Introduction and summary
From birth through age 18, children in the United States are routinely immunized against a host of preventable childhood diseases. These include measles, mumps, rubella, polio, human papillomavirus (HPV), hepatitis A and B, tetanus, diphtheria, and other diseases. Routine childhood immunization is highly effective at preventing disease over a lifetime, reducing the incidence of all targeted diseases, and, for the U.S. population in 2019, preventing more than 24 million cases of disease.1 Yet despite this success, childhood vaccination rates have seen a troubling decline in this country since the onset of the COVID-19 pandemic, deepening preexisting gaps in vaccination participation. The decline in routine childhood vaccinations is concerning from health, equity, and economic perspectives.
Vaccine coverage is below the levels that are needed to protect children from vaccine-preventable diseases and to avoid community outbreaks of preventable diseases. Recent measles outbreaks provide an illustrative example: In 2019, the United States reported a record number of measles cases since 1992.2
There are also large disparities in vaccination rates by race, income, and geography. According to U.S. Centers for Disease Control and Prevention (CDC) data, from 2018 to 2020, children in the United States born in 2017 and 2018 who were uninsured, Black, Hispanic, or had family income below the federal poverty level had lower childhood vaccination coverage than those who were privately insured, white, or had family incomes at or above the federal poverty level. 3 These children are also disproportionately likely to have missed routine immunizations; according to the 2018–2020 National Immunization Survey, by 24 months of age, Black and Hispanic children born from 2017 to 2018 had statistically significant lower vaccination rates than the white population of most recommended childhood vaccines.4 Other than for the hepatitis B birth dose, uninsured children had lower vaccine rates than privately insured children for all vaccines, ranging from a percentage-point difference of 9.2 for three or more hepatitis B doses to 37.8 for two or more influenza vaccine doses.5 Children in rural areas have lower rates of routine childhood vaccinations compared with children in nonrural areas, and these disparities widened during the pandemic.6
Moreover, the problem of missed vaccines is not contained within U.S. borders. Although the global decline started years earlier, UNICEF, which called the pandemic a “disaster for childhood immunization,”7 reported that 67 million children missed vaccines from 2019 to 2021 during the height of the pandemic and noted the reemergence of preventable diseases.
A variety of factors have contributed to the decline. For some populations with previously existing barriers to accessing health care, their difficulties were exacerbated by pandemic-related disruptions in care. Disinformation and polarization of support for the COVID-19 vaccine also provided fuel to parents who were skeptical about vaccines and seeking childhood vaccine exemptions.
Policymakers can take a variety of approaches to counteract declining vaccination rates. This report discusses reasons why routine childhood vaccination rates have dropped in the United States and recommends these actions for improvement:
- Bolster resources for immunization programs through the federal Vaccines for Children (VFC) and Section 317 programs.
- Expand the vaccination workforce through policies that facilitate provider enrollment in the VFC program and support vaccinators, such as school nurses and pharmacists.
- Increase vaccine reimbursement to cover costs associated with vaccination, such as vaccine education, and reduce administrative burdens.
- Tighten and reenforce school vaccine requirements that have been effective in producing high vaccination rates.
- Engage trusted community leaders, such as health care providers, school staff, and faith-based organizations, to counter vaccine disinformation with accurate and effective messaging.
Rates of childhood vaccination are declining
Childhood vaccination is one of the lowest-cost and most effective public health strategies8 to control and prevent disease, improve health and quality of life, and extend lifespan. Most dangerous and deadly vaccine-preventable childhood diseases have been reduced or eliminated in the United States due to immunization programs,9 including measles, mumps, and rubella (MMR); polio; several strains of HPV; hepatitis A and B; whooping cough; and diphtheria. Researchers who calculated the 2019 disease burden with and without childhood immunization found that routine childhood immunization for 14 vaccine-preventable diseases reduced the incidence of all targeted diseases. Results ranged from a 17 percent reduction in incidence of influenza to 100 percent for six other diseases, including measles, mumps, and polio.10
Despite this success, according to a mid-January 2023 report from the CDC, vaccination coverage decreased in most states for all vaccines among kindergarteners for the 2021-22 school year when compared with the previous school year, which were already below pre-pandemic levels.11 This decrease is concerning because high vaccination rates are critical to protect individual children from vaccine-preventable diseases and to create herd immunity,12 which prevents community outbreaks of preventable diseases. Herd immunity happens when a large percentage of a population is immune from a disease, making the disease less likely to spread and thus providing some protection from contracting the disease even for those who are not immune. Herd immunity is particularly important for people who are not able to be vaccinated, such as those who are too young or are immune compromised.
