Dr. Vinson Diep is used to dealing with parents who have concerns about routine childhood vaccinations. The Honolulu-based pediatrician views it as a red flag if parents want to refuse vaccines entirely, but he’s always willing to show parents safety data and try to get to the source of their hesitation. 

Diep was surprised last year though, when he pressed a mother in his Honolulu practice about why she didn’t want her infant vaccinated. She hadn’t read a debunked study or fallen prey to misinformation online — two answers he is used to hearing. The mom group she hung out with was pressuring her not to vaccinate her child.

“It’s kind of alarming,” Diep said, “that now you have people pushing (against vaccines) and making people feel bad and kind of going against what they believe is best for their child.”

Diep is one of many pediatricians and health professionals across the country who say that misinformation and distrust of the medical community during the pandemic has been accelerating the number of families who oppose vaccines for illnesses as varied as measles and tetanus.

Dose #1 of Pfizer-BioNTech COVID-19 vaccine in syringe during press event held at Queen's Medical Center as 5 front line medical members volunteered to get the vaccine. December 15, 2020
Health officials are concerned that misinformation about Covid vaccines and a growing distrust of the medical community may be contributing to decreases in routine childhood immunizations. Cory Lum/Civil Beat/2020

The percentage of students in Hawaii who either skipped routine childhood vaccinations or had incomplete vaccination records more than doubled during the pandemic.

I just think Covid made it worse because there’s even more misinformation out there and more of a public distrust against medical providers and vaccines in general,” Diep said. 

Part of the increase in unvaccinated students is due to new requirements in 2020 for incoming seventh graders to be vaccinated for human papillomavirus, or HPV. Middle schools — the schools most impacted by the new requirement — had by far the highest rates of students with incomplete vaccination records.

But the new vaccine requirements alone can’t account for the shift.

In the school year that ended this month, at least 10,000 children in Hawaii were either unvaccinated or were missing paperwork proving they had received the immunizations they are supposed to have in order to attend class.

The total number is likely far higher. Covid was such a disruptive force to the school system that roughly 100 schools failed to submit information about vaccinations to the health department for the 2021-22 school year. Of the schools that did submit information, 7.6% of students — about one in every 13 kids — had incomplete vaccine records.

Concerns about in-person doctor visits, the suspension of vaccine reporting requirements during virtual learning, a lack of follow-up on the part of school leaders, new vaccine requirements, and growing misinformation about immunizations are all likely factors in the dismal numbers this year.

“Talk about a perfect storm,” said Ronald Balajadia, the health department’s immunization branch chief. “So many things were happening all at the same time and just impacting routine vaccinations in general.”

New Requirements

In 2019, Hawaii became the third state in the nation to require the HPV vaccine for middle school students. It also added requirements for students to get meningococcal conjugate and tetanus-diphtheria-pertussis vaccines by seventh grade and for young children to be vaccinated for Hepatitis A and to get the pneumococcal conjugate vaccine before entering preschool or kindergarten. 

The HPV vaccine can prevent several types of cancers that are caused by the human papillomavirus. The virus is contracted most frequently though sexual activity, which made the vaccine somewhat controversial when it was rolled out in the U.S. in 2006.

It took several years for Hawaii lawmakers to successfully pass the measure to make it mandatory for students. 

Initially, a number of parents opposed the vaccine because of concerns that it would promote sexual activity, but a study in 2021 showed that a growing number of parents are declining the vaccine for their children out of safety concerns — despite serious side effects remaining rare. 

Samoa Measles Crisis Vaccinations Medical Mission
Hawaii pediatrician Jennie Montijo vaccinates a Samoan patient during a measles outbreak there in 2019. The possibility of outbreaks of preventable diseases is one reason that health officials are concerned about declines in vaccinations in the state. Kuʻu Kauanoe/Civil Beat/2019

The requirements for the new vaccines in Hawaii went into effect for the 2020-21 school year, but efforts to publicize and implement them were derailed by Covid. 

“We really didn’t have any chance to do as great a rollout as we would like,” said Balajadia of the health department. 

The health department is currently embarking on a renewed effort to publicize the requirements and also encourage families to resume routine checkups that they may have put off during the pandemic, said DOH spokeswoman Kaitlin Arita-Chang. 

At SEEQS, a charter school in Honolulu for students in grades six through eight, nearly three-quarters of students had incomplete vaccination records last year — the highest rate for a public school on Oahu. 

Executive Director Buffy Cushman-Patz was surprised when she saw the numbers. 

“It was alarming,” she said, adding that the number of incomplete vaccinations was more concerning to her than the number of students with religious exemptions on file.

Some of the missing vaccination records were due to a clerical error (sixth graders were marked as incomplete on some forms if they didn’t have an HPV vaccine even though that’s not a requirement until seventh grade).

There also aren’t many students who are missing all of their vaccinations, said the school’s office manager, Jackie Kimbro. 

“Most of our missing immunizations are the second or third in a series, so I think it might honestly be that people are lazy or forget or didn’t follow up,” Kimbro said.

A Community Issue

At the same time that parent skepticism about vaccines has been growing, so has the number of vaccines students are required to have. By the time they reach seventh grade, children in Hawaii are now supposed to have received 17 vaccinations. 

Diep says he often hears from parents who want to space out vaccines and have children on a different schedule or don’t believe their children need the vaccines at all. He struggles with this as a pediatrician.

“Our job is to protect kids and vaccines are our way of doing that. We know they work,” he said. 

Vaccination rates varied dramatically between schools and islands — part of why Diep and others are concerned about the idea that groups of parents may be pressuring fellow parents not to get their children vaccinated. 

Kauai had the highest overall rate of missing vaccinations, with 7.1% of students claiming a religious exemption to vaccines and roughly one in eight students in total either having an exemption or missing records. On Oahu, 1.5% of students at reporting schools had religious exemptions and 6% in total had exemptions or missing vaccines. 

A health department interactive map shows vaccination rates by school and island. The red dots indicate schools where more than 10% of students have vaccine exemptions. Click on the image to go to the DOH site. Screenshot / 2022

At Hana High and Elementary School on Maui, one in four students had a religious exemption or incomplete vaccine paperwork.

At Kona Pacific Charter School, 99.5% of students had incomplete vaccination records — meaning that only one student in the school was fully vaccinated or had completed all the paperwork. 

School leaders at those schools did not respond to a request for comment.

The Department of Education warns that students may be excluded from attending in-person classes if they are not fully vaccinated within 90 days of the start of the school year. It’s unclear, though, if any school in Hawaii has ever refused entry to a student over vaccination status.

There is no penalty at SEEQS for not having complete vaccinations, though the school is now looking at how to better follow up with parents about the vaccines required in seventh grade. 

“It’s hard to say, ‘your child can’t come to school for this reason’ and yet it’s a public health reason,” Cushman-Patz said.

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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