Number of Childhood and Adolescent Vaccinations Administered Before and After the COVID-19 Outbreak in Colorado

Completion of multidose vaccine series in early childhood: current challenges and opportunities

PURPOSE OF REVIEW

Completion of all doses in multidose vaccine series provides optimal protection against preventable infectious diseases. In this review, we describe clinical and public health implications of multidose vaccine series noncompletion, including current challenges to ensuring children receive all recommended vaccinations. We then highlight actionable steps toward achieving early childhood immunization goals.

RECENT FINDINGS

Although coverage levels are high for most early childhood vaccinations, rates of completion are lower for vaccinations that require multiple doses. Recent research has shown that lower family socioeconomic status, a lack of health insurance coverage, having multiple children in the household, and moving across state lines are associated with children failing to complete multidose vaccine series. These findings provide contextual evidence to support that practical challenges to accessing immunization services are impediments to completion of multidose series. Strategies, including reminder/recall, use of centralized immunization information systems, and clinician prompts, have been shown to increase immunization rates. Re-investing in these effective interventions and modernizing the public health infrastructure can facilitate multidose vaccine series completion.

SUMMARY

Completion of multidose vaccine series is a challenge for immunization service delivery. Increased efforts are needed to address remaining barriers and improve vaccination coverage in the United States.

Tri-State Evaluation of the Effects of the COVID-19 Pandemic on Routine Vaccine Uptake in Iowa, Minnesota, and North Dakota, 2017-2021

The objective of this analysis was to evaluate and compare the effects of the COVID-19 pandemic on routine and annual influenza vaccination in Iowa, Minnesota, and North Dakota. Routine and annual influenza vaccination uptake and coverage between 2017 and 2021 was collected from each state's immunization information system (IIS) by age group and stratified by provider and vaccine type. Data from 2017 to 2019 were averaged to obtain a pre-pandemic baseline and compared to 2020 and 2021 data. Percent changes were calculated to evaluate differences in uptake and coverage. Changes in coverage and administration varied by state, but each state had some level of decreased administration across the different age groups and vaccine types. The most consistent decreases in vaccine administration occurred in the 15-year-old cohort with each state finding decreased administrations in 2020 and 2021. The 12-year-old age group had decreased administration of hepatitis B, measles, mumps, and rubella, and varicella vaccine while the 2-year-old age group had the most consistent decrease in coverage across all vaccines analyzed. Trends by provider type were also noted in all three states, with local public health (LPH) experiencing the largest and most consistent declines in vaccine administrations by age group. Adult influenza coverage improved to varying degrees in 2020 (+ 14.1% IA, + 2.1% MN, + 1.5% ND), but either decreased or approached the 2017-19 average in 2021. All three states saw some level of decreased vaccine administration across the age groups, vaccines, and provider types assessed. The COVID-19 pandemic affected how many children and adults received recommended immunizations, leaving communities vulnerable to vaccine-preventable diseases.

The COVID-19 Pandemic and Parental Attitudes Toward Routine Childhood Vaccines

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic may have impacted parental attitudes toward childhood vaccines. However, few data sources followed attitudes before and after onset of the pandemic. We used data from a parental survey to describe the effect of the pandemic on parental attitudes toward childhood vaccines.

METHODS

Data were analyzed from the Health eMoms survey which randomly sampled birthing parents in Colorado from 2018 to 2021 on several health topics including vaccine hesitancy. Population weighted multivariable regression was used to measure the association between overall vaccine hesitancy and 5 individual hesitancy questions and different COVID-19 pandemic periods: prepandemic (April 2018-February 2020); pandemic prevaccine (April 2020-December 2020); and pandemic postvaccine (January 2021-August 2021), adjusting for demographic factors.

RESULTS

Overall, 20.4% (726/3553) of respondents were vaccine hesitant. Vaccine hesitancy during pandemic time periods was not different from the prepandemic period (prevaccine adjusted odds ratio [aOR] = 0.82, 95% confidence interval [CI] = 0.65-1.04; postvaccine aOR = 1.07, 95% CI = 0.85-1.34). In analyses of individual hesitancy questions, parents were more likely to be unsure about trusting vaccine information in the pandemic postvaccine time period compared with the prepandemic period (aOR = 2.14; 95% CI = 1.55-2.96), and less likely to be unsure about their hesitancy toward childhood vaccines (aOR = 0.48; 95% CI = 0.27-0.84).

CONCLUSIONS

The COVID-19 pandemic was not associated with changes in parental vaccine hesitancy overall, although there were changes in trust about vaccine information and a polarization of vaccination attitudes.

Recommendations for Prevention and Control of Influenza in Children, 2023-2024

This technical report accompanies the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccine and antiviral medications in the prevention and treatment of influenza in children during the 2023-2024 season. The rationale for the American Academy of Pediatrics recommendation for annual influenza vaccination of all children without medical contraindications starting at 6 months of age is provided. Influenza vaccination is an important strategy for protecting children and the broader community against influenza. This technical report summarizes recent influenza seasons, morbidity and mortality in children, vaccine effectiveness, and vaccination coverage, and provides detailed guidance on vaccine storage, administration, and implementation. The report also provides a brief background on inactivated and live-attenuated influenza vaccines, available vaccines this season, vaccination during pregnancy and breastfeeding, diagnostic testing for influenza, and antiviral medications for treatment and chemoprophylaxis. Strategies to promote vaccine uptake are emphasized.

Estimating Vaccine Hesitancy in Colorado by Using Immunization Information System Data

OBJECTIVES

Vaccine hesitancy is a complex issue that threatens global health. We used data from the Colorado Immunization Information System (CIIS) to quantify vaccine hesitancy.

METHODS

We examined immunization records from CIIS for patients age 2 up to 9 months to estimate vaccine hesitancy by tabulating the number of doses received per visit and comparing it with the number of expected doses based on recommendations of the Advisory Committee on Immunization Practices. We calculated the percentage of patients in each vaccine hesitancy group who were up to date on the 7-antigen series by age 35 months. We examined the distribution of vaccine-hesitant populations among vaccination providers who report to CIIS to estimate the difference in vaccine-hesitant patient populations among vaccination providers in Colorado.

RESULTS

Of 201 450 patients, 5147 (2.6%) consistently limited the number of shots received at each visit as compared with recommendations from the Advisory Committee on Immunization Practices; 166 927 (82.9%) patients did not limit the number of shots received; 5693 (2.8%) limited the number of shots received at >1 visit but not all visits; and 23 683 (11.8%) limited the number of shots received at only 1 visit. We found differences in vaccine hesitancy distributions among certain Colorado vaccination providers.

