Vaccination rates for the combined-seven vaccine series fell nationally among children born in 2020 and 2021, when there were significant disruptions in access to care during the COVID-19 pandemic. Recent declines in childhood vaccination rates exacerbate already existing income-based disparities. Nationally, the combined seven-vaccine series completion rate has consistently been lower for children from lower-income families over time. Children from lower-income families are also less likely to receive doses of the combined seven-vaccine series on time. In some instances, children may start the combined-seven vaccine series but fail to receive all doses. A study of incomplete multidose vaccinations found that children from lower-income households were less likely to receive all needed doses; and around 8 percent of children (regardless of income) needed just one additional vaccine dose to complete the series.
After a large measles outbreak between 1989 and 1991 resulted in thousands of cases of measles, particularly among unvaccinated low-income and uninsured children, the federal government created the Vaccines for Children (VFC) program in 1994. It provides routine vaccinations at no cost for children who meet certain criteria, including being uninsured, covered by Medicaid, or being American Indian or Alaska Native. Today, more than half of all U.S. children are eligible for the program and pediatricians participate widely. The VFC program has helped millions access routine childhood vaccination and has substantially reduced disparities over time, but some gaps persist. Combined seven-vaccine series vaccination rates are lower among children living below the poverty level and among uninsured children than they are for children covered by Medicaid. Vaccination rates for the combined series were about 14 percent lower among children born in 2020 and eligible for the VFC program compared to those who are not eligible for the program.
While the VFC program reduces the financial barriers to vaccination among low-income children, cost is only one obstacle. Logistical challenges, including long travel times in rural areas, appointment scheduling issues, and caregiver challenges like difficulty taking time off from work, and transportation and childcare issues can lead to missed appointments. When families move from one state to another, there can be problems accessing care or with immunization record-keeping, as evidenced by lower rates of completion for the combined seven-vaccine series. Parental vaccine hesitancy and the quality of caregivers’ relationship and communication with health care providers also plays a role.
Interventions that may increase early childhood vaccination rates include reminder and recall systems, which involve contacting parents or caregivers to inform them that immunizations are due (or overdue). Immunization information systems — that is, confidential, population-based databases used to record vaccinations — can support reminder and recall systems by centralizing records. Electronic health record reminders for health care providers can help reduce missed opportunities for vaccinations during well-child and acute-care visits. We need further study of interventions to address barriers to early childhood vaccination among low-income families. But growing vaccine hesitancy, driven by the COVID pandemic, the spread of vaccine-related misinformation, and declining public trust in health and science institutions, could hinder the efficacy of interventions. Strategies for clinicians to communicate effectively and build trust with parents and caregivers about childhood vaccines are needed more than ever.
Recent changes to federal vaccine policy could impose additional barriers. The list of vaccinations made available through the VFC program is set by the Advisory Committee on Immunization Practices (ACIP). Recently, we’ve seen dramatic changes in the membership of ACIP, weakened recommendations for COVID vaccines for healthy children, and recommendations against the use of the combined measles, mumps, rubella, and varicella vaccine for children under age 4. It is unclear what changes may come next from the federal or state governments; certain state-level policy changes, like Florida’s plan to eliminate vaccine mandates, will likely lead to lower vaccination rates and higher rates of disease and preventable deaths.
