BALTIMORE — There are thousands of children across Maryland who not only haven’t been vaccinated against COVID-19, but also lack protection from influenza and the kinds of diseases that routine shots long ago made scarce, such as measles and chickenpox.
It’s a worrisome trend for public health experts, who see a surging number of children infected with the coronavirus and fear another outbreak in particular may be on the horizon — measles.
“I’m most worried about measles; we know it’s very contagious,” said Dr. William Moss, the executive director of Johns Hopkins’ International Vaccine Access Center.
“I’ve been tracking it through the pandemic globally, and I do think communities in the United States, including in Maryland, are going to be at increased risk,” he said. “Measles does not respect borders or stay in one place, and it moves quickly.”
Measles was declared eliminated from the United States in 2000 due to high rates of vaccination, but made a comeback in recent years when international travelers reintroduced the disease in unprotected groups of people.
Measles can cause fatal complications in children, such as pneumonia and encephalitis. The U.S. Centers for Disease Control and Prevention is following outbreaks “occurring in every region of the world” due to interruptions in vaccination campaigns.
There have been few cases reported so far this year in the United States. There have been more cases of flu and respiratory syncytial virus (RSV), and far more cases of COVID-19.
The World Health Organization reported more than 17,000 measles cases worldwide in the first two months of the year, up almost 80% from the same period in 2021. Thousands of cases have been added since.
The last major U.S. outbreak was pre-pandemic in 2019, when there were 1,282 cases in 31 states, including Maryland.
That local outbreak made an impression on Dr. Ashley Crimmins, who lives with her family in Baltimore County, not far from where the cases were reported.
Vaccines were always a priority, but the measles cases “reinforced their importance” since her daughter was an infant at the time and not eligible for the highly effective measles, mumps and rubella, or MMR, vaccine.
“All it takes is a whiff in the wrong direction,” Crimmins said. “You share air space with someone with active measles and if you have no vaccine, you’ll get measles.”
Crimmins, an emergency medicine physician, ended up getting the MMR vaccine early for her daughter and kept up with vaccine schedules through the coronavirus pandemic for her daughter, now almost 4, and her son, 9 months. They also have their flu shots and she’s anxiously waiting for COVID-19 vaccines to be authorized for children under age 5, something that’s expected to happen in the coming weeks.
Crimmins treats people who avoided medical care during the pandemic and understands how parents get behind on routine shots and even why they may have put off the COVID-19 vaccine. But she urges them to consider what happens to kids even when they don’t get sick enough for the emergency room. Her daughter’s day care was closed most of December due to COVID-19 because other children had the coronavirus.
“She really missed the structure of school,” Crimmins said.
Public health experts say people have a lot of reasons to skip vaccines, from concerns about going to the doctor or missing work, fear of side effects of the new COVID-19 vaccine, or even feeling well enough that they don’t believe vaccines are necessary.
The CDC reported in April that Maryland had among the largest drops of state reporting in routine vaccinations in the 2020-2021 school year, when more than 8% of kindergartners didn’t show proof of vaccination when starting school. Normally, kindergartners have had two doses of the MMR vaccine. In the years before the pandemic, nearly all were either vaccinated or had obtained an exemption.
The Maryland Department of Health did report progress during the school year: There were about 10,000 kids without routine vaccinations in November, down from more than 23,000 during the summer, among 17 counties and Baltimore City that reported data to the state. Not all counties updated their data in the fall, and no new data has been provided.
Some, but not all, likely have caught up, said Dr. James Campbell, a pediatric infectious disease specialist in the University of Maryland School of Medicine and the site’s principal investigator on children’s COVID-19 vaccines.
“It’s definitely worrying that there still is a gap,” he said. “Things that worry us the most are the ones that are most contagious and measles is the most contagious.”
Campbell said he also worries about other vaccinations, such as one for the human papillomavirus, or HPV, a virus that causes cancer often decades after infection. It’s not required by schools, but the CDC recommends it for preteens.
“We tend as a public to get scared of pandemics and outbreaks and fast-breaking COVID, but tens of thousands die every year from HPV-related cancers,” he said. “People don’t always see an urgency.”
He said flu shots also can be a hard sell, as they’re often not as protective, especially in years (like this one) where the strains covered by the shot are a mismatch for those circulating among people. But like the COVID-19 vaccine, having the shot often protects against severe disease. About 30% of Marylanders have gotten the flu vaccine.
While COVID-19 vaccinations are far higher, children have the lowest rates with 58% of those aged 5 to 17 fully inoculated. COVID and flu shots are not required by schools. In Maryland, students are required to have the MMR vaccine, as well as immunizations against chickenpox; polio; diphtheria, tetanus, and whooping cough; hepatitis B; and meningitis. Specific exemptions are required for any exemptions on medical or religious grounds.
For required vaccines, state health officials and school leaders already have notified local school superintendents and health officers that they need to begin preparing now for the next school year.
“To reduce the number of students that may be out of compliance at the start of the 2022-2023 school year, school officials should begin now to complete assessments of school immunization records and inform parents of children who may be out of compliance,” said an April 22 letter to the county education and health officials.
“This will allow parents maximum time for the parent to get their children up to date,” it said.
Tiffany Tate, who runs the nonprofit group Maryland Partnership for Prevention, has been working with Baltimore and other counties to offer students flu, COVID-19 and routine vaccinations. She said the pandemic has interrupted vaccinations of all kinds and health officials across the state have been setting up extra clinics.
“Typically at this time of year, we’d be talking about fall and flu season, but more are talking about routine vaccinations,” Tate said. “Some counties are booking for mid- to late summer to do back-to-school vaccines. Some want to get students now, before they leave for vacation.”
Tate said even vigilant parents have fallen behind on vaccinations schedules because of the pandemic. And now that summer is close, even with rising COVID-19 cases, “things feel good. so they aren’t worried about vaccines,” she said.
Tate said her organization will push ahead with clinics for elementary and middle school students, offering all of the vaccines. With the U.S. Food and Drug Administration last week authorizing COVID-19 booster vaccines for children ages 5 to 11, it will offer those, too.
“We’ll evolve and respond; we’ll fill in all the gaps,” she said. “People are so focused on COVID because it’s an immediate threat to health, but there are other threats.”
