In a Nutshell:

• Since the start of the COVID-19 pandemic, vaccination rates for toddlers have dropped nationally and in Michigan.
• The decline is caused by several factors, including misinformation, philosophical and religious objections, lack of concern about the risk of disease, inconvenience, and a lack of access to care.
• Limiting philosophical waivers, increasing public education about vaccines, and establishing easy-to-access vaccine clinics are valuable steps to take before the declines become permanent.

Background

The COVID-19 pandemic reinvigorated discussion and debate surrounding vaccines.  For many years, vaccines were viewed as a public health necessity, although some individuals objected to mandatory vaccine requirements.  Erroneous claims linking vaccines to autism arose in the late 1990s and early 2000s, sparking an “anti-vax” movement that gained significant attention in the mainstream media.  The global pandemic brought vaccines front and center once again.  And, just as before, uncertainty and misinformation, along with practical challenges created by the pandemic, have contributed to a decline in vaccine rates for not just COVID-19, but other preventable diseases.

The problem has been particularly noticeable in data on childhood vaccination rates.  Nationally, vaccination coverage among kindergartners was lower during the 2020-2021 school year than the previous year.  Recent reports from physicians and public health leaders in Michigan have brought attention to a drop in vaccine rates, especially for toddlers.  Vaccination rates have dropped by six percent for children ages 19 months to three years.  As a result, the proportion of toddlers who have received all doses of state recommended vaccines has fallen below 70 percent as of August 2022.  In other words, about 30 percent of toddlers in Michigan are at a higher risk for preventable diseases. 

Toddlers are particularly vulnerable to disease and illness, as their bodies are still developing necessary immunity.  Further, toddlers have a notorious proclivity for exploring the world using all five senses, which generally exposes them to more germs and bacteria than older children or adults.  The result makes vaccines even more vital for this age group, and the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Health and Human Services (MDHHS) highly encourage vaccinating children as soon as possible. 

While COVID-19 vaccines are now available for children of all ages, the demand for vaccines for toddlers has been lower than expected. CDC data shows that this pace of vaccination has been significantly slower than the pace for older kids and teenagers.   For example, within the first few weeks of vaccine availability, the weekly number of toddlers who had received the first dose of the COVID-19 vaccine stayed below 200,000, and after three months of vaccine availability just 7.7 percent of all toddlers had received their first dose (Chart 1).  In contrast, when the vaccine became available for children ages 5-11, the weekly number of students vaccinated peaked after three weeks at 1.6 million (Chart 2). And, by this point, approximately 31 percent of all 5 to 11 year-olds in the U.S. received a first dose.

Chart 1
Weekly and Cumulative Increase in the Number of U.S. Infants and Toddlers Receiving Initial Dose of COVID-19 Vaccine

Source:  AAP analysis of data series titled “COVID -19 Vaccinations in the United States, Jurisdiction”. CDC COVID -19 Data Tracker (URL: https://data.cdc.gov/Vaccinations/COVID-19-Vaccinations-in-the-United[1]States-Jurisdi/unsk-b7fc )

Chart 2
Weekly Increase in the Number of U.S. Children Ages 5-11 Receiving Initial Dose of COVID-19 Vaccine

Source: AAP analysis of data series titled “COVID -19 Vaccinations in the United States, Jurisdiction”. CDC COVID -19 Data Tracker (URL: https://data.cdc.gov/Vaccinations/COVID-19-Vaccinations-in-the-United-States-Jurisdi/unsk-b7fc ).

The drop in vaccination rates for other illnesses, combined with the lethargic pace of COVID-19 vaccinations, has worried public health officials and sparked discussion among policymakers regarding the most effective ways to increase vaccine uptake, particularly for vulnerable age groups.

