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Of Mandates and Flu Shots

October 10, 2023

Editor’s Note: Dr. Eli Cahan (he/him/his) is the editor of the Section on Pediatric Trainees (SOPT) Feature in Pediatrics and an investigative journalist. He is also a resident physician in pediatrics at The Boston Combined Residency Program, which rotates at Boston Children’s Hospital, where the authors hold affiliations. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

I like to think my clinic is special. These kids, these families, they know me, I tell myself of the select few whom I’ve met more than once—residency inpatient schedules as they are. An 8:30 am start time, work rooms with tall windows, banana bread courtesy of a generous attending who’d used their Sunday to bake: what could go wrong?

Of course, once the clock strikes 8:31 am, my clinic looks like many others: coughs and colds and sniffles and sneezes, ears, ears, and more ears, a post-discharge check here, and pre-op clearance there. Oh, and the shots: shots, shots, for everyone. Except, that is, for those who refuse some or all completely.

Vaccine hesitancy has become commonplace following the COVID-19 pandemic. Data from the Centers for Disease Control and Prevention (CDC) shows that, in some regions of the country, 1 in 3 Americans are overtly vaccine hesitant; since the time that data were collected, follow-up COVID-19 vaccination rates have languished: as of December 2022, months after the introduction of the bivalent vaccine, only 18% of American adults had received that booster, CDC data show.

It's not just COVID-19, and it’s not just adults.

Research has documented “spillover” effects of vaccine hesitancy into routine childhood vaccinations, including influenza. And while rates of routine vaccinations for children under 24 months of age have remained stable so far (through 2021), immunization rates have diminished for older children; CDC data showed that, for kindergarteners in the majority of states, 2021 vaccination rates declined relative to the prior year. Flu vaccines have seen particularly marked declines.

In reaction to these trends, some states, like Massachusetts, have implemented vaccine mandates for school children. However, the impact of such mandates—which, historically, have not been used routinely across the country—is poorly understood. In an article, and an accompanying video abstract, being early released this week in Pediatrics, Dr. Claire Abraham and colleagues at Harvard University and Boston University sought to better characterize this relationship by evaluating vaccination rates in New England following the Massachusetts mandate (10.1542/peds.2023-061545).

The authors found that, across the board, mandates increased vaccine uptake. Notably, the authors also found that mandates more than doubled the rate of immunizations in children who had not received a flu shot in the year prior.

“An influenza vaccine mandate appears to be an effective but not sufficient strategy to achieve optimal vaccine coverage rates,” Abraham et al wrote of these findings, given that the majority of prior-non-vaccinators still went without shots.

The authors’ comment on the “effective but not sufficient” nature of vaccine mandates may refer to a longer-term issue, too. They note that the fall 2020 flu season was “ultimately mild,” leading to the discontinuation of the vaccine mandate in January 2021. Additional studies will be required to evaluate the “downstream effects of the COVID-19 pandemic” including “negatively influenced influenza vaccination rates,” Abraham and colleagues write.

Other studies have raised concern about whether such mandates may breed distrust, resentment, and polarization, leading to reductions in future vaccination rates. Only time will tell whether these concerns are justified, and if so, how it should inform the future implementation of vaccine mandates.

I encourage readers interested in better understanding the complex dynamics of vaccination mandates in a post-pandemic world to read the entire article.

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