Almost 250,000 kindergartners in the 2021-22 school year … may not have been protected against measles.
In regard to the national measles cases in 2019, most outbreaks were limited due to high community immunity. However, outbreaks in New York City and in the state,13 which occurred in densely populated areas with low vaccination rates, lasted longer and had the highest rates of measles cases in the nation in 2019. A measles outbreak in Clark County, Washington, infected 71 county residents and led to the declaration of a public health emergency. The outbreak cost society more than $3.4 million when including productivity loss and direct medical costs, translating to more than $47,000 per case.14
The U.S. vaccination rate of 93.5 percent coverage for the MMR vaccine is below the Office of Disease Prevention and Health Promotion’s Healthy People 2030 goals for the nation:15 that translates to almost 250,000 kindergartners in the 2021-22 school year who may not have been protected against measles.16 The rate is down from the 95 percent rate recommended for measles herd immunity17—and with 95 percent of the population vaccinated,18 measles would be expected to no longer spread.
Vaccines save lives and money, yet vaccine-preventable diseases still pose a notable threat to child health, signaling the critical need to continue to increase routine childhood vaccination. Researchers estimate that every dollar spent on childhood vaccination saves more than $10 in societal costs and $3 in direct medical savings. 19 The CDC estimates that the vaccination of children born between 1994 and 2021 will prevent 472 million illnesses, almost 30 million hospitalizations, and more than one million deaths, saving nearly $2.2 trillion in total societal costs, including $479 billion in direct costs.20
Every dollar spent on childhood vaccination saves more than $10 in societal costs and $3 in direct medical savings.
A variety of factors have contributed to the drop in childhood vaccine rates
The decline in vaccination rates can be attributed to a variety of factors, including barriers to accessing care during the pandemic and vaccine hesitancy, which is associated with a decline in trust in government and science and a rise in vaccine disinformation.21 While many of the barriers existed prior to the pandemic, they have been exacerbated over the past several years, as described below.
Access to health care
Preventive medical visits are a critical component of well-child care. These visits are used for tracking developmental milestones and can reduce hospitalizations and emergency department use.22 They also help cultivate the development of trusting relationships between families and primary care providers that can be used to provide education, ease fears about childhood vaccines, and counteract misinformation.
Yet, in the initial stage of the pandemic, when stay-at-home orders were in effect and schools, workplaces, and other public places were closed, there were significant disruptions in well-child visits,23 which are commonly used to administer vaccinations. Although health care providers reported capacity to provide routine childhood vaccines to catch children up on vaccines by May 2020, in a March 2021 survey, 41 percent of parents reported that their youngest child missed a routine medical visit during the past year due to the COVID-19 pandemic.24 In addition, from April 2020 through October 2020, the rates of Black and Latinx households reporting missed preventive care visits—with 33 percent and 35 percent respectively—were significantly higher than that of white households, which had a rate of 27 percent. 25
The COVID-19 pandemic has contributed to access barriers in other ways as well, including pediatric staffing shortages,26 a shifted focus from administering routine childhood vaccinations to the COVID-19 vaccine in school vaccine clinics, and the prioritization of medical resources to care for older adults who are most at risk of severe illness from COVID-19.