Causes of Vaccine Decline for Toddlers

Several inter-related factors contribute to the decline in vaccine rates for children, many of which existed before the rise of COVID-19.  Vaccine hesitancy – defined as the reluctance or refusal to vaccinate despite the availability of vaccines – has been growing among different populations.  While some groups question the timing and safety of new vaccines, other groups reject vaccines altogether for religious or philosophical reasons.  In addition, some populations that have experienced discrimination, oppression, and mistreatment by the medical profession express a distrust of certain medical interventions, contributing to vaccine hesitancy overall.   

The discrepancies in vaccinations rates across the country have been explained by the politicization of the issue.  An NPR analysis found that U.S. counties that supported former President Trump have both lower vaccination rates and greater morbidity and mortality from COVID-19.  In Michigan, however, politics cannot entirely explain the differences in vaccine rates across counties.  Counties with healthier environments, higher educational attainment, and lower rates of income inequality and unemployment generally have much higher rates of vaccine uptake.  Further, politicization cannot explain why vaccine uptake for young children has progressed at a slower rate than older populations.

For the COVID-19 vaccine specifically, health officials point to several potential explanations for the sluggish pace.  Some parents simply became accustomed to life with unvaccinated children and are therefore not in a hurry to vaccinate.  Adding to the lack of urgency is the perceived low health risk of COVID-19 for young children, as symptoms for most children have been relatively minor compared to the disease manifestation in adults.  In addition, two and half years into the pandemic, many young children have already been infected with the virus, leading many parents to believe that their child already has the necessary immunity.  Parent concern about safety regarding the newness of the vaccine has also contributed to the “wait and see” approach. 

While the COVID-19 vaccine rollout has been slow, immunization rates for established vaccines have also declined.  Prior to the pandemic, a study from the American Academy of Pediatrics found that the primary reason for parental resistance to vaccinate their children is not the misinformation regarding the potential dangers of vaccines – they simply found them to be unnecessary.  Ironically, this belief stems from the success of vaccines, as high vaccine rates over time have essentially wiped out the most dangerous diseases that threaten children.  Without health education, it is understandable that many parents do not want to vaccinate their children for diseases that appear to be non-existent.

In spite of the noted decline in vaccine rates for toddlers recently, Michigan’s immunization rates for children generally remain relatively high compared to the national average, but are below CDC targets.  Michigan’s coverage among kindergartners for the MMR vaccine (measles, mumps, and rubella) in 2021 was only slightly lower than the CDC target (95 percent) and was higher than the national estimate (93.7 percent).  The additional barriers and misinformation ignited by COVID-19, however, has public health officials looking for proactive steps to increase the vaccination rates of children and toddlers specifically.

School Vaccine Requirements and Exemptions

School vaccine requirements often get increased public attention with the start of a new school year. Every state has some type of vaccine requirement for children attending school and licensed childcare centers.  Michigan law requires children entering public or nonpublic school for the first time to be vaccinated against certain diseases.  An administrative rule requires vaccinations for younger children in group childcare programs as well.  The COVID vaccine is not currently included in the required vaccinations for schools and childcare programs.  

Many states, including Michigan, provide exemptions for parents who refuse or are unable to vaccinate their children.  In Michigan, a required vaccine may be waived or delayed if:

1. The child cannot receive the vaccine due to medical reasons (medical contraindication).
2. The parent or guardian holds religious or philosophical beliefs against vaccinations.

Michigan is one of 15 states that allow philosophical exemptions for children whose parents object to immunizations because of personal or moral beliefs.  In an effort to increase vaccine uptake, some policymakers across the country are making efforts to reduce the number of exemptions available to parents.  For example, California and Vermont passed bills removing exemptions in 2015.  More recently in 2019, Maine removed personal and religious belief exemptions from public school immunization requirements, and Washington removed the personal belief exemption for MMR for all schools and childcare centers.  

While some states have removed exemptions, other states attempt to make the exemption process more inconvenient.  Seven states, including Michigan, require parents to undergo some type of educational training about the benefits of vaccination and the risks of opting out before they can obtain a non-medical exemption. 