CONCLUSIONS

Immunization information system data, although sometimes incomplete, offer an opportunity to investigate state-level vaccine hesitancy. Areas of future research include performing similar analyses over time and determining geographic and socioeconomic factors that contribute to vaccine hesitancy.

The impact of the COVID-19 pandemic on vaccination uptake in the United States and strategies to recover and improve vaccination rates: A review

The COVID-19 pandemic disrupted routine healthcare delivery, causing declines in CDC-recommended vaccination rates across the life-course in the United States (US). Ensuring protection against disease outbreaks and associated morbidity and mortality depends on improving vaccine coverage rates (VCRs) and uptake. The authors conducted a targeted literature review to assess the pandemic's effects on routine vaccination rates across different populations, evaluating VCR recovery and improvement efforts. The review highlights articles published with data measuring or evaluating VCR decline across the US during the COVID-19 pandemic from January 2020 to April 2022, associated health impacts, and policy and programmatic strategies to recover routine VCRs. While vaccination rates stagnated or declined across some populations pre-pandemic, the review indicated there were further VCR declines in 2020 and 2021 compared to 2019 across numerous CDC-recommended vaccines, ages, and geographies, with some vaccines and sub-populations disproportionally impacted. The review additionally identified declines in patient healthcare visit frequency and increases in morbidity and mortality associated with vaccine-preventable disease (VPD) complications. Reviewed publications highlighted multifaceted strategies that could aid in recovering VCRs. Overall, findings demonstrate a significant reduction in VCRs across all age groups and highlight promising solutions to inform vaccine uptake efforts and ensure broader protection against VPDs.

Efficacy of the Outsmart HPV Intervention: A Randomized Controlled Trial to Increase HPV Vaccination among Young Gay, Bisexual, and Other Men Who Have Sex with Men

BACKGROUND

Routine human papillomavirus (HPV) vaccination is recommended for young adults, yet many young gay, bisexual, and other men who have sex with men (YGBMSM) remain unvaccinated. We report the efficacy of Outsmart HPV, a web-based HPV vaccination intervention for YGBMSM.

METHODS

From 2019 to 2021, we recruited YGBMSM in the United States who were ages 18-25 and unvaccinated against HPV (n = 1,227). Participants were randomized to receive either: (i) Outsmart HPV content online and monthly interactive text reminders (interactive group); (ii) Outsmart HPV content online and monthly unidirectional text reminders (unidirectional group); or (iii) standard information online about HPV vaccine (control group). Regression models compared study groups on HPV vaccination outcomes.

RESULTS

Overall, 33% of participants reported initiating the HPV vaccine series and 7% reported series completion. Initiation was more common among participants in the interactive group compared with the control group [odds ratio (OR) = 1.47, 98.3% confidence interval (CI): 1.03-2.11]. Completion was more common among participants in both the interactive group (OR = 3.70, 98.3% CI: 1.75-7.83) and unidirectional group (OR = 2.26, 98.3% CI: 1.02-5.00) compared with the control group. Participants who received Outsmart HPV content reported higher levels of satisfaction with online content compared with the control group.

CONCLUSIONS

Outsmart HPV is an efficacious and acceptable HPV vaccination intervention for YGBMSM. Future efforts are needed to determine how to optimize the intervention and disseminate it to settings that provide services to YGBMSM.

IMPACT

Outsmart HPV is a promising tool for increasing HPV vaccination among YGBMSM with the potential for wide dissemination.

Well Child Wednesdays: An interprofessional pilot-program to increase pediatric immunizations Post-COVID

Background

The COVID-19 pandemic halted routine medical care, including well-child visits (WCVs) and immunizations.

Purpose

Describe the development and impact of a multidisciplinary initiative on the number of WCVs and immunizations delivered in aftermath of the COVID-19 pandemic over a four week period between April 14, 2021 and May 5, 2021.

Methods

Student pharmacists (SP), family medicine residents (FMRs), and nurses within a family medicine practice in a medically underserved community, developed a program to increase the number of pediatric patients up-to-date on WCVs and immunizations. "Well-child Wednesdays" used adjusted staffing to conduct visits with patients behind on vaccines. The 4-week pilot program utilized SPs to identify immunization gaps in patients less than 12 years old following chart review and to coordinate scheduling. During the visit, FMRs completed the components of the well-child visit; immunization gaps were communicated to the nurse who, after review, administered needed immunizations.

Discussion

Of 193 patient charts reviewed for immunization needs, 68 were not up-to-date on routine vaccines and 29 patients (mean age 5 years old, 58.6% male) were able to be reached and agreed to schedule a visit. Of these, 20 kept their appointment and a total of 69 vaccines were administered, with DTaP as the most common with 13 doses administered followed by Hepatitis A with 10 doses given.

Conclusions

An interprofessional immunization program was an effective strategy to address the decline in immunizations and WCVs as a result of COVID-19.

Impact of COVID-19 Outbreak on Influenza and Pneumococcal Vaccination Uptake: A Multi-Center Retrospective Study

During the coronavirus disease 2019 (COVID-19) pandemic, global vaccination efforts declined due to the burden on health systems and community resistance to epidemic control measures. Influenza and pneumococcal vaccines have been recommended for vulnerable populations to prevent severe pneumonia. We investigated community response towards influenza and pneumococcal vaccines (pneumococcal conjugate vaccine and pneumococcal polysaccharide vaccine) after the COVID-19 outbreak in Taiwan. We retrospectively included adults who visited Chang Gung Memorial Hospital (CGMH) institutions for influenza or pneumococcal vaccination from January 2018 to December 2021. The first case of COVID-19 in Taiwan was detected in January 2020; therefore, in this study, hospitalized cases from January 2018 to December 2019 were defined as "before COVID-19 outbreak," and hospitalized cases from January 2020 to December 2021 were defined as "after COVID-19 outbreak". A total of 105,386 adults were enrolled in the study. An increase in influenza vaccination (n = 33,139 vs. n = 62,634) and pneumococcal vaccination (n = 3035 vs. n = 4260) were observed after the COVID-19 outbreak. In addition, there was an increased willingness to receive both influenza and pneumococcal vaccinations among women, adults without underlying disease and younger adults. The COVID-19 pandemic may have increased awareness of the importance of vaccination in Taiwan.