Individuals may delay or refuse vaccines for themselves or their families despite vaccines being available, which is commonly referred to as vaccine hesitancy.27 They may distrust the health care system based on previous negative experiences, such as historic medical mistreatment and discrimination that Black communities have experienced.28 Misinformation and disinformation also drive vaccine hesitancy. The Pan American Health Organization has cited misinformation in relation to vaccine hesitancy as one factor that has led to a 30-year high risk of disease outbreaks in the Americas.29 Even before the pandemic, researchers used 2018–2019 data to attribute parents’ vaccine hesitancy to an estimated 6 percent to 31 percent of cases in which children and adolescents were not vaccinated, depending on the specific vaccine.30 The anti-vaccination movement, which was surging with support from visible vaccination opponents prior to the pandemic,31 got a boost from the pandemic. The scientific understanding of an unknown and quickly evolving virus led to changes in guidance that affected trust in government, science, and the health care industry, along with and a reliance on social media for scientific information and a rise in disinformation associated with COVID-19 vaccines.32
In May 2021, researchers reported that most of the misleading claims and disinformation about COVID-19 vaccines that are commonly found on social media came from just 12 people. Referred to as “The Disinformation Dozen”33—many of whom have preyed on fears and doubts to discredit vaccines, circulate disproved medical claims and conspiracies, distort information, and sell their own supplements for years—produce 65 percent of anti-vaccine misinformation on social media platforms.
Loosening of vaccination requirements
Every state and the District of Columbia requires certain immunizations to attend school, 34 although some states allow medical, religious, or personal belief exemptions. A higher number of vaccine exemptions is correlated with an increased risk of vaccine-preventable diseases.35
According to the Association of State and Territorial Health Officials,36 as of May 2022, 44 states allowed religious exemptions and 15 states allowed personal belief exemptions, with 13 states proposing new nonmedical exemptions as of March 2023. According to Dorit Reiss, who studies vaccine policy at the University of California College of the Law, San Francisco, state “bills challenging vaccine mandates — whether Covid-specific or not — have gained new momentum in the years since the pandemic’s onset.”37
Public health officials fear that misinformation and public distrust of the COVID-19 vaccine has led to an increase in the percentage of children who have received exemptions38 in 38 states and the District of Columbia during the 2021-22 school year.39 As just one example, according to the Texas Department of State Health Services,40 exemptions in Texas increased among K-12 students from 0.45 percent in the 2010-11 school year to 2.7 percent in the 2021-22 school year, with even higher rates for private schools.
In fact, 30 states reported to the CDC that COVID-19 resulted in a decrease in vaccination coverage during the 2021-22 school year,41 largely due to reduced access, but also due to “local or school level extensions of grace period or provisional enrollment policies.”
A multi-faceted approach is needed to reduce barriers to routine childhood vaccinations and increase vaccine rates, which are both critical to protecting individual children and communities from vaccine-preventable disease and their associated health and financial costs. Barriers to vaccination can be addressed through a variety of means, such as bolstering the underfunded vaccine and public health infrastructure and expanding and supporting the vaccination workforce.42 Other efforts to boost confidence and counter vaccine hesitancy can involve countering disinformation, reducing exemptions, and engaging communities and trusted messengers in vaccine outreach campaigns.
Bolster resources for immunization programs
Federal support for childhood vaccination comes through several critical programs. The Vaccines for Children program provides no-cost vaccines for eligible children who otherwise may be unvaccinated due to costs,43 including Medicaid-eligible, uninsured, underinsured, or American Indian or Alaska Native children—according to specific vaccine recommendations of the Advisory Committee on Immunization Practices. The CDC purchases vaccines at a discounted rate for state and local public health agencies, which then distribute them to registered VFC providers. The VFC, in providing vaccines to about half of all children in the United States,44 is a critically important element of the U.S. vaccination strategy.
