Middle Eastern countries. In addition, countries in South Asia experienced the largest gap between expected and estimated 2020 coverage for both vaccines.

Interestingly, countries in sub-Saharan Africa experienced the smallest disruptions; however, this was largely observed because the region’s expected vaccination rates were already much lower than other regions, further highlighting vaccination disparities that had long predated COVID-19.

“COVID-19 could easily compound pre-pandemic inequities and health risks in underserved and marginalised populations. Collecting and analysing such disaggregated data, particularly for groups inadequately represented by traditional health information systems, will be important to ensure greater equity in provision of routine immunisation services,” wrote the investigators.

Similarly, within the United States, the pandemic has exacerbated the existing socioeconomic inequalities, which have prevented millions of Americans from having affordable access to health care services, potentially impacting the speed of vaccination recovery.

“There may be an equity issue, as well as the health equity issue, in that there may be families who are having a hard time getting their children into care. They may have lost their insurance. They may have a number of jobs trying to keep up with the pandemic. So, trying to get their kids into care may take longer and may be more difficult for them now than it was before the pandemic,” said Yvonne Maldonado, MD, a professor of pediatrics for infectious diseases and of epidemiology and public health at Stanford University, in an interview with AJMC®.

Where Do We Go From Here?

The study delved into several potential avenues that health systems can implement to help accelerate and stabilize vaccination recovery, including conducting vaccination sites outside of clinics, regularly collecting information on children who have missed doses, and improving routine immunization data systems and delivery models.

“During the next phase of the pandemic, wherein a major focus is scaling up COVID-19 vaccines and containing new variants, routine immunisation catch-up and expansion efforts must be sustained, otherwise the world’s fragile progress could easily give way to vaccine- preventable disease outbreaks in 2021 and beyond,” suggested the investigators.

Additionally, Minges recommended that health systems should combat vaccine misinformation by regularly providing educational material on the safety, efficacy, and importance of routine vaccinations and COVID-19 vaccines.

“I think health systems have a big role at kind of spreading out this information about how valuable vaccines should be. They should be also communicating with perhaps public school settings, where there can be vaccine clinics available once the vaccine becomes possible for children with a parent’s permission,” said Minges.

Maldonado elaborated further, saying that providers should be reaching out to families that may have missed vaccinations to remind and encourage them to get their children caught up on vaccinations to avoid potential future outbreaks of illnesses other than COVID-19.

“What we risk is having a whole generation of children who are going to have missed, on top of the many other things that they've missed this last year, some of their incredibly important vaccines and these can really increase the risk that there could be, for example, whooping cough outbreaks or measles outbreaks,” Maldonado said.

Mosser also discussed that when children under 12 years old in the United States eventually become eligible to receive COVID-19 vaccines, there could be a potential opportunity for those vaccines to be delivered in conjunction with routine vaccines.

“The CDC now recommends that you can give a COVID-19 vaccine and another vaccine at the same time without regard to timing. This opens up the door for simultaneous COVID-19 vaccination and catch up on administration of other routine vaccines, which is great. So, it's going to be important…for providers to recognize this opportunity, and use it in every visit, to administer all necessary vaccines to every child,” Mosser said.

Mosser also expressed the concern that vaccination efforts will primarily focus on COVID-19 vaccines and will lack an emphasis on important routine vaccinations, stressing that this is an ongoing effort requiring attention on multiple health concerns.

“In moving forward…it's going to be important to really ensure that there's still a priority placed on providing these essential routine immunizations,” said Mosser.

In the end, all hands within global health systems will be on deck to catch children up on the vaccines that were missed and to continue to address the inequalities that have made matters worse. More concerted efforts are needed to ensure more equitable, accessible, and sustainable vaccine services for all and to ensure that children are protected against all forms of viral outbreak, not just COVID-19.


Causey K, Fullman N, Sorensen RJD, et al. Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: A modelling study. Lancet. August 7, 2021;398(10299):P522-534. doi: 10.1016/S0140-6736(21)01337-4

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