Headed Back To School in 2023: A Look at Children’s Routine Vaccination Trends

This week the U.S. Food and Drug Administration (FDA) approved the first monoclonal antibody shot to protect young children against respiratory syncytial virus (RSV). While rates have now fallen, the three respiratory viruses (RSV, influenza, and COVID-19) surged among children last winter. Routine vaccinations, including the COVID-19 and flu shot, and the new RSV injection can provide important protection for children as they head back to school and into the winter season this year. This issue brief examines the most recent trends in children’s routine vaccinations, including COVID-19, and explores what to watch as children head back to school this year.

What are recent trends in children’s routine vaccination rates?

Since the beginning of the COVID-19 pandemic, the share of kindergarten children up to date on their vaccinations has ticked down. The CDC recommends children receive immunizations against 14 diseases by the age of two (or 24 months), with additional doses and immunizations through age 18. Data collected and aggregated annually by the CDC from state and local immunization programs, found that for the second year in a row, the national measles, mumps, and rubella (MMR) vaccination rate among kindergarten students fell below the Healthy People 2030 target of 95%, which is the level needed to prevent community transmission of measles. Specifically, the share of kindergarteners with all state-required vaccines, including MMR, DTaP (diphtheria, tetanus, and acellular pertussis), and varicella, has declined for the two school years following the onset of the pandemic, from approximately 95% in 2019-2020 to 94% in 2020-2021 and then declining again to 93% in 2021-2022. While this is a small decline, this is the lowest MMR rate reported in almost a decade and leaves approximately 250,000 school children unvaccinated and unprotected against measles, one of the world’s most contagious viruses.

While vaccination rates vary by state, the majority of states experienced declines in the share of kindergarteners up to date on their vaccines. There is substantial variation in vaccination coverage by state, with the latest available data for kindergarteners during the 2021-2022 school year showing MMR vaccine coverage rates ranged from 78% in Alaska to 98.6% in Mississippi (Figure 1). There is similar state variation in coverage for other state-required vaccines including DTaP, varicella, and polio. In addition, vaccine coverage rates for all vaccines among kindergarteners declined in a majority of states when comparing the 2021-2022 school year to the previous school year. Looking specifically at MMR coverage, 32 states saw declines, with the largest decline (over 5 percentage points) in Georgia.

There is evidence of declines in vaccination coverage rates for kindergarteners, but early data for children in other age groups is more mixed. A CDC survey (National Immunization Survey (NIS) – Child) of younger children found no decline in vaccination coverage overall for children aged 24 months associated with the pandemic. Another CDC survey of teens (NIS-Teen) ages 13-17 reported human papillomavirus (HPV) vaccine coverage remained stable but found potential decreases in meningococcal conjugate (MenACWY) and tetanus, diphtheria, and pertussis (Tdap) coverage associated with the pandemic. However, researchers noted they are unable to assess the full impact of the pandemic on adolescent routine vaccinations until more children age into the teen survey sample.

There is also evidence that disparities in vaccine coverage rates that pre-dated COVID, persisted during the pandemic and may have worsened for some groups. While the CDC survey of children aged 24 months mentioned above found no decline in vaccination coverage overall for children aged 24 months associated with the pandemic, it did find declines among specific groups of children, including low-income children and children living in rural areas. Even before the pandemic, the percent of children aged 24 months immunized was lower for children with Medicaid or uninsured children (compared with privately insured children), Black and Hispanic children (compared with White children), low-income children (compared with children in families with incomes greater than 133% of the federal poverty level), and children in rural areas (compared with children in more densely populated areas) (Figure 2). Research has shown that distrust, safety concerns, and experiences with discrimination and other factors can contribute to racial disparities in vaccination rates. Structural barriers such as distance to vaccine provider and other logistical challenges can also contribute to these differences across groups. KFF COVID-19 Vaccine Monitor data have shown Hispanic and Black parents are more likely than White parents and to cite concerns that reflect access barriers to vaccination, including not being able to get the vaccine from a trusted place, believing they may have to pay an out-of-pocket cost, having difficulty traveling to a vaccination site, or needing to take time off work to get their child vaccinated. Parents of children with household incomes under $50,000 were more likely than those with higher incomes to report similar concerns.