Cost-Effectiveness Analyses of Digital Health Technology for Improving the Uptake of Vaccination Programs: Systematic Review

BACKGROUND

Vaccination is the most effective strategy to prevent infectious diseases, yet vaccination coverage has not reached the target level. To promote vaccination uptake, digital health interventions (DHIs) have been used in various vaccination programs.

OBJECTIVE

This study aimed to perform a systematic review of the cost-effectiveness analyses of DHIs for the improvement of the uptake of vaccination programs.

METHODS

A literature review was conducted in MEDLINE (Ovid), Embase (Ovid), APA PsycINFO (Ovid), Web of Science, Scopus, CINAHL Ultimate (EBSCOhost), Center for Review and Dissemination, and Institute for IEEE Xplore up to October 2022. Health economic evaluations that met the following inclusion criteria were included: (1) adult or pediatric vaccination programs; (2) interventions delivered through digital technology; (3) full-scale health economic analyses including cost-effectiveness, cost-utility, cost-benefit, or cost-consequence analyses; and (4) evaluations conducted by model-based or trial-based analyses. The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

The systematic review included 7 studies. Four of the cost-effectiveness studies were conducted by model-based analyses, and 3 were trial-based analyses. One study reported the additional cost per quality-adjusted life years (QALYs) gained, whereas 6 studies reported the additional cost per individual vaccinated (or return case). The vaccines targeted the human papillomavirus (HPV) vaccine, influenza vaccination, measles-mumps-rubella (MMR) vaccine, and children immunization at different ages. The DHIs were delivered by television campaign, web-based decision aid, SMS text message, telephone, and computer-generated recall letters. The studies were classified as very good (n=5) and good (n=2) qualities. One study concluded that the DHI was cost-saving, and 6 studies concluded that the DHI was cost-effective.

CONCLUSIONS

This study is the first systematic review on cost-effectiveness analyses of DHIs to improve vaccination uptake. All included studies have good to very good quality on study assessment and reported the DHIs to be cost-saving or cost-effective in the improvement of vaccination uptake.

Lower human papillomavirus vaccine initiation and completion among Asian American adolescents compared to their peers: National Health and Nutritional Examination Survey 2011-2018

PURPOSE

To compare human papillomavirus (HPV) vaccination initiation and completion between Asian American adolescents and their peers.

METHODS

HPV vaccine initiation and completion of adolescents aged 9-17 years old were analyzed using the National Health and Nutritional Examination Survey data from 2011 to 2018. The outcomes were HPV vaccine initiation percentage among all adolescents and completion percentage among initiators. Odds ratios for initiation or completion among Hispanics, Blacks, and Asians (referred to as racial/ethnic minorities) versus Whites were compared using logistic regression, adjusted for adolescent's age, annual family income, parent education, and insurance coverage.

RESULTS

From 2011 to 2018, overall initiation was less than 40% among U.S. adolescents. The initiation increased among boys (from 10% in 2011-12 to over 30% in 2017-2018) but not among girls. Compared to White girls, Black and Hispanic girls were more likely, while Asian girls were less likely to initiate vaccination. Although not statistically significant, Asian girls had ORs ranging from 0.65 to 0.99 for initiation compared to White girls in each of the four survey cycles. Black and Hispanic boys were more likely to initiate vaccination compared to White boys. Initiation among Asian boys increased to 39% in the 2017-2018 survey cycle. Racial/ethnic minority girls were less likely to complete the series compared to White girls, while the opposite was seen in Black boys.

CONCLUSION

HPV vaccination status varies among racial/ethnic groups. Future efforts should be made to achieve the Healthy People 2020 goal of 80% vaccination among U.S. adolescents and address the gap among Asian American girls.

School immunization coverage in adolescents during the COVID-19 pandemic: A retrospective cohort study

INTRODUCTION

Few studies have assessed the impact of the coronavirus disease 2019 (COVID-19) pandemic on immunization coverage for adolescents, and little is known about how coverage has changed throughout the pandemic. We aimed to: (1) assess the change in coverage for school-based vaccines in Alberta, Canada resulting from the pandemic; (2) determine whether coverage differed by geographic health zone and school type; and (3) ascertain whether coverage has returned to pre-pandemic levels.

METHODS

Using a retrospective cohort design, we used administrative health data to compare coverage for human papillomavirus (HPV) and meningococcal conjugate A, C, Y, W-135 (MenC-ACYW) vaccines between pre-pandemic (2017-2018 school year) and pandemic (2019-2020 and 2020-2021 school years) cohorts (N = 289,420). Coverage was also compared by health zone and authority type. The 2019-2020 cohort was followed over one year to assess catch-up.

RESULTS

Compared to 2017-2018, immunization coverage for HPV was significantly lower in the 2019-2020 (absolute difference: 60.8%; 95% CI: 60.4-61.3%) and 2020-2021 cohorts (absolute difference: 59.9%; 95% CI: 59.4-60.3%). There was a smaller, significant decline in MenC-ACYW coverage comparing 2017-2018 to 2019-2020 (absolute difference: 6.1%; 95% CI: 5.6-6.5%) and 2020-2021 (absolute difference: 32.2%; 95% CI: 31.6-32.7%). Private schools had low coverage overall, while coverage fluctuated by zone. During follow-up of the 2019-2020 cohort, coverage for HPV and MenC-ACYW increased from 5.6% to 50.2%, and 80.7% to 83.0%, respectively.

CONCLUSION

There was a substantial decrease in school-based immunization coverage during the COVID-19 pandemic, and coverage has not returned to pre-pandemic levels, suggesting further catch-up is needed.

Effects of the COVID-19 pandemic on self-reported 12-month pneumococcal vaccination series completion rates in Canada

Routine childhood vaccination improves health and prevents morbidity and mortality from vaccine-preventable diseases. There are indications that the COVID-19 pandemic has negatively impacted immunization rates globally, but systematic studies on this are still lacking in Canada. This study aims to add knowledge on the pandemic's effect on children's immunization rates with pneumococcal vaccine using self-reported immunization data from CANImmunize. An interrupted time series analysis was conducted on aggregated monthly enrollment of children on the platform (2016-2021) and their pneumococcal immunization series completion rates (2016-2020). Predicted trends before and after the onset of the COVID19-related restriction (March 1, 2020) were compared by means of an Autoregressive Integrated Moving Average (ARIMA). The highest monthly enrollment was 3,474 new infant records observed in January 2020, and the lowest was 100 records in December 2021. The highest Self-reported pneumococcal immunization series completion rate was 78.89%, observed in February 2017, and the lowest was 6.94% in December 2021. Enrollment decreased by 1177.52 records (95% CI: -1865.47, -489.57), with a continued decrease of 80.84 records each month. Completion rates had an immediate increase of 14.57% (95% CI 4.64, 24.51), followed by a decrease of 3.54% each month. The onset of the COVID-19 related restrictions impacted the enrollment of children in the CANImmunize digital immunization platform and an overall decrease in self-reported pneumococcal immunization series completion rates. Our findings support efforts to increase catch-up immunization campaigns so that children who could not get scheduled immunization during the pandemic are not missed.