The president’s budget for fiscal year (FY) 2024 includes approximately $6 million in mandatory funding and an increase of more than $1.5 million above the FY 2023 enacted budget. The budget also includes a legislative proposal to expand the VFC program to all children younger than age 19 who are enrolled in a Children Health Insurance Program (CHIP) and to eliminate their vaccine copayments.45
The Section 317 Immunization Program also provides federal support.46 Although the program focuses on no-cost vaccines for uninsured and underinsured adults, it supports vaccine infrastructure for the VFC program and vaccine supply to more than 40,000 private physicians in the VFC program.47 However, this program receives insufficient funding to maintain the vaccine infrastructure, promote routine vaccination, administer missed doses, engage health care providers and stakeholders, and reach populations with lower vaccination rates. In fact, CDC estimates that Section 317 was underfunded by at least $750 million in 2021. 48
The historically underfunded vaccine infrastructure has been stretched particularly thin during the COVID-19 pandemic. The FY 2023 omnibus appropriations bill increased the Section 317 program funding by $31 million from the year prior to almost $682 million,49 but this is insufficient to meet the true need. The “FY24 Governmental Public Health Appropriations Book,”50 which contains public health associations’ recommendations and priorities, urges a $448 million increase above the FY 2023 appropriations for the Section 317 program, raising it to $1.13 billion.
The increase is intended to support immunization programs in catching up on routine childhood immunizations; updating states’ immunization information systems, 51 which document immunization statuses; and maintaining improvements to immunization infrastructure that were made through COVID-19 emergency funding such as the American Rescue Plan Act of 2021,52 which provided states with critical funding to support vaccination programs.53
Modernizing states’ immunization information systems is critical to improving vaccine data and ensuring children receive timely and accurate vaccinations. Reinforcing the data infrastructure is a critical component of federal immunization funding. States have used this funding to enroll providers in the program; improve the quality of immunization data, including the collection of race and ethnicity data; exchange timely information with patients, health care providers, and the federal government; implement reminder and recall messages to inform families when their children are behind on immunizations or when their immunizations will be due soon;54 and improve vaccine ordering and inventory processes. However, this funding expires at the end of 2024.
Support and expand the vaccination workforce
Most childhood vaccinations are administered within a medical home, which is an approach to primary care that emphasizes accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective care. It also enables pediatric providers to simultaneously conduct a comprehensive health care assessment and identify other health or developmental concerns.55 Children who are vaccinated within a medical home are more likely to be up to date on their vaccinations. Although this situation is ideal, not all children have medical homes.56
The COVID-19 pandemic fueled the need to make vaccines widely accessible and available. In response, the U.S. Department of Health and Human Services authorized pharmacists to administer childhood vaccines to children ages 3–18 through the Public Readiness and Emergency Preparedness (PREP) Act. The PREP Act addresses concerns about vaccinating outside of medical homes by requiring pharmacists to communicate the importance of well-child visits to caregivers and to refer children to providers as appropriate.
When pharmacists’ authorization through the PREP Act expires at the end of 2024, states can continue to enroll pharmacists in the VFC program. However, states may face barriers to increasing enrollment, including limited staff capacity and resources for administering the program; misconceptions or concerns from providers about program requirements such as the need for separate vaccine storage units for VFC vaccines; and pushback from the provider community that vaccinations should be prioritized within the medical home.57 Communication and guidance from state immunization programs and from the CDC could address some of these issues.58
Nevertheless, states are expanding the vaccination workforce and addressing a shortage of pediatric primary care providers and school nurses through laws that expand the scope of practice and new outreach strategies to address previously limited success in enrolling pharmacists in the VFC program.59 In Michigan, for instance, recently passed S.B. 219 would allow pharmacists who are not operating under the supervision of a physician to administer vaccines recommended by the CDC to individuals who are at least 3 years old as long as they receive special training and comply with reporting requirements.60
States are also tapping into federal school funding resources such as the Elementary and Secondary School Emergency Relief (ESSER) funds and the Governor’s Emergency Education Relief funds to improve school health infrastructures that can better support school-located vaccination, including hiring school nurses and establishing school-based health centers and mobile health clinics.61 Mississippi, for instance, has dedicated ESSER funds to increase the capacity of nurses to deliver health services and education to students and staff.62
Increase vaccine reimbursement and reduce administrative burden
Providers enrolled in the VFC program can charge Medicaid a vaccine administrative fee to provide vaccines, but in many states the cost of administering the vaccine—including ordering the vaccine, family education and counseling expenses, equipment, and storage—has exceeded the fee, which limits providers’ ability to vaccinate these populations.63 Countering vaccine hesitancy requires additional time for providers to educate and counsel families about the benefits of vaccination. According to a 2016 Health Affairs study, practices lose between $5 and $15 per dose of VFC-administered vaccines.64 In a 2020 Avalere survey, more than 80 percent of providers reported that increased reimbursement for administration fees would help them overcome barriers to offering vaccines.65
State policymakers set Medicaid reimbursement rates and determine the types of providers who can be reimbursed through each state’s Medicaid program. They can expand access by taking steps to increase provider payments and expand the types and settings in which providers are reimbursed. As such, states can amend their state Medicaid plans to increase reimbursement for administrative fees and expand the workforce. States can add school-based Medicaid billing, increase vaccine administration rates, include new types of vaccine providers within Medicaid programs such as dental hygienists, and cover administrative fees in pharmacy settings.66 They also can investigate whether they can remove any state compliance requirements beyond those required by the VFC program.
