Vaccination rates have declined since the COVID-19 pandemic, and vaccine-preventable diseases are on the rise. On the front lines are children and their parents, who face chaotic schedules, accessibility issues, and misinformation.
Getting vaccines, hearing about vaccines, caring about vaccines, arguing about vaccines—it can all feel exhausting. And part of that is likely because vaccination, or immunization, is the most lifesaving development in the history of medicine.
Vaccines have saved more human lives than any other medical invention, according to the World Health Organization. Every year, 4 million deaths worldwide are prevented by childhood vaccination, as per the Centers for Disease Control and Prevention (CDC).
This information is important right now because of some troubling trends.
In Minnesota, as well as the rest of the country, rates of vaccination have been going down while cases of vaccine-preventable diseases are going up—“including some very concerning ones, like measles,” says Jessica Hancock-Allen, the Minnesota Department of Health’s director of the Infectious Disease Epidemiology, Prevention, and Control Division.
Concerns are most urgent for the very young. Those younger than 2 years old—the age at which children are recommended to have received the first dose of most of their vaccines—have seen the steepest decline in vaccine rates. They present a higher risk of serious virus complications.
“We don’t want to scare parents. That’s not our goal here,” Hancock-Allen says. “But [these two trends] that are happening simultaneously … are concerning.”
What kind of drop are we seeing? For Minnesota children aged 24-35 months, immunization rates across the seven-vaccine childhood series dropped, individually, about 4-6 percentage points from 2020 to 2023. Those 2023 rates range from 68.8% for the diphtheria, tetanus, and pertussis vaccine to 82.4% for the polio vaccine. The Office of Disease Prevention and Health Promotion’s goals for 2030 include about 90% coverage of certain recommended vaccines among young children. Just 63% in that 24- to 35-month bracket in Minnesota were current on their immunizations in 2023, down from 69.6% in 2020. This is about the same rate of vaccination as a decade ago. Prior to the pandemic, that figure had been steadily rising since 2015.
Meanwhile, the increase in vaccine-preventable diseases “is likely due to a couple of different factors,” the Department of Health states, including “the dip in childhood immunizations, decreased levels of community immunity from lack of circulating diseases during the pandemic, and increased travel since the pandemic.” As the world opened up, so did the spread of infections.
Measles Uptick
For as long as it has been around, vaccination has aggravated the anxious imagination. It has stoked fears of religious sacrilege. It has raised hackles about unproven effects. Traditionally speaking, vaccination is the controlled bodily introduction of a weak or dead virus. This touches off the immune system, so the body, remembering the germ, fights it better upon exposure. That basic idea has been in practice since at least the 15th century. People in different parts of the world began intentionally exposing healthy folks to smallpox to prevent serious illness. The smallpox vaccine arrived in the late 1700s, and by 1980, it had cleansed that scourge from the earth.
Usually, vaccination involves a needle. Side effects are possible, typically mild and short-term. The landscape of viral threats to human health has morphed dramatically thanks to inoculation. Getting two doses of the 1971-introduced MMR vaccine, for instance, can protect a person against measles, mumps, and rubella with about 90% e ectiveness. These illnesses were once extremely common and sometimes fatal.
“Using measles as an example, I would say that [the rise in cases] should be everyone’s concern,” Hancock-Allen says. The virus, which tends to cause a fever and a rash of red spots, is seeing more cases in Minnesota, nationally, and globally. It “can be the most serious,” resulting in hospitalization or even death. (In the United States, 1 in 5 unvaccinated people with measles will be hospitalized, and 1-3 of 1,000 children will die, per the CDC.)
“For measles, what we look for, optimally, is a 95% vaccination rate in order to reach herd immunity,” Hancock-Allen says. That way, as the highly contagious respiratory illness—spread easily, via talking and breathing—tries to latch on, “there’s just nowhere for the virus to go.”
The Department of Health recommends children receive the first dose of the MMR vaccine between 12 and 15 months of age. The second should come between ages 4 and 6. About 87.7% of Minnesota kindergarteners (about 5 years old) were fully immunized against measles in the 2022-23 school year. This was down from 92.6% in 2019-20. In 2023-24, it slid to 87%. For children in the 24- to 35-month age range, the rates are lower: MMR vaccination sat at 78.7% in 2023, down from 83.5% in 2020.
The state requires kids enrolled in school to show they have received immunizations. Otherwise, families must fi ll out—and have notarized—a non-medical exemption, excusing children from certain vaccines. MMR exemptions among kindergarteners in Minnesota reached 4.3% in the 2022-23 school year. That’s up from 3.5% in 2019-20. “Exemptions [at or over 5%] limit the level of achievable vaccination coverage,” the CDC states, “which increases the risk for outbreaks.”
The nearly 5% decline in the MMR vaccine rate since 2020 among young kids is alarming, Hancock-Allen says, in part because measles outbreaks have increased worldwide since 2010.
In 2022, about 83% of the world’s children received one dose of the measles vaccine by their first birthday, per the World Health Organization. This was the lowest since 2008. In 2023, more than 300,000 measles cases globally made for a 79% increase over 2022.