Impact of the COVID-19 pandemic on timeliness and equity of measles, mumps and rubella vaccinations in North East London: a longitudinal study using electronic health records

OBJECTIVES

To quantify the effect of the COVID-19 pandemic on the timeliness of, and geographical and sociodemographic inequalities in, receipt of first measles, mumps and rubella (MMR) vaccination.

DESIGN

Longitudinal study using primary care electronic health records.

SETTING

285 general practices in North East London.

PARTICIPANTS

Children born between 23 August 2017 and 22 September 2018 (pre-pandemic cohort) or between 23 March 2019 and 1 May 2020 (pandemic cohort).

MAIN OUTCOME MEASURE

Receipt of timely MMR vaccination between 12 and 18 months of age.

METHODS

We used logistic regression to estimate the ORs (95% CIs) of receipt of a timely vaccination adjusting for sex, deprivation, ethnic background and Clinical Commissioning Group. We plotted choropleth maps of the proportion receiving timely vaccinations.

RESULTS

Timely MMR receipt fell by 4.0% (95% CI: 3.4% to 4.6%) from 79.2% (78.8% to 79.6%) to 75.2% (74.7% to 75.7%) in the pre-pandemic (n=33 226; 51.3% boys) and pandemic (n=32 446; 51.4%) cohorts, respectively. After adjustment, timely vaccination was less likely in the pandemic cohort (0.79; 0.76 to 0.82), children from black (0.70; 0.65 to 0.76), mixed/other (0.77; 0.72 to 0.82) or with missing (0.77; 0.74 to 0.81) ethnic background, and more likely in girls (1.07; 1.03 to 1.11) and those from South Asian backgrounds (1.39; 1.30 to 1.48). Children living in the least deprived areas were more likely to receive a timely MMR (2.09; 1.78 to 2.46) but there was no interaction between cohorts and deprivation (Wald statistic: 3.44; p=0.49). The proportion of neighbourhoods where less than 60% of children received timely vaccination increased from 7.5% to 12.7% during the pandemic.

CONCLUSIONS

The COVID-19 pandemic was associated with a significant fall in timely MMR receipt and increased geographical clustering of measles susceptibility in an area of historically low and inequitable MMR coverage. Immediate action is needed to avert measles outbreaks and support primary care to deliver timely and equitable vaccinations.

Parent Attitudes Towards Childhood Vaccines After the Onset of SARS-CoV-2 in the United States

OBJECTIVE

To understand the influence of a novel infectious disease epidemic on parent general attitudes about childhood vaccines.

METHODS

We conducted a natural experiment utilizing cross-sectional survey data from parents of infants in Washington and Colorado participating in a larger trial that began on September 27, 2019. At enrollment, parents completed the short version of the Parental Attitudes about Childhood Vaccines (PACV-SF), a validated survey scored from 0 to 4, with higher scores representing more negative attitudes. The exposure variable was onset of the SARS-CoV-2 pandemic in the United States, with the before-period defined as September 27, 2019 to February 28, 2020 and the after-period defined as April 1, 2020-December 10, 2020, with the after-period further separated into proximate (April 1, 2020-July 31, 2020) and distant periods (August 1, 2020-December 10, 2020). The outcome variable was parent negative attitudes about childhood vaccines, defined as a score of ≥2 on the PACV-SF. We estimated the probability of the outcome after (vs before) the exposure using log-binomial regression with generalized estimating equations adjusted for demographic confounding variables.

RESULTS

Among 4562 parents, the risk of negative attitudes was lower immediately after (vs before) SARS-CoV-2 onset (adjusted risk ratio [aRR] = 0.58; 95% confidence interval [CI], 0.36, 0.94; P = .027), but by August-December 2020, the average rate of negative attitudes was 35% higher than during April-July 2020 (aRR: 1.35; 95% CI: 1.13, 1.61; P = .0009).

CONCLUSIONS

A reduced risk of negative general vaccine attitudes observed immediately after SARS-CoV-2 onset was quickly attenuated.

Recommendations for Prevention and Control of Influenza in Children, 2022-2023

This technical report accompanies the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccine and antiviral medications in the prevention and treatment of influenza in children during the 2022 to 2023 season. The American Academy of Pediatrics recommends annual influenza vaccination of all children without medical contraindications starting at 6 months of age. Influenza vaccination is an important strategy for protecting children and the broader community as well as reducing the overall burden of respiratory illnesses when other viruses, including severe acute respiratory syndrome-coronavirus 2, are cocirculating. This technical report summarizes recent influenza seasons, morbidity and mortality in children, vaccine effectiveness, and vaccination coverage, and provides detailed guidance on storage, administration, and implementation. The report also provides a brief background on inactivated and live attenuated influenza vaccine recommendations, vaccination during pregnancy and breastfeeding, diagnostic testing, and antiviral medications for treatment and chemoprophylaxis. Updated information is provided about the 2021 to 2022 influenza season, influenza immunization rates, the effectiveness of influenza vaccination on hospitalization and mortality, available vaccines, guidance for patients with history of severe allergic reactions to prior influenza vaccinations, and strategies to promote vaccine uptake.

Preventable Disease, the Case of Colorado: School District Demographics and Childhood Immunizations

The objective of this study was to evaluate the impact of selected sociodemographic factors on childhood vaccination hesitancy and to define their role according to specific exemptions. This population-based cohort study utilized vaccination rate and sociodemographic data from 1st to 12th grade from 2017 to 2021 for all school districts in Colorado. Data included immunization status and exemptions for each vaccine, race, ethnicity, and free and reduced meal status. Data were evaluated through dimensional analysis and Generalized Linear Mixed Models. School districts with a higher representation of White students had lower immunization rates and use more personal exemptions while school districts with larger Hispanic populations and higher proportions of free and reduced lunches had higher vaccination rates and used more religious exemptions. Black and Pacific Islander populations had higher rates of incomplete vaccination records while Asian American population displayed increased vaccination compliance. Colorado is a robust example of how socioeconomic and cultural differences are important factors with a direct influence on vaccination rates. Future childhood vaccination campaigns and legislation should consider complex socioeconomic and cultural factors.

