Between October 1 and October 22, 2022, the Centers for Disease Control and Prevention (CDC)’s FluSurv-NET hospitalization network reported 443 flu hospitalizations, the highest in a decade at this time of year. The rates are the highest among adults over age 65 and children under 4. Families and the medical community have come to depend on the wide distribution of immunizations like the flu vaccine to protect the vulnerable population, including children. But not all children are getting vaccinated. According to the American Academy of Pediatrics (AAP), last flu season, only 53% of children ages 6 months through 17 years old were vaccinated for the flu. That number was eight percentage points less for Black children. Part of the reason is due to vaccine access and inequity within communities. This year, a similar trend is developing. As of October 15, 2022, about 22.1% of children have been vaccinated against the flu compared to 21.7% last year. The CDC recommends all children ages 6 months and up receive the flu vaccine, preferably by the end of October. As we get deeper into the season, this decline in children being vaccinated for the flu is concerning for health officials. We spoke with medical experts to discuss some factors which may account for this decline.
What is Vaccine Inequity?
Vaccine inequity occurs when not all persons have access to vaccines. When there is inequitable access to lifesaving vaccines, the divide between rich and poor populations is exacerbated. We see an increase in malnutrition, risk of vaccine-related deaths, and preventable school closures. The recent COVID-19 pandemic is the most glaring example of the danger of vaccine inequity. Social, geographical, political, economic, and environmental factors sometimes affect access to vaccines. More often this affects racial and ethnic groups. During the pandemic, this meant that some people who are Black and Hispanic or Latino were not as likely to get vaccinated against COVID as people who are White.
What Causes Vaccine Inequity?
The root cause of vaccine inequity is usually socio-economic issues. Some children are unable to visit a pediatrician because they are experiencing homelessness or live in rural areas. There are also children who live in congregate settings such as those who are incarcerated or those who live in group homes. “[Some] children who have historical disadvantages when it comes to health—such as those in racial and ethnic minority groups or households with lower incomes, children with developmental disabilities, and children who have special healthcare needs,” says Dr. Boden-Albala. Another factor affecting access is children from non-English speaking homes, who are immigrants and may have undocumented status. The language barrier, lack of health insurance, and fear of deportation may prevent families from seeking pediatric care for their children, which includes routine vaccinations. “Among the most common reasons related to vaccine inequity are lack of health insurance, lack of access to primary care, lack of support to take time off work to vaccinate children, and the need to delay medical care due to costs,” says Diego Hijano, MD, MSc, assistant member of St. Jude Research Hospital Faculty. Dr. Hijano explains that in addition, we know that vaccine hesitancy due to disinformation and misinformation has increased over the pandemic leading to a decline in vaccine confidence. People were concerned about safety, effectiveness, and adverse effects. Vaccine hesitancy was also born out of virus-related conspiracy theories. Although, a study in January 2022 found that since December 2020, COVID vaccine hesitancy decreased faster among people who are Black than among people who are White. The study indicated that was because those in the Black community came to believe the vaccines were necessary protection. Declining trust in public health during the pandemic suggests that COVID vaccination hesitation has spilled over to flu vaccination behavior. Adult flu vaccination rates have declined in states with low rates of COVID vaccination. However, regardless of when COVID vaccines were made available, flu vaccination rates among children fell. “For adults, there is a correlation between low COVID vaccination and low influenza vaccination, says Bernadette M. Boden-Albala, MPH, DrPH, the director and founding dean of the University of California, Irvine program in public health. “However, it is not the case for children as the influenza vaccination rate declined even among states with high rates of COVID vaccination. There may be a parental influence on their child’s health behaviors, but further research is needed to account for this trend.”
Inequity in Healthcare, Not Just Vaccines
While examples of vaccine inequity are clearly illustrated by the COVID pandemic and flu vaccination rates, inequity isn’t just an issue when it comes to vaccines. Healthcare inequities persist as well. Much of that depends on social determinants of health. Those are non-medical factors that influence health outcomes like where people are born, grow, live, work and age. The Department of Health and Human Services places the determinants into five groups. They are economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social community and context. All five domains are intertwined because they examine how the environment people grow up and live in, when combined with how we are educated, ultimately affects their health care. The connecting thread is funding and how it plays a role in either enhancing or impeding all these factors. Social determinants are the underpinning of how and when patients access care and the quality of care they get. Social determinants of health may help explain previous research done within the Medicare community. It suggests that even though access to care and recommendations to vaccinate for flu do not differ between minority and non-minority patients, minority patients are less likely to visit a healthcare provider for the purpose of receiving the vaccine. Healthcare access and medical literacy are also barriers among diverse communities and can exacerbate inequity in childhood vaccinations.
Solutions to End Vaccine Inequity
In order to increase the flu vaccination rate, the AAP recommends providers “offer presumptive, strong influenza vaccine recommendation, bundle recommendation for influenza vaccine with recommendations for other needed vaccines, use consistent messaging across care team members and identify influenza vaccine champion(s).” They also recommend that healthcare systems adopt the habit of “reviewing influenza vaccination status at all visits, bundling influenza vaccine with other needed vaccines, vaccinating at all visit types (eg, well child, acute care visits) and in all health care settings (eg, hospital, emergency department, subspecialty practice).” But ending vaccine inequity is another battle. Dr. Albala believes solutions can include improving health literacy, making low-cost vaccination available, and encouraging providers to use other office visits as opportunities to mention vaccination to patients. “Each community faces different barriers and nuances that require a multi-faceted perspective. Effective influenza vaccination campaigns must be tailored to each community and the barriers they uniquely face,” adds Dr. Hijano. Vaccines for Children (VFC) is a federally funded program run by the CDC. It provides vaccines at no cost to children who might not otherwise be vaccinated because of the inability to pay. This helps ensure that all children have the best shot at receiving all of their recommended childhood immunizations. Parents can find out if their child is eligible through the website. “This is a very complex problem that requires a multidisciplinary approach that goes beyond economical barriers to solve it,” says Dr. Hijano.