There were nine probable measles cases reported in Minnesota by the Department of Health as of late May. All nine cases were under age 10, all unvaccinated for MMR. That gives this year the fourth-highest caseload since 2000. Minnesota previous measles occurrence was in 2022, with 22 cases.
In 2017, a significant outbreak involved 75 cases among an under-immunized Twin Cities community. Risk for widespread U.S. measles transmission remains low because of high population immunity. With 93% of kindergarteners vaccinated against measles nationally in the 2022-23 school year, the country is nonetheless falling short of the 95% mark, which it had held stable for 10 years pre-pandemic.
Technically, the virus is eliminated in the United States. Without “sustained circulation,” no endemic cases have cropped up since 2000. But measles occur in the United States when travelers bring this easy-to-import illness with them from abroad. “A rapid rise in measles cases in the first months of 2024 threatens the United States’ elimination status,” Minnesota’s Center for Infectious Disease Research & Policy said in April, citing the CDC, “a situation the nation hasn’t faced since 2019.”
It described a 17-fold increase in cases in this year’s first quarter, compared to the mean from 2020 to 2023. Especially at risk are close-knit, under-immunized communities. In these pockets, such viruses find footholds.
The Chicago Department of Public Health is tracking a current example. A measles outbreak resulted in 64 cases this year as of late May. A study released by the CDC linked it to a migrant shelter. More than 70% of cases occurred in persons considered unvaccinated, meaning they lacked documentation of measles immunization.
“A rapid rise in measles cases in the first months of 2024 threatens the United States’ elimination status, a situation the nation hasn’t faced since 2019.”
–The Center for Infectious Disease Research & Policy
Reasons for Falling Behind
Children and their families make up the “front line.” And families face three primary obstacles to vaccination, Hancock-Allen says.
There’s the overall chaos of parenthood: schedules, schoolwork, checkups. Wellness visits? Missed. Vaccinations? Put off.
There are accessibility issues, as when insurance gets in the way for parents who may not realize the Minnesota Vaccines for Children Program aims to keep all children up to date with state law by providing free and low-cost immunization. Also, “like any other business, it’s difficult when clinics are not fully staffed,” says Pamela Gigi Chawla, the lead pediatrician at Children’s Minnesota. The Department of Health notes anecdotal reports of low staffng at clinics. Gigi Chawla says Children’s aims to schedule visits within two weeks “If [a parent is] trying to make an appointment a month from now,” she says, “life can get in the way of that.”
Then, there’s misinformation about vaccines. It tends to spread on social media and falsely suggests harmful associations. Anti-vaccine activists have targeted certain communities, such as the local Somali community, erroneously tying the MMR vaccine to autism, for example.
Another setback has been the COVID-19 pandemic. The globally disruptive event made the juggle of parenthood more intense, so it felt overwhelming for some to get their children into clinical settings for shots. “I think of what people were accessing during the pandemic. It was really about sick care,” Gigi Chawla says. Attention fell away from preventive care, which includes wellness visits, when children get vaccines.
Intervals between wellness visits can fl y by. “It’s two, four, six months, nine months, one year, 15 months, 18 months, two years, two and a half, and then annually after that. And at each of those visits, there are either vaccines or catch-up vaccines that are offered if a family has missed their well-child check,” Gigi Chawla says. Well-child visits “fell o during the pandemic… and now I think it’s just no longer top of mind.”
Distrust around the new COVID-19 vaccine also may have lingered. A survey of U.S. adults released in late 2023 found “eroding confidence” in vaccines, plus greater willingness to accept misinformation about vaccines and COVID-19 over the previous two years, according to a release by the University of Pennsylvania.
The Minnesota Department of Health counters that “while overall vaccine hesitancy may have increased during the COVID-19 pandemic, vaccine confidence and intent to vaccinate has remained fairly stable.” If 1 in 5 U.S. children has a parent who feels hesitant about childhood shots, the department report states, that hesitancy “does not necessarily translate into decreased intent to vaccinate, and parents continue to assign great importance to routine childhood vaccines.”
Gigi Chawla still worries about what could amount to anxiety or shame among parents. She says Children’s, partnering with the health department, texts families whose kids are behind on immunization, to gently remind them of its importance. “Oftentimes, families think their child is up to date, and they don’t know that their child isn’t.”
Coverage Catch-Up
Susan Mather, a nurse with the St. Paul Public Schools, says the biggest snag in vaccinating children occurs when a form that a parent needs to sign simply languishes in a backpack.
“I’ve done the health assessment. All you have to do is sign the paper”—but things get stuck. “Kids come home, their backpacks are a mess, and now it’s dinner, it’s sports, it’s other things.”
Mather works at the school district’s Placement Center. The goal here is to close an accessibility gap. Students and families in the St. Paul district come to the University Avenue building—walk-ins only—when they either lack insurance coverage or have it through the state. It’s an unassuming place that resembles a pediatric doctor’s office, with lollipops to distract from the poke of a needle. The Placement Center gets all vaccines through the Minnesota Vaccines for Children program. Along with the mandated shots, for infections like the measles and chickenpox, there are the recommended ones, such as for the flu and HPV. “I go over the screening questions, to make sure that it’s safe for them to get a vaccine, and then we get everything ready,” she says.