Impact of COVID ‐19 pandemic on routine vaccination coverage of children and adolescents: A systematic review

Background and Aims

Scientists and healthcare workers have expressed their concerns on the impacts of the COVID‐19 pandemic on vaccination coverage in children and adolescents. Therefore, we aimed to systematically review the studies addressing this issue worldwide.

Methods

We conducted a systematic search of relevant studies using the keywords on databases of PubMed, Web of Science, and Cochrane on May 22, 2021. The identified records were imported into EndNote software and underwent a two‐phase screening process consisting of title/abstract and full‐text screenings against inclusion criteria. The data of the included studies were summarized into a table and the findings were analyzed in a systematic approach.

Results

From 26 eligible studies, 21 studies demonstrated decreased vaccination rates in the children during the COVID‐19 pandemic, while three studies found increased or no significant changes only in influenza vaccination. The two remaining studies from Brazil and Sweden also showed no significant changes in vaccination rates in the children during the pandemic.

Conclusion

Most of the reports worldwide reported a decline or delay in vaccination at the time of the COVID‐19 pandemic. A sustained catch‐up program seems to be necessary, especially in low‐income countries, to avoid any vaccine dose missing. Facilitating the vaccination process is recommended, such as decreasing the waiting time for vaccination at the health center, addressing the fear and concerns related to COVID infection for parents, and enhancing vaccine availability, and promoting access in remote areas. Countries should ensure proper vaccination to prevent future pandemics related to vaccine‐preventable diseases.

Childhood immunization during the COVID-19 pandemic: experiences in Haiti, Lesotho, Liberia and Malawi

Objective

To examine changes in vaccination of children younger than 1 year during the coronavirus disease 2019 (COVID-19) pandemic (March 2020–August 2021) in Haiti, Lesotho, Liberia and Malawi.

Methods

We used data from health management information systems on vaccination of children aged 12 months or younger in districts supported by Partners In Health. We used data from January 2016 to February 2020 and a linear model with negative binomial distribution to estimate the expected immunization counts for March 2020–August 2021 with 95% prediction intervals, assuming no pandemic. We compared these expected levels with observed values and estimated the immunization deficits or excesses during the pandemic months.

Findings

Baseline vaccination counts varied substantially by country, with Lesotho having the lowest count and Haiti the highest. We observed declines in vaccination administration early in the COVID-19 pandemic in Haiti, Lesotho and Liberia. Continued declines largely corresponded to high rates of COVID-19 infection and discrete stock-outs. By August 2021, vaccination levels had returned to close to or above expected levels in Haiti, Liberia and Lesotho; in Malawi levels remained below expected.

Conclusion

Patterns of childhood immunization coverage varied by country over the course of the pandemic, with significantly lower than expected vaccination levels seen in one country during subsequent COVID-19 waves. Governments and health-care stakeholders should monitor vaccine coverage closely and consider interventions, such as community outreach, to avoid or combat the disruptions in childhood vaccination.

Vaccine Administration in Children's Hospitals

OBJECTIVES

To examine inpatient vaccine delivery across a national sample of children's hospitals.

METHODS

We conducted a retrospective cohort study examining vaccine administration at 49 children's hospitals in the Pediatric Health Information System database. Children <18 years old admitted between July 1, 2017, and June 30, 2019, and age eligible for vaccinations were included. We determined the proportion of hospitalizations with ≥1 dose of any vaccine type administered overall and by hospital, the type of vaccines administered, and the demographic characteristics of children who received vaccines. We calculated adjusted hospital-level rates for each vaccine type by hospital. We used logistic and linear regression models to examine characteristics associated with vaccine administration.

RESULTS

There were 1 185 667 children and 1 536 340 hospitalizations included. The mean age was 5.5 years; 18% were non-Hispanic Black, and 55% had public insurance. There were ≥1 vaccine doses administered in 12.9% (95% confidence interval: 12.8-12.9) of hospitalizations, ranging from 1% to 45% across hospitals. The most common vaccines administered were hepatitis B and influenza. Vaccine doses other than the hepatitis B birth dose and influenza were administered in 1.9% of hospitalizations. Children had higher odds of receiving a vaccine dose other than the hepatitis B birth dose or influenza if they were <2 months old, had public insurance, were non-Hispanic Black race, were medically complex, or had a length of stay ≥3 days.

CONCLUSIONS

In this national study, few hospitalizations involved vaccine administration with substantial variability across US children's hospitals. Efforts to standardize inpatient vaccine administration may represent an opportunity to increase childhood vaccine coverage.

Impact of the COVID-19 pandemic on pediatric and adolescent vaccinations and well child visits in the United States: A database analysis

BACKGROUND

The COVID-19 pandemic has disrupted healthcare, including immunization practice and well child visit attendance. Maintaining vaccination coverage is important to prevent disease outbreaks and morbidity. We assessed the impact of the COVID-19 pandemic on pediatric and adolescent vaccination administration and well child visit attendance in the United States.

METHODS

This cross-sectional study used IBM MarketScan Commercial Database (IMC) with Early View (healthcare claims database) and TriNetX Dataworks Global Network (electronic medical records database) from January 2018-March 2021. Individuals ≤ 18 years of age who were enrolled during the analysis month of interest (IMC with Early View) or had ≥ 1 health encounter at a participating institution (TriNetX Dataworks) were included. We calculated the monthly percent difference between well child visit attendance and vaccine administration rates for 10 recommended pediatric/adolescent vaccines in 2020 and 2021 compared with 2018-2019. Data were stratified by the age groups 0-2 years, 4-6 years, and 9-16 years.

RESULTS

In IMC with Early View, the average monthly enrollment for children 0-18 years of age was 5.2 million. In TriNetX Dataworks, 12.2 million eligible individuals were included. Well child visits and vaccinations reached the lowest point in April 2020 compared with 2018-2019. Well child visit attendance and vaccine administration rates were inversely related to age, with initial reductions highest for adolescents and lowest for ages 0-2 years. Rates rebounded in June and September 2020 and stabilized to pre-pandemic levels in Fall 2020. Rates dropped below baseline in early 2021 for groups 0-2 years and 4-6 years.