States also can address the costs to providers through universal vaccine purchase programs. Through these programs, state governments can offer vaccines at no cost to providers by collaborating with insurers to fund the purchase of vaccine supply at a discounted rate. Such programs lower costs for providers, including the burden of ordering private vaccines. According to a 2020 impact analysis of Maine’s universal purchase program, the state saves insurance providers more than $4 million annually.67 Fourteen states operate these programs.68
The CDC’s legislative proposals also would reduce administrative costs.69 Expanding VFC eligibility to all children under age 19 enrolled in the CHIP program would remove costs for states by transferring CHIP vaccine purchase costs to the VFC program. The proposal would update the provider administration fee structure, with the expected result of increasing provider involvement in the VFC.
As science evolves, the CDC also should consider expanding the types of medications that are eligible for the VFC.70 Nirsevimab, which may become the first respiratory syncytial virus (RSV) prevention medication available for newborns and infants, currently is under review by the U.S. Food and Drug Administration.71 However, it is a monoclonal antibody rather than a vaccine, and monoclonal antibodies were not specifically included in the law that created the VFC program.72 If Nirsevimab is ineligible for the VFC program, uninsured children and those covered by the Medicaid program will not have coverage for the medication, which could further exacerbate disparities.
Tighten and enforce vaccine requirements
According to a March 2023 Pew Research Center survey, a smaller majority of Americans—70 percent—say that healthy children should be required to be vaccinated in order to attend public schools than in both 2019 and 2016, when it was 82 percent.73
States can increase vaccination rates by tightening vaccine requirements and reducing nonmedical exemptions. According to the Association of State and Territorial Health Officials, “low state exemption rates are positively correlated with high state vaccination rates.”74 In fact, Mississippi and West Virginia, the first and only states without nonmedical school vaccine exemptions for more than 30 years, have had among the highest school vaccine rates in the country for decades.75 The elimination of nonmedical exemptions in California through state law following a measles outbreak in 2014–2015 led to a 3.3 percentage-point increase in the MMR vaccination rate, enough to raise children above the measles immunity threshold.76 For these reasons, the American Academy of Pediatrics and other major professional societies advocate for the elimination of nonmedical vaccine exemptions.77
Recent experience in Maine shows that religious organizations may support the removal of nonmedical exemptions, including religious exemptions. The removal of religious and philosophical exemptions to vaccine mandates was signed into law in 2019 and was upheld by the U.S. Supreme Court. The Maine Council of Churches, which represents seven different denominations of Christianity, supported the law, describing it as “welcomed by many religious groups in the state.”78 According to the Maine Council of Churches’ executive director, the Rev. Jane Field, “we believe that when such exercise of religious freedom promotes a risk to public health, it becomes antithetical to the very core of our deepest-held beliefs—that God calls us to love our neighbors as ourselves; to protect the weak, marginalized, and vulnerable; and to make sacrifices on behalf of others.”79 The law is having its desired effect. Maine’s percentage of kindergarten students with any exemption for four vaccines—diphtheria, tetanus, and pertussis; polio; MMR; and varicella-zoster virus (VAR)—fell from 4.6 percent in the 2019-20 school year to 1.3 percent in the 2021-22 school when the law was implemented.80
Along with tightening vaccine requirements by removing personal exemptions, states can take other measures such as strengthening enforcement of existing requirements and reinforcing the importance of vaccines and vaccination rate requirements to parents and caregivers. The Association of State and Territorial Health Officials shares examples of state policy strategies, including requirements for annual exemption forms, specific paperwork, and parental education about vaccines.81
