What Can We Learn From the COVID-19 Pandemic? The Importance of Improving Vaccination Acceptance in Utah
The Utah Citizens Counsel (UCC) recently completed a comparative analysis of three studies that measured the relative performance of the 50 states and their healthcare systems in the management of the COVID-19 pandemic. Utah performed well compared to other states but struggled to achieve optimum vaccination levels that would have reduced hospitalizations and saved lives. (The full UCC analysis can be found here.) Our review of the studies also raises the question of the relationship between Utah’s lower than average COVID-19 vaccinations and its declining immunization levels for childhood infectious diseases.
Background
After the first several months of the pandemic, decisions about the most effective policies to balance health risks, and whether to allow businesses, schools and churches to stay open were left to the states. It was a learning experience, with different states and their governors and legislators making their own policy choices and employing different strategies with varying degrees of success. And they are still learning. The purpose of the UCC analysis was to learn from these studies and identify opportunities to improve the management of future pandemics to better protect the health of Utahns. The following studies were considered in the UCC analysis:
Covid’s deadly trade-offs, by the numbers: How each state has fared in the pandemic, published by Politico in December of 2021.
Final Report Card on the State Response to COVID-19, a working paper published for review by the National Bureau of Economic Research (NBER) in April of 2022.
2022 Scorecard on Health System Performance—How did states do during the COVID-19 pandemic, published by the Commonwealth Fund in June of 2022.
Overall, Utah ranked high in all three studies (1st in NBER, 2nd in Politico, 7th in Commonwealth). Utah ranked well for economic and educational performance in both NBER and Politico (the latter used in-person school days as the education measure) and well for both mortality and excess mortality indicators in both the NBER and Commonwealth analysis. State and local decision making can be credited for Utah’s high performance on both economic and educational measures but was likely not a factor for low mortality and for health system performance. Utah’s youngest median age in the country (31.4) and healthy population, combined with the quality of health care in Utah, were most likely the most important contributing factors to Utah’s low mortality rate and overall health performance.
Potential for Improvement
The most notable weakness in Utah’s performance was related to measures of COVID-19 vaccinations, ranking 33rd in Politico and 22nd and 24th on two different measures in the Commonwealth study. The uptake of vaccinations in Utah was well below top performing states. Utah required 360 days to get to 70% of the population over age 12 vaccinated, 178 more days than the top performing state, Vermont, and 102 days more than New York, which ranked tenth. In a separate study the UCC noted that Utah’s vaccination rates for childhood infectious diseases are declining and for school year 2021-2022 were below both the national average and the median for other states.[ This raises an important question: Is there a causal relationship between low COVID-19 vaccination rates in Utah and the declining rate of vaccinations for childhood infectious diseases?
Why Do Vaccinations Matter? Historically the development of safe and effective vaccines against serious and deadly diseases has been “one of the foremost scientific advances of the 21st century.”[ Importantly, vaccinations have also proven to be the most significant intervention in getting the pandemic under control.
Vaccinations and COVID-19 hospitalizations and deaths
The Commonwealth Fund estimated that, from December 2020 through November 2022, the COVID-19 vaccination program prevented more than 18.5 million additional hospitalizations and 3.2 million additional deaths. Without vaccinations, there would have been nearly 120 million more COVID-19 infections. For October to November 2021 the Centers for Disease Control (CDC) reported that weekly average deaths per 100,000 population were significantly higher for unvaccinated than for those who were vaccinated.
The Utah Department of Health produced a useful table that illustrates the power of the COVID-19 vaccines in preventing hospitalizations and death in Utah during the Omicron period of COVID-19.
Given the significant advantage the COVID-19 vaccines offered in preventing hospitalizations and deaths, it is important to understand why it was so difficult to get Utahns to get shots in the arm and to articulate a plan to improve performance in the future.
Childhood infectious diseases are serious
The development of safe and effective vaccinations against serious and deadly diseases has been “one of the foremost scientific advances of the 21st century.” In the 19th century, viruses were ever-present but poorly understood and exacted an enormous toll on the population as hundreds of thousands were infected and tens of thousands died. About one-fifth of children died before reaching age 5, many from infectious diseases such as smallpox, diphtheria, polio, mumps and rubella that are now preventable with vaccines. However, of these, only smallpox has been officially eradicated. The others are still with us. A measles outbreak in Ohio in November of 2022 infected more than 80 children, 32 of whom were hospitalized. All the infections were among unvaccinated or partially vaccinated children. Measles is a good example and important reminder of the importance of vaccines. It is highly contagious and the virus can linger for up to two hours in the air after an infected person has coughed or sneezed. Up to 90% of people who come in contact with an infected person will also develop the measles if unprotected, according to the CDC. Research shows there can be clusters of people who delay or refuse vaccines in certain communities. When measles gets into communities with pockets of unvaccinated people, outbreaks are more likely to occur. These communities make it difficult to control disease spread and make us vulnerable to having the virus re-establish itself in our country. The same is true of other infectious diseases such as polio, diphtheria, tetanus, and pertussis.
Measles is also a good example of why we should be concerned about even cluster outbreaks of the diseases. According to the CDC, “As many as one in 20 children with measles develops pneumonia, . . . which is the leading cause of death among young children. About one in 1,000 children will also develop encephalitis, or swelling of the brain, which can lead to serious complications, including death. ‘Make no mistake, measles is not a benign illness,’ says Sean O’Leary, a member of the American Academy of Pediatrics’ Committee on Infectious Diseases.”[
Declining Childhood Immunizations and the Importance of School Vaccination Programs
Utah, like other states has published a schedule of required immunizations to prevent childhood infectious diseases for entry into kindergarten and seventh grade including provisions for exemptions. In the past, school vaccinations have been an extremely important intervention for achieving a highly vaccinated population. Unfortunately, vaccine levels for Utah’s children have declined to levels that are of concern. CDC recommends high vaccination levels to prevent the potential for cluster outbreaks. Utah’s level declined to around 90% for the 2021-22 school year. This is a significant decline from 2005 to 2010 when Utah had vaccination levels consistently ranked with the top states for vaccine performance, as illustrated in the following table.
The CDC recently completed a study of kindergartners, ranking the 50 states by potentially achievable vaccination levels for measles, mumps, and rubella.[ The estimates were based on up-to-date vaccinations for the 2021-22 school year and the percentage of unvaccinated students without a documented vaccine exemption. Utah ranked 49th with a projected potential vaccination level below the Healthy People 2030 target of 95%.
Conclusions and Recommendations
The overall relative performance of Utah in managing the COVID-19 pandemic was positive in comparison to other states. We can take pride in this. Higher vaccination rates, however, would have most likely resulted in lower hospitalization rates and fewer deaths. The broader problem of declining vaccination rates for childhood infectious diseases and the specific challenge of getting the population vaccinated for COVID-19 may be related and should be a significant public policy concern. In spite of the remarkable historical public health achievements, the pandemic has had the unanticipated effect of discrediting public health in the U.S. In many states, including Utah, the traditional role of public health has been challenged. This may have impacted vaccine hesitancy in Utah.
It is recommended that a study forum be created consisting of professionals with credible experience and expertise in preventive health, COVID-19 management, and the use of vaccines to improve population health. The study should focus on declining immunization levels in Utah, why vaccinations for COVID-19 were lower than hoped for, and how to better define the role of public health in the future.