CONCLUSIONS

We found substantial disruptions in well child visit attendance and vaccination administration for children and adolescents during the COVID-19 pandemic in 2020 and early 2021. Continued efforts are needed to monitor recovery and catch up to avoid outbreaks and morbidity associated with vaccine-preventable diseases.

Ethnicity, Social Determinants of Health, and Pediatric Primary Care During the COVID-19 Pandemic

This study assessed the relationship between ethnicity, social determinants of health (SDH), and measures of health outcomes for children during the COVID-19 pandemic. This retrospective study reviewed electronic medical records of 1234 in-person well child visits (WCVs for age <18 years) at a single academic primary care clinic in a Chicago suburb for the results of SDH screening in the domains of food, financial, and transportation insecurity. The association between ethnicity, unmet SDH domains, routine medical care delay, vaccine delays, and utilization of acute and emergency department (ED) visits were evaluated. Patients with unmet SDH were more likely to be non-White (P < .001), ≥3 years of age (P < .001) and have Medicaid coverage (P < .001). Unmet social needs were also associated with more acute visits (P < .001), ED visits (P < .001), and WCV delays (P < .001). The results suggest that the COVID-19 pandemic has disproportionately affected patients with unmet SDH in obtaining routine pediatric well child care.

Association of the COVID-19 Pandemic With Routine Childhood Vaccination Rates and Proportion Up to Date With Vaccinations Across 8 US Health Systems in the Vaccine Safety Datalink

IMPORTANCE

The COVID-19 pandemic has affected routine vaccine delivery in the US and globally. The magnitude of these disruptions and their association with childhood vaccination coverage are unclear.

OBJECTIVES

To compare trends in pediatric vaccination before and during the pandemic and to evaluate the proportion of children up to date (UTD) with vaccinations by age, race, and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This surveillance study used a prepandemic-postpandemic control design with data from 8 health systems in California, Oregon, Washington, Colorado, Minnesota, and Wisconsin in the Vaccine Safety Datalink. Children from age groups younger than 24 months and 4 to 6, 11 to 13, and 16 to 18 years were included if they had at least 1 week of health system enrollment from January 5, 2020, through October 3, 2020, over periods before the US COVID-19 pandemic (January 5, 2020, through March 14, 2020), during age-limited preventive care (March 15, 2020, through May 16, 2020), and during expanded primary care (May 17, 2020, through October 3, 2020). These individuals were compared with those enrolled during analogous weeks in 2019.

EXPOSURES

This study evaluated UTD status among children reaching specific ages in February, May, and September 2020, compared with those reaching these ages in 2019.

MAIN OUTCOMES AND MEASURES

Weekly vaccination rates for routine age-specific vaccines and the proportion of children UTD for all age-specific recommended vaccines.

RESULTS

Of 1 399 708 children in 2019 and 1 402 227 in 2020, 1 371 718 were female (49.0%) and 1 429 979 were male (51.0%); 334 216 Asian individuals (11.9%), 900 226 were Hispanic individuals (32.1%), and 201 619 non-Hispanic Black individuals (7.2%). Compared with the prepandemic period and 2019, the age-limited preventive care period was associated with lower weekly vaccination rates, with ratios of rate ratios of 0.82 (95% CI, 0.80-0.85) among those younger than 24 months, 0.18 (95% CI, 0.16-0.20) among those aged 4 to 6 years, 0.16 (95% CI, 0.14-0.17) among those aged 11 to 13 years, and 0.10 (95% CI, 0.08-0.13) among those aged 16 to 18 years. Vaccination rates during expanded primary care remained lower for most ages (ratios of rate ratios: <24 months, 0.96 [95% CI, 0.93-0.98]; 11-13 years, 0.81 [95% CI, 0.76-0.86]; 16-18 years, 0.57 [95% CI, 0.51-0.63]). In September 2020, 74% (95% CI, 73%-76%) of infants aged 7 months and 57% (95% CI, 56%-58%) of infants aged 18 months were UTD vs 81% (95% CI, 80%-82%) and 61% (95% CI, 60%-62%), respectively, in September 2019. The proportion UTD was lowest in non-Hispanic Black children across most age groups, both during and prior to the COVID-19 pandemic (eg, in May 2019, 70% [95% CI, 64%-75%] of non-Hispanic Black infants aged 7 months were UTD vs 82% [95% CI, 81%-83%] in all infants aged 7 months combined).

CONCLUSIONS AND RELEVANCE

As of September 2020, childhood vaccination rates and the proportion who were UTD remained lower than 2019 levels. Interventions are needed to promote catch-up vaccination, particularly in populations at risk for underimmunization.

US Primary Care Providers' Experiences and Practices Related to Routine Pediatric Vaccination During the COVID-19 Pandemic

OBJECTIVE

To describe, among pediatricians (Peds) and family physicians (FPs), 1) changes made to routine childhood vaccination delivery as a result of the pandemic, and 2) perceived barriers to delivering vaccinations from March 2020 through the time of the survey.

METHODS

A nationally representative survey among Peds and FPs was administered by mail or Internet in October-December 2020.

RESULTS

Response rate was 64% (579/909). For children aged 0 to 2 years, among those who vaccinated that age group prepandemic (Peds n = 265, FPs n = 222), 5% of Peds and 15% of FPs reported they had stopped vaccinating these children at any time. For children aged 4 to 6 years (Peds n=264, FPs n = 229), 19% of Peds and 17% of FPs reported they had stopped vaccinating at any time. For children aged 11-18 years (Peds n = 265, FPs n = 251), 24% of Peds and 19% of FPs reported they had stopped vaccinating at any time. Nearly all reported returning to prepandemic vaccination services at the time of the survey. Factors most frequently reported as major/moderate barriers to providing vaccinations included fewer in-person visits because patients/parents were concerned about risk of SARS-CoV-2 infection (Peds, 52%; FPs, 54%), fewer in-person visits for sports clearance (Peds, 39%; FPs, 44%), and fewer back-to-school in-person visits because some children were in virtual learning (Peds, 25%; FPs, 33%).

CONCLUSIONS

Although some physicians reported interrupting vaccination services at some point during the pandemic, the majority reported continuing to provide vaccinations throughout, with essentially all returning to prepandemic vaccination services by end of 2020.

