Research In Practice Blog

Editor’s Note: With the latest uptick in COVID cases, we are reminded that some viruses evolve quickly—like flu—and require more frequent vaccinations/boosters. But, we also know that for the viruses which mutate slowly—like measles and polio—vaccination immunity can last decades or even a lifetime. Because each virus is different, vaccines are administered at various points throughout childhood. To keep children as healthy as possible, adhering to evidence-based vaccine schedules is key. This blog post, written by Clinical Research Program Manager, Mary Kate Kelly, MPH, summarizes a recent study about missed opportunities for vaccination during the recent pandemic. 

The pandemic’s impact on teen vaccination

Beginning in 2020, pandemic-related shutdowns, infection concerns, and primary care office staffing and workflow challenges posed barriers that caused many children to fall behind on preventive care, including routine vaccinations. That trend was particularly alarming among teens because they seek healthcare less often than younger children and can take longer to catch up on missed vaccinations.

An important strategy to keep teens up-to-date involves capitalizing on all healthcare visit opportunities to administer vaccinations. However, it’s not clear whether this strategy was commonly used during the COVID-19 pandemic. With this in mind, our team designed a study that examined how opportunities to vaccinate teens at well-care visits changed as the pandemic progressed.

Missed opportunities to vaccinate teens increased during the pandemic, especially for the HPV vaccine

Using electronic health record data from 24 pediatric primary care sites across the U.S., we examined how often vaccine-eligible teens came into the office for a well-care visit and did not receive a recommended vaccine (this is called a “missed opportunity”).  We analyzed data from January 2018 through December 2021 and focused on three adolescent vaccines: human papillomavirus (HPV), meningococcal conjugate (MenACWY), and tetanus, diphtheria, and acellular pertussis (Tdap).

While missed opportunities for all three vaccines were decreasing (improving) prior to the pandemic, that trend reversed following the onset of the pandemic and missed opportunities began increasing (worsening) for all three vaccines (see Figure). Compared to the pre-pandemic period, missed vaccination opportunities during the pandemic increased by 15.9 percentage points for HPV, by 9.4 percentage points for MenACWY, and by 8.2 percentage points for Tdap – all of which represent statistically significant upticks in missed opportunity rates.

Impact and opportunities for improvement

Our findings demonstrate another impact of the pandemic – a worsening in missed opportunities to vaccinate teens. Though this study did not directly assess the reasons for these increases in missed vaccination opportunities, the pandemic presented many challenges that may have contributed. Disruptions in pediatric primary care staffing and workflow (including shortages in nurses and medical assistants), increased parental vaccine hesitancy, and competing demands related to COVID-19 vaccination could have presented barriers to vaccination delivery.

The increasing trend of missed vaccination opportunities observed in this study could lead to long-term gaps in vaccine coverage that put teens at increased risk for preventable diseases now and in the future. It’s important to prioritize the delivery of all vaccines due whenever a teen comes into the office. As the pandemic evolves, there are several strategies to consider to capture more vaccination opportunities, including:

• Vaccinating at all visit types, including non-preventive visits. Our data showed that, even prior to the pandemic, vaccination at non-preventive visits (e.g., sick visits, chronic care follow-up visits) was exceedingly rare. These visits represent important vaccination opportunities and could be key to keeping teens who are less likely to come in for well-care visits up-to-date on vaccinations
• Implementing prompts to remind clinicians during each visit which vaccines are due. Prompts can come from other office staff (e.g., nurses) or via an alert in the electronic health record. Easily visible prompts may be especially useful at non-preventive visits where there is less focus on vaccination.
• Training clinicians in vaccine communication strategies to mitigate vaccine hesitancy. Sharing effective and concise messages to address concerns and reduce vaccine refusal or delay.

Though this study highlights a concerning trend in teen vaccination delivery that emerged from the pandemic, we hope that our findings will raise awareness about the need to prioritize vaccination at every opportunity.

Figure. Proportion of adolescent vaccine missed opportunities (MO) at well-care visits by month

This figure shows missed opportunities, or the proportion of well-care visits when a vaccine-eligible teen did not receive a recommended vaccine. Lower numbers represent a more favorable outcome – fewer missed vaccination opportunities.

Study authors from Clinical Futures: Mary Kate Kelly, MPH, Robert Grundmeier, MD, and Alexander Fiks, MD MSCE

Kelly MK, Stephens-Shields AJ, Hannan C, et al. Missed Opportunities for Adolescent Immunizations at Well-Care Visits During the COVID-19 Pandemic. Journal of Adolescent Health. Published online June 2023:S1054139X23002677. doi:10.1016/j.jadohealth.2023.05.008