As Kansas students return to schools for in-person classes, fewer of them likely received their full schedule of mandatory vaccinations, state health data shows.


And school health and immunization experts said that lower vaccination rates among children could lead to outbreaks of other infectious diseases like measles and mumps, piling on top of a health system already burdened with COVID-19 cases.


One measure that the Kansas Department of Health and Environment uses to track yearly vaccination rates is the number of orders it places through the Centers for Disease Control and Prevention’s Vaccines for Children program. Individual states request vaccines — specifically ones that the CDC determines are necessary for public health — through the federally funded program and distribute those vaccines free of charge to local doctors and health clinics. Those doctors then vaccinate children whose families may otherwise be unable to afford the vaccines.


From January to the end of July this year, Kansas’s orders of federal vaccines fell 21% to 199,000, compared to 252,000 in the same time period in 2019, according to KDHE data.


While the KDHE measure looks mostly at children who meet a certain criteria, Gretchen Horman, a Wichita pediatrician and immediate past chair of the Immunize Kansas Coalition, said it also usually indicates that overall vaccinations have gone down. The coalition advocates for increased access to and use of immunizations across the state.


"We know that immunization providers across the state started ordering fewer vaccines, and that’s a good translation into them giving fewer vaccines," she said. "When we saw that data starting to go through in April, it was very concerning."


In the pandemic’s early stages, experts quickly noticed that doctors were giving fewer vaccines as families avoided trips to the doctor. A May report from the CDC said that lower vaccination rates could "indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases."


Since then, vaccination rates have picked back up, but Ronda Hutchinson, a school nurse at OK Elementary in Wichita and president of the Kansas School Nurses Association, said the state needs to catch back up to its normal rates for the start of the school year.


"When there was the major shutdown in our state, the immunization rates went down, but after we opened back up, we’ve been hoping that people are getting back in," she said. "I don’t know if they have for sure, but they’ve had time to come in. People are still hesitant to go to the doctor."


Since April, Kansas doctor’s offices and county health departments have implemented various practices suggested by the American Academy of Pediatrics to ensure safety and low chances of COVID-19 transmission. Those practices include scheduling "well" visits, or healthy patients, in the mornings while reserving afternoons for sick people, separating patients into different parts of the building, and finding alternate places for children to receive routine care.


Generally, Kansas families have been great about getting their children vaccinated, Hutchinson said, in large part because state law requires that children receive the CDC’s schedule of recommended vaccinations before they can enroll in schools. The only exceptions the law allows are for medical or religious beliefs, but not personal beliefs, Hutchinson said.


And while state law requires students to complete their required immunizations before enrolling in school, most districts give parents time to comply with the requirements.


"School nurses have been working closely with their health departments to set up extra clinics," Hutchinson said. "The state law says you need to have your immunizations up to date by the time you enroll, but that’s not usually the case. Most districts give a grace period for that."


The main concern is that even one case of an easily preventable but highly infectious disease could lead to outbreaks, particularly in schools.


"Continuing your child’s vaccine schedule is necessary, particularly during the COVID-19 pandemic, to protect individuals and communities from vaccine-preventable diseases and outbreaks," said Kristi Zears, KDHE director of communications. "Routine vaccination prevents illnesses that lead to unnecessary medical visits, hospitalizations and strain the health care system."


"Even though we may not see a lot of disease in our area, it’s not uncommon for states that have lower immunization rates to have an infected person come from maybe another country, and then you see clusters of measles and mumps in those areas," Hutchinson said. "We don’t want that to happen here."


Looking to the fall semester


School nurse’s offices will be crucial parts of their buildings this coming year, Hutchinson said, and several districts are adapting to allow nurses to focus on COVID-19 mitigation efforts.


"A lot of districts are putting in place first aid kits in classrooms for things teachers can do themselves," Hutchinson said. "Maybe someone lost a tooth or has a bloody nose or a shoe problem. Sometimes they send students to the nurse and it’s not a medical problem, so for those little things they can do in their classroom, a lot of districts are giving them first aid kits and some direction."


Schools are particularly emphasizing practices like washing your hands, wearing your mask and watching your distance, which Hutchinson called the three W’s. They’re practices that have always been in place but have taken on greater priority during the pandemic, she said.


"Maybe in the past, you would’ve come into the nurse’s office and just stood right by the nurse or stood right next to the secretary," she said. "Now you have to think about how you can social distance yourself. It’s not been normal to be six feet or more apart from people when you’ve been talking to them, so it’s going to take practice."


But nurses, and teachers alike, will have to carefully watch for any signs of the coronavirus in their classrooms.


"Certainly anyone with the symptoms COVID-19, which could also be symptoms of the flu, will be sent home," she said. "That’s the difficult part, and why it’s so important to get your flu shot this year."


Experts said it’s too early to tell exactly how this year’s flu season, which runs from October to late May, might play out. But data from the southern hemisphere, and particularly Australia, shows that COVID-19 mitigation strategies have potentially helped cut down on flu rates, as well. However, countries like Australia have had better public buy-in on wearing masks compared to the U.S., making it difficult to predict what will happen in the U.S. later this year, Hutchinson said.


Ultimately, this school year will be a test for school nurses, but it will be in skills they’ve been practicing all of their careers.


"We’ve always been good about contact tracing," Hutchinson said. "We do it with other diseases — measles, mumps, chickenpox, we do it all the time. It’s nothing new to us, but it may be on a grander scale this year."