What are recent trends in children’s COVID-19 vaccination rates?

COVID-19 vaccination uptake has stalled, and vaccination rates remain low for young children. Last year, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to add COVID-19 vaccines to the recommended pediatric immunization schedule that includes the other routine vaccines for children discussed above. As of May 2023, 5.5% of children under age five, 32.9% of children ages 5-11, and 61.8% of children ages 12-17 had completed their COVID-19 primary series. Some of this variation in uptake may reflect parental views and concerns. KFF’s COVID-19 Vaccine Monitor from December 2022 reported that 45% of parents of children under five said they will “definitely not” get their child vaccinated, which is has increased from earlier surveys, when the vaccines were not yet available.

What to watch looking ahead?

It will take some time before we can understand the full impact of the pandemic on children’s routine vaccination rates and what is driving the recent changes. There is evidence of declines in vaccination coverage rates for kindergarteners, but early data for younger children (0-24 months) and adolescents (13-17) is more mixed. Even so, there have been recent reports that the CDC is expected to decrease federal funding for state vaccination programs due to budget cuts by Congress, a move that could impact data collection used to track vaccinations and prevent outbreaks. Some children missed or delayed preventive care early in the pandemic, and it is unclear the extent to which they will catch up and the magnitude of gaps that will remain. One study found weekly routine vaccination administration rates declined early in the pandemic, but then rebounded back to pre-pandemic levels by fall 2020. Despite the rebound in vaccine administration, the share of children up to date with all their vaccinations declined, likely due to some children still needing to make up for missed vaccinations early in the pandemic. Preliminary data for Medicaid/CHIP children through July 2022 show a similar trend.

There have been some recent shifts in public opinion as well as state vaccination policies that will be important to watch as they could have implications for children’s vaccination rates going forward. The KFF Vaccine Monitor in December 2022 found that about seven in ten adults (71%) say healthy children should be required to get vaccinated for MMR in order to attend public schools. This remains high but is down from 82% who said the same in an October 2019 Pew Research Center poll. Almost three in ten (28%) now say that parents should be able to decide not to vaccinate their school-age children, even if this creates health risks for others, up from 16% in 2019. All states allow a medical exemption from required vaccinations, and 46 states (including D.C.) allow for a religious or personal belief exemption (or both). The most recent CDC data showed the percentage of children claiming a vaccine exemption remained low at 2.6% for the 2021-2022 school year, but the percentage did increase in 38 states and D.C compared to the previous school year. While one state (D.C.) currently requires the COVID-19 vaccine for school children, 21 states have banned student COVID-19 vaccine mandates. Vaccine misinformation and disinformation may be contributing to vaccine hesitancy and the recent uptick in exemptions and slight declines in vaccination coverage.

With gains in enrollment during the pandemic, Medicaid now covers almost half of children in the U.S.; however, some children may lose coverage during the unwinding of the continuous enrollment provision which could impact vaccination rates. It is estimated that between 2 and 7 million children could lose Medicaid coverage during the unwinding of the Medicaid continuous enrollment provision that was in place during most of the pandemic, though the share of individuals disenrolled across states will vary due to differences in how states prioritize renewals. Significant declines in Medicaid enrollment are likely to increase the number of uninsured, which may have implications for children’s vaccination rates, as uninsured children typically have the lowest vaccination rates (Figure 3). Still, even with the COVID-19 public health emergency (PHE) having ended in May, all ACIP recommend vaccines (including the COVID-19 vaccine) are available with no cost sharing for all children, either through an insurer or the Vaccines for Children program (VFC). Various tools, including discussions with providers, incentives, outreach, and the media, can be used to increase children’s vaccination rates.