During the 2021-22 school year, when many COVID-19 protocols were still in place, states granted exceptions to school vaccine requirements due to staff shortages and limited capacity to ensure students were up to date. These came in the form of what the CDC describes as “grace periods (attendance without proof of complete vaccination or exemption during a set interval) or provisional enrollment (school attendance while completing a catch-up vaccination schedule).”82 Also during that school year, 4.4 percent of kindergarten students without vaccine exemptions nationally were not up to date with the MMR vaccine. Identifying and following up with these children through catch-up campaigns and connecting them to vaccinators provides a significant opportunity to improve coverage rates.83 Leading researchers suggest that amending these exemptions will help ensure compliance with vaccine requirements.84
Engage communities to counter disinformation and message effectively
In 2019, the World Health Organization declared vaccine hesitancy as one of the top 10 global threats.85 Although a March 2023 Pew Research Center survey found higher confidence in childhood vaccines than in the COVID-19 vaccine, the politicization of vaccination during the height of the COVID-19 pandemic has influenced some public perspectives about routine childhood vaccination, including school vaccination requirements.86 New federal investments in scientific communication are needed.87 It is increasingly important to get timely, accurate, culturally sensitive, and evidence-based information in plain language, with appropriate messaging from trusted community leaders, to families and communities in order to counter misinformation.
The CDC’s Routine Immunizations on Schedule for Everyone (Let’s RISE) initiative provides community leaders, health care professionals, and partners with strategies, examples, and data to support efforts to catch up on routine childhood vaccinations.88 The Maine Immunization Program, as one example, has developed targeted messages and outreach strategies by identifying characteristics of families in various areas of the state and the types of messages to which they will be most receptive.89
Health care providers, schools, faith-based organizations, and other trusted community leaders who have supported COVID-19 outreach and vaccination efforts for children should be engaged in routine vaccination efforts.90 According to a Pew Research Center survey in March 2023, 88 percent of adults had a lot or some confidence in their health care provider to accurately present childhood vaccine benefits and risks, and those with the highest level of confidence were also the most confident about the benefits of the MMR vaccines.91
School-based and community-based partnerships that prioritize vaccine accessibility and community trust are also critical for improving immunization rates for children, particularly children who may have limited access to health care providers and pharmacies.92 School staff are important messengers about the importance of vaccination. A November 2021 poll by the Kaiser Family Foundation found that parents and guardians who reported being encouraged by school staff to have their children vaccinated for COVID-19 were four times more likely to report that their children were vaccinated than those who reported that they were not encouraged.93 Back-to-school clinics also are a critical opportunity to increase vaccination rates and are recommended by the Community Preventive Services Task Force of the U.S. Department of Health and Human Services as evidence-based, best-practice strategies.94 The CDC offers guidance, templates, and tools for planning school-located vaccination, including letters to inform providers and parents, and parental consent forms, as well as a checklist and guidance on best practices for vaccination clinics held at satellite, temporary, or off-site locations.95
Strategies to improve access and boost confidence in routine childhood vaccines are critical to control and prevent disease, improve health and quality of life, and extend lifespan. These approaches include increasing support for vaccine programs and for the vaccination workforce; bolstering vaccine confidence, reducing hesitancy, and combating disinformation; and reinstituting and reinforcing vaccine requirements in schools.
The author would like to thank Emily Gee, Hailey Gibbs, Marquisha Johns, Jesse O’Connell, Mariam Rashid, Sarnata Reynolds, Allie Schneider, and Megan Shahi for their thoughtful review of this report, and a special thank you to Marquisha Johns for her assistance with data analysis.