COVID-19 and Routine Childhood and Adolescent Immunizations: Evidence from Louisiana Medicaid

The COVID-19 pandemic disrupted routine vaccinations for children and adolescents. However, it remains unclear whether the impact has been different for children and adolescents from low-income families. To address this, we compared monthly routine vaccination use per 1000 vaccine-eligible children and adolescents enrolled in Louisiana Medicaid in the years before (2017–2019) and during the COVID-19 pandemic (2020). Compared to the 2017–2019 average vaccination rates, we found a 28% reduction in measles, mumps, and rubella (MMR), a 35% reduction in human papillomavirus (HPV), and a 30% reduction in tetanus, diphtheria, pertussis (Tdap) vaccinations in 2020. Vaccine uptake was lower in April 2020 after the declaration of a state of emergency and in late summer when back-to-school vaccinations ordinarily occur. We found little evidence of recovery in later months. Our findings suggest that a substantial number of disadvantaged children may experience longer periods of vulnerability to preventable infections because of missed vaccinations.

Impact of the COVID-19 pandemic on adolescent vaccinations: projected time to reverse deficits in routine adolescent vaccination in the United States

OBJECTIVE

The COVID-19 pandemic has led to significant reductions in the administration of routinely recommended vaccines among adolescents in the US including tetanus, diphtheria, and acellular pertussis (Tdap); meningococcal (ACWY); and human papillomavirus (HPV) vaccines. The extent to which these deficits could persist in 2021 and beyond is unclear. To address this knowledge gap, this study estimated the cumulative deficits of routine vaccine doses among US adolescents during the COVID-19 pandemic and estimated the time and effort needed to recover from those deficits.

METHODS

Monthly reductions in Tdap, meningococcal, and HPV doses administered to US adolescents during the COVID-19 pandemic were quantified using MarketScan Commercial Claims and Encounters data. The time and effort required to reverse the vaccination deficit under various catch-up scenarios were estimated.

RESULTS

Annual doses administered of Tdap, meningococcus, and HPV vaccines decreased by 21.2%, 20.8%, and 24.0%, respectively, in 2020 compared to 2019. For 2021, the reduction in doses administered is projected to be 6%-21% compared to 2019 under different scenarios. The projected deficit of missed doses is expected to be cleared between winter 2023 and fall 2031.

CONCLUSIONS

Administration rates of routine vaccines decreased significantly among US adolescents during COVID-19. Reversing these deficits to mitigate long-term health and economic consequences will require a sustained increase in vaccination rates over multiple years.

Silent Consequences of COVID-19: Why It's Critical to Recover Routine Vaccination Rates Through Equitable Vaccine Policies and Practices

In the United States, routine vaccination rates have plummeted across all age groups due to the COVID-19 pandemic, with our most vulnerable and under-served populations suffering the greatest declines. Returning to a "new normal" and recovering our nation's health and economy is of the utmost importance; however, there is a critical need to recover and protect communities against the spread of other vaccine-preventable diseases and outbreaks. While routine vaccination rates are slowly recovering for certain age groups, the introduction of COVID-19 vaccines adds complexities and challenges to recovery efforts. If not addressed, hard-won gains in routine vaccination may be lost, which could result in communities missing out on the social, economic, and health benefits offered by vaccinations.There is an urgent need to utilize evidence-based and innovative strategies to support both immediate and long-term efforts to recover, maintain, and sustain routine vaccination. Key short-term strategies include leveraging digital and mainstream media to drive awareness, coordinating across health and education sectors, utilizing centralized reminder recall, expanding access points to vaccination services, and elevating trusted voices for vaccination. In order to build back stronger, long-term strategies include enhancing immunization information systems, mitigating financial barriers to vaccination, investing in building vaccine confidence, and ensuring sustainable funding for immunization infrastructure.Annals "Online First" article.

Effects of the COVID-19 pandemic on routine pediatric vaccination in Brazil

BACKGROUND

COVID-19 pandemic has disrupted health services, including vaccination demand. We describe the impact of the COVID-19 pandemic on routine pediatric vaccination in Brazil.

METHODS

We conducted a retrospective analysis of all vaccine doses provided to children aged 0-6 years from January 2019 to December 2020. We obtained data stratified by age group (0 to 2 years and >2 to 6 years) and Brazilian region. Difference-in-difference (DiD) analyses were performed to compare vaccine uptake in the pre-pandemic (January-February), stay-at-home (March-June), and reopening (July-December) periods.

RESULTS

The number of vaccine doses administered declined in the stay-at-home period. For children aged 0 to 2 years, the highest reductions were recorded in the North (-25.3%), Northeast (-16.8%) and Central-West (-10.2%) regions. For children aged >2 to 6 years, the highest decline was observed in the North (DiD = -27.2%) and South (DiD = -14.0%) regions. The number of vaccine doses administered in the reopening period has slightly increased in all regions.

CONCLUSIONS

Vaccination decreased during the COVID-19 pandemic. Although the number of doses recovered in part during the reopening phase, additional strategies, such as increased public awareness and vaccination booster campaigns are required.

Disruption in essential health services in Mexico during COVID-19: an interrupted time series analysis of health information system data

INTRODUCTION

The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020.

METHODS

We used health information system data for January 2019 to December 2020 from the Mexican Institute of Social Security (IMSS), which provides health services for more than half of Mexico's population-65 million people. Our analysis includes nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. We used an interrupted time series design and linear generalised estimating equation models to estimate the change in service use and outcomes from April to December 2020. Estimates were expressed using average marginal effects on the risk ratio scale.

RESULTS

The study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included a decline of over two thirds for breast and cervical cancer screenings (79% and 68%, respectively), over half for sick child visits and female contraceptive services, approximately one-third for childhood vaccinations, diabetes, hypertension and antenatal care consultations, and a decline of 10% for deliveries performed at IMSS. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22% and 17%, respectively. Caesarean section rate did not change.

CONCLUSION

Significant disruptions in health services show that the pandemic has strained the resilience of the Mexican health system and calls for urgent efforts to resume essential services and plan for catching up on missed preventive care even as the COVID-19 crisis continues in Mexico.

Pediatric Vaccination During the COVID-19 Pandemic

OBJECTIVES

The impact of the coronavirus disease 2019 pandemic on vaccination coverage, critical to preventing vaccine-preventable diseases, has not been assessed during the reopening period.