Michigan added an educational requirement in 2014.  After this change, the percentage of Michigan school children waiving at least one vaccine dropped by more than a third (from 4.8 percent in 2014 to 3.1 percent in 2015).  Since then, waiver rates fluctuated between 3.0 and 4.0 percent, but that ended in 2021 when percentage jumped to 4.2 percent.  A 2021 University of Michigan study assessed the short-lived drop in waiver rates and concluded that adding a small inconvenience to the exemption process, like an educational requirement, is not enough to reduce the number of exemptions long-term. 

Some evidence suggests that eliminating non-medical waivers completely can sustain a higher vaccination rate.  A 2020 Stanford University study found that California’s new vaccine policy was associated with a three percent increase in statewide MMR vaccine coverage.  More drastic measures on exemptions, like those implemented in California and Vermont, may be necessary to successfully increase immunizations.  This may be especially true in Michigan, where the vast majority of waivers in 2021 were for non-medical reasons; religious and philosophical waivers account for 96 percent of the total (Chart 3).  An elimination of non-medical exemptions, however, may not have the same impact on vaccination rates for toddlers, as the proportion of toddlers enrolled in childcare centers is smaller than the proportion of children enrolled in K-12 school.  Therefore, implementing additional strategies may be necessary to target the state’s youngest children.

Chart 3
Percentage of School Immunizations Waivers in Michigan By Reason, 2009-2021

Source: MDHHS, Immunization Status of School Children in Michigan, 2021. https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Adult-and-Childrens-Services/Children-and-Families/Immunization-Information/School-Waiver-Information/School-Summary_2021

Other Strategies

As mentioned, immunization requirements only apply to children who attend K-12 school or daycare.  Policymakers must also focus on strategies designed to encourage parents to vaccinate their children.  Low motivation to vaccinate children, combined with high hurdles to access vaccines, contribute to declining immunization rates.  Two potential avenues include public policies that focus on, 1) supporting targeted health education campaigns, and 2) reducing the inconvenience of obtaining vaccines.

Health Education

National and state organizations, including the CDC and MDHHS, make educational materials available to the general public regarding the importance and safety of vaccinating children.  However, different populations may have low vaccinations rates for different reasons, and the best health education campaigns are tailored to specific needs.  The CDC and MDHHS currently fund Michigan State University Extension’s Michigan Vaccine Project, which provides targeted vaccine education to adults and children in rural communities.  The program employs various strategies that include collaboration with local community partners to provide educational presentations, an educational webinar series, social media and digital outreach, and a podcast.  Expanding the project or creating similar efforts aimed at other Michigan communities would help connect more residents with the health education needed to improve vaccine rates. 

Convenience

Parents who are interested in vaccinating their children may be slow to do so due to the general inconvenience of the process.  While most parents trust their child’s health care provider the most, not all providers are equipped to provide an easy, efficient process for parents.  Unless the child already has a scheduled appointment, parents must either schedule an appointment or endure unpredictable wait times of a provider’s walk-in clinic.  Funding for additional pop-up vaccine clinics could help parents, but the unfamiliarity may be a deterrent.  The UMass Worcester Prevention Research Center of UMass Chan Medical School conducted focus groups on how to make vaccine clinics more appealing.  They found that vaccine clinics should strive to be as inclusive as possible, increase privacy during vaccination, make waiting times easier and safer, and provide incentives for children and parents.  Establishing more clinics that are designed with convenience in mind, and advertised successfully to parents, may motivate parents to take the necessary steps to vaccinate their children.

Conclusion

Increasing toddler vaccinations rates is beneficial to the entire community. As policymakers deliberate over how to deploy the state’s budget surplus, an area of focus should be on reversing the COVID-19 era vaccine decline. While revising the state’s school and childcare exemptions to limit philosophical waivers would likely improve vaccination rates, supporting targeted health education programs and easy-to-access vaccine clinics are options that the state can pursue without engaging in the contentious political controversy that has arisen in response to the COVID-19.