The anti-vaccine movement has zeroed in on the MMR vaccine. Usually, if a parent is exempting their kid from the immunization requirement—for religious or philosophical reasons, if it’s a non-medical decision, Mather says—they’re opting out of the one that protects against measles, mumps, and rubella.
This has long been a dominant story in the world of vaccines: “Misinformation is oftentimes telling people there’s a link between the MMR [vaccine] and autism, which there isn’t,” Mather says. “There has been millions of dollars of research done to see if there’s a link, and none has been found.”
This misinformation caught on thanks to a now-disgraced former physician named Andrew Wakefield. The British academic put out a research paper in 1998 fraudulently claiming causative links between the MMR vaccine and autism.
In Minnesota, that misinformation has influenced Somali families particularly. Anti-vaccine activists jumped on suggestions that Somali children are affected by autism spectrum disorder at disproportionate rates, according to reporting at the time of a 2017 measles outbreak in Hennepin County that involved the Somali community. (A University of Minnesota study has found Somali children have autism at about the same rate as white children and at higher rates than Black and Hispanic children. Again, no evidence shows vaccines cause autism.)
The 2017 outbreak was the largest in the state since 1990. It was the second major outbreak affecting the Minnesota Somali community in six years, according to the Department of Health.
Children’s has partnered with Somali leaders, Gigi Chawla says, to vouch for the MMR vaccine. “We’ve had great success also in partnering with families.” But misinformation among Somali families remains a problem, Gigi Chawla and Hancock-Allen say.
“Any pocket of un- or under-immunized kids can pose a risk that we’re concerned about,” a statement from the Department of Health reads. Areas of vulnerability, with disparities in vaccination rates, occur among both geographical communities, such as those in rural areas, and communities with common social or cultural ties, such as faith communities and new immigrant groups.
A study from earlier this year found that efforts to counter vaccine misinformation lag behind misinformation’s spread.
“Anti-vaccine misinformation is as old as vaccines themselves, but anti-vaccine campaigns have proliferated in recent years on social media—particularly since the start of the COVID-19 pandemic,” the study states. Led by a Columbia University researcher, it compiles prior findings and notes that hesitancy stems from many sources, including “genuine safety concerns,” which is why Mather screens kids to ensure they’re good vaccine candidates.
The return of measles “after aggressive anti-vaccine campaigns” led the World Health Organization in 2019 to list vaccine hesitancy among the biggest threats to global health.
The study also describes how successful counter-messaging works. To fight anti-vaccine misinformation, such messaging “typically affirms cultural values”—such as autonomy of choice or protection of loved ones. It addresses reasons for hesitancy rather than regurgitating facts. Community health workers, faith leaders, and U.S. military members have served well as messengers.
Debunking campaigns and misinformation bans, meanwhile, can “backfire,” entrenching people more deeply in anti-vaccine beliefs.
“It doesn’t really matter” if health care professionals can show no proof exists that the MMR vaccine causes autism, Gigi Chawla says. Communities must trust in health care first.
“We have staff members in our vaccine-preventable disease program who are able to speak to communities and come from that community, so it’s a trusted voice,” Hancock-Allen says. Mather says the Placement Center sometimes calls upon a health assistant who speaks Somali.
Some families who opt out want to track their children’ development. “I’m seeing more families say, ‘I’m not going to do it now; I’m going to wait until they’re a little bit older,’ ” Mather says. “[The children are] still at risk, because they’re not vaccinated as early as they could be,” and measles complications are most common among kids under age 5, the World Health Organization states.
Others bide their time while a so-called “debate” unfolds, even though one side may cite a disgraced physician’s debunked study. “They don’t know what the real concern is,” Gigi Chawla says. “They may have even, in fact, fully vaccinated their older children, so they have personal experience that vaccines are fine, safe, and effective. Now, because … they have not had enough time to understand that conversation, they find themselves pausing in order to let the conversation play out—not even necessarily to actively do their own research.”
“I’m seeing more families say, ‘I’m not going to do it now; I’m going to wait until they’re a little bit older.’ [The children are] still at risk, because they’re not vaccinated as early as they could be.”
–Susan Mather, St. Paul Public Schools nurse
The Placement Center will soon introduce a protocol for parents seeking exemption, Mather says. “We go over the consequences of not getting vaccines. ‘This is what could happen.’ And they have to sign that they’ve been given education on refusing vaccinations.” This could take 10-15 minutes, in addition to the 20-minute appointment. She says the American Academy of Pediatrics recommends this step.
One positive trend? Vaccination rates tend to improve as children age and the chaos of parenthood wanes, Hancock-Allen says. For those who have fallen behind, she notes, “it’s never too late to get caught up. If you’re a few months late or a couple of years late, that’s OK. It’s always better to get vaccinated.”
Illustrations by Alexis Politz