METHODS

Vaccine uptake and vaccination coverage for recommended vaccines and for measles-containing vaccines at milestone ages were assessed in a large cohort of children aged 0 to 18 years in Southern California during January to August 2020 and were compared with those in the same period in 2019. Differences in vaccine uptake and vaccination coverage (recommended vaccines and measles-containing vaccines) in prepandemic (January to March), stay-at-home (April to May), and reopening (June to August) periods in 2020 and 2019 were compared.

RESULTS

Total and measles-containing vaccine uptake declined markedly in all children during the pandemic period in 2020 compared with 2019, but recovered in children aged 0 to 23 months. Among children aged 2 to 18 years, measles-containing vaccine uptake recovered, but total vaccine uptake remained lower. Vaccination coverage (recommended and measles-containing vaccines) declined and remained reduced among most milestone age cohorts ≤24 months during the pandemic period, whereas recommended vaccination coverage in older children decreased during the reopening period in 2020 compared with 2019.

CONCLUSIONS

Pediatric vaccine uptake decreased dramatically during the pandemic, resulting in decreased vaccination coverage that persisted or worsened among several age cohorts during the reopening period. Additional strategies, including immunization tracking, reminders, and recall for needed vaccinations, particularly during virtual visits, will be required to increase vaccine uptake and vaccination coverage and reduce the risk of outbreaks of vaccine-preventable diseases.

Changes in childhood vaccination during the coronavirus disease 2019 pandemic in Japan

Background

The coronavirus disease 2019 (COVID-19) pandemic has greatly affected daily life. COVID-19 often causes asymptomatic or mild disease in children; however, delayed routine childhood immunization is a concern, as it could increase the risk of vaccine-preventable disease. No study has evaluated the status of childhood vaccinations in Japan during the COVID-19 pandemic.

Methods

This retrospective observational study evaluated the number of vaccine doses administered to children in 4 Japanese cities (2 cities in the Tokyo metropolitan area and 2 cities far from Tokyo) during the period from 2016 to 2020. Vaccine doses administered between January and September 2020 during the COVID-19 pandemic were compared, by month, with those given during 2016–2019. Age-stratified demographic data were collected to determine whether factors other than change in the child population over time affected vaccination trends.

Results

In all cities the decrease in vaccine doses administered was most apparent in March and April 2020, i.e., just before or coincident with the declaration of a nationwide COVID-19 emergency on April 7, 2020. The decrease started as early as February in the Tokyo metropolitan area. As child age increased, the decrease became more apparent. Before the lift of national emergency on May 25, catch-up of the vaccination was observed in all age groups in all cities. Vaccine doses persistently increased in older age groups but not in infants. The overall vaccination trends did not differ significantly among the 4 cities.

Conclusions

The COVID-19 pandemic significantly affected routine childhood immunization in Japan. Thus, a nationwide electronic surveillance system and announcements for guardians to encourage timely routine immunization are warranted.

Assessing mandatory stay-at-home and business closure effects on the spread of COVID-19

BACKGROUND AND AIMS

The most restrictive nonpharmaceutical interventions (NPIs) for controlling the spread of COVID-19 are mandatory stay-at-home and business closures. Given the consequences of these policies, it is important to assess their effects. We evaluate the effects on epidemic case growth of more restrictive NPIs (mrNPIs), above and beyond those of less-restrictive NPIs (lrNPIs).

METHODS

We first estimate COVID-19 case growth in relation to any NPI implementation in subnational regions of 10 countries: England, France, Germany, Iran, Italy, Netherlands, Spain, South Korea, Sweden and the United States. Using first-difference models with fixed effects, we isolate the effects of mrNPIs by subtracting the combined effects of lrNPIs and epidemic dynamics from all NPIs. We use case growth in Sweden and South Korea, 2 countries that did not implement mandatory stay-at-home and business closures, as comparison countries for the other 8 countries (16 total comparisons).

RESULTS

Implementing any NPIs was associated with significant reductions in case growth in 9 out of 10 study countries, including South Korea and Sweden that implemented only lrNPIs (Spain had a nonsignificant effect). After subtracting the epidemic and lrNPI effects, we find no clear, significant beneficial effect of mrNPIs on case growth in any country. In France, for example, the effect of mrNPIs was +7% (95% CI: -5%-19%) when compared with Sweden and + 13% (-12%-38%) when compared with South Korea (positive means pro-contagion). The 95% confidence intervals excluded 30% declines in all 16 comparisons and 15% declines in 11/16 comparisons.

CONCLUSIONS

While small benefits cannot be excluded, we do not find significant benefits on case growth of more restrictive NPIs. Similar reductions in case growth may be achievable with less-restrictive interventions.

Trends in Pediatric Primary Care Visits During the Coronavirus Disease of 2019 Pandemic

OBJECTIVE

Months after the declaration of the coronavirus disease of 2019 (COVID-19) national emergency, visits among children remained suppressed for unclear reasons, which we sought to understand by examining child visit rates.

METHODS

Using de-identified claims data for children <18 years old from OptumLabs® Data Warehouse, a large commercial claims database, we compared monthly primary care visit and vaccination rates from January-October 2020 to January-October 2018 and 2019. Visit rates were analyzed by visit reason and by the month after (eg, month +1) the COVID-19 public health emergency declaration using a series of child-level Poisson regression models.

RESULTS

There were 3.4, 3.4, and 3.1 million children in 2018, 2019, and 2020 cohorts, respectively. Compared to the same months in prior years, primary care visits in 2020 were 60% lower in month +1 (incidence rate ratio [IRR] 0.40, 99% confidence interval [CI] 0.40-0.40) and 17% lower in month +7 (IRR 0.83, 99% CI 0.83-0.83). Preventive visit rates were 53% lower in month +1 (IRR 0.47, 99% CI 0.47-0.47), but 8% higher than prior years in month +7 (IRR 1.08, 99% CI 1.08-1.08). Monthly rates of vaccine administration followed a similar pattern. Problem-focused visits remained 31% lower in month +7 (IRR 0.69, 99% CI 0.68-0.69), with notably fewer infection-related visits (acute respiratory tract infections IRR 0.37, 99% CI 0.36-0.37; gastroenteritis IRR 0.20, 99% CI 0.20-0.20).

CONCLUSION

Seven months after the COVID-19 emergency declaration, receipt of pediatric care remained suppressed due to fewer problem-focused visits, with notably fewer infection-related visits. By October 2020, rates of preventive visits and vaccination exceeded rates in prior years.