Recently, I took care of a toddler who needed to be sent to an ER. At the time, there had been an active measles exposure in our area. Measles is one of the most contagious pathogens. Before the measles vaccine was introduced in 1963, measles epidemics every two to three years killed an estimated 500 children per year in the U.S.
As part of the history, I asked the toddler’s mother about the child’s vaccination status. She told me that her children had not had vaccines since the Covid-19 pandemic began, including measles. As she told me, she seemed as though she was bracing herself. She told me she had lost trust in many of the recommendations from the medical community. I pulled up a chair, took a few moments, and gently explained my concerns in this setting specifically with measles, focusing on her child. This mother teared up. She thanked me for giving her specific information and for not condemning her choices. She told me I had helped her build some trust. It was a very personal interaction.
Measles makes most pediatricians sweat because it significantly affects unimmunized pediatric patients. For every 1000 children who get measles, one to two will die, and one will get brain swelling that can leave a child intellectually impaired. One in 20 children with measles will get pneumonia. It is simply not one of those diseases that we pediatricians want to see “run its natural course.” We might be more sensitive to it in Philly. Our city has a history: In 1991, measles tore through two Philly churches whose congregants didn’t believe in doctors or immunizations and refused all medical treatment. Six children in these two small churches died that year, and three other children from outside the churches also tragically lost their lives.
The measles vaccine is typically given at age 12 months and again at age four to six. Once vaccinated, people have a 95% protection rate, even in outbreaks. The problem is that children under 12 months have no protection, and are highly susceptible, due to age. And unvaccinated children over 12 months have the same risk. Higher concentrations of those unvaccinated against measles will invariably lead to outbreaks.
That is how the ‘91 Philly outbreak happened. Philly had a population of those who were not vaccinated, and given its highly contagious nature, measles spread outside of that population. The percentage of children who completed their first dose of the measles vaccine was 83% last year, an increase since the losses during the pandemic years, but still much lower than the 86% achieved in 2019. When we have lower rates, measles can take hold, as it did in Philly in 1991.
It’s no secret that fewer than 45% of Americans trust what the CDC says about Covid-19. School closures, mandatory masks, and missteps on natural immunity and vaccination wore them out. You cannot pretend that a bump in myocarditis is not a big deal and expect that parents will not notice.
Among parents, their medical choices echoing this distrust is more startling.
Under age five, only 13% of American parents have chosen to give their child even one dose of the Covid-19 vaccination—despite the CDC and the American Academy of Pediatrics (AAP) recommending Covid-19 vaccination for all children over six months. For the age 5-11 crowd, the number is under 40%. American parents are not listening to the medical establishment regarding Covid-19.
We can see a decline not only for the measles vaccination, as discussed above, but for influenza vaccination as well since the pandemic began. In the year before Covid-19, 63.7% of children received influenza vaccinations in America. Post-Covid-19 numbers are 57.8%.
What does it look like to get the flu without vaccine protection? Previous to Covid-19, I would meet a handful of patients who would not get their flu vaccine, then get hit with seven to nine days of high fever, vomiting, and lethargy. In an unvaccinated patient, the flu can be nasty, and last longer than most respiratory viruses. Last fall, there were dozens of patients like this. I recall one mom’s tears streaming down her face, with three kids, one after another felled by flu, each sick for a solid week. If a parent chooses this possibility for their child, knowing the level of sickness they may tangle with…. And many do, it’s informed consent to choose not to immunize against the flu. In my experience, most parents don’t know till they are dealing with all those days of 104 degrees.
In the spring, I was explaining this to a local elected official with no medical training and further explaining how awful the fall of 2022 and winter of 2023 had been for children. Bad flu, and one respiratory illness after another, with kids sicker than in any year I had ever practiced. Every pediatrician I know was talking about it. “Dr. Mass, do you think it was due to children being locked down and in masks for so long?” he asked. “Yes, yes I do”, I replied. There is no solid evidence of this due to the many confounding variables around the pandemic, but the hypothesis of “immunity debt”—how COVID lockdowns may have left children with immune systems that are more “naive” to multiple respiratory illnesses—deserves consideration and more public discussion. After last fall, any mom who says “never again” to months-long lockdowns should not be chided.
When I explained my concerns about the declining measles vaccination and flu vaccination rates, he asked if I thought it was because the Covid-19 vaccination was pushed too hard on parents. Again, I agreed, then explained that we needed to hone our advice toward that which could most devastate our young patients. Excited, he called over his colleague, also an elected official and from his party. We reiterated our discussion. She became angry: “Parents should just follow all the guidelines, otherwise they are showing us how stupid they are,” she snapped. Even he looked surprised at her tone and words.
And that, right there, is the problem encapsulated. When we do not talk to one another, when we condemn, when we respond in anger, the result is erosion of trust. Our patients and in pediatrics, parents, need it most of all.
If elected leaders choose to be dismissive instead of conversant and thoughtful, we will continue to drive Americans apart, rather than find common paths to achieving good health and other important goals.
One of the most wonderful roles of being a pediatrician is pulling up a chair and fostering a personal interaction with the parents of the children you serve. Offering them all assurance that you are there to care for their child, and educating kindly.
We cannot afford to allow divisiveness and dismissiveness to continue to flourish. Kids’ health is on the line.