Declining childhood vaccination: An interview with Michigan's top doctor

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0:00:48.3 Host: Hello, and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level from the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries and around the world.

0:01:18.2 Host: For the past three years, childhood vaccination rates have declined 9% in the state of Michigan, that's putting thousands of kids at risk for diseases like measles, polio, pertussis, and compromising public health norms like herd immunity. It's a trend being seen across the country with falling rates in neighboring states like Ohio and Pennsylvania as well. To delve into some of the causes, as well as some of the solutions, we convened a pair of epidemiological experts for our conversation on childhood vaccination. First is Matthew Boulton, epidemiology professor at the University of Michigan School of Public Health. He has held several leadership positions in the state of Michigan's Health Department, including serving as Chief Medical Executive in the mid 2000s. He sat down with Dr. Natasha Bagdasarian, the current Chief Medical executive in Michigan. She's also a graduate of the University of Michigan School of Public Health. Bagdasarian took her post in October of 2021 during the height of the COVID-19 pandemic. In addition to addressing the downturn in childhood vaccination, Boulton and Bagdasarian discuss how the Chief medical executive's role can provide leadership and guidance through the pressing public health issues in the state to ensure the wellbeing of Michigan's communities. Here's their conversation.

0:02:24.7 M.B.: My name is Matthew Boulton, and I'm Senior Associate Dean for Global Public Health and a professor of epidemiology at the University of Michigan School of Public Health. I have the distinct pleasure today of interviewing Dr. Natasha Bagdasarian, Chief Medical Executive for the state of Michigan, and an adjunct clinical professor of epidemiology at Michigan Public Health. Dr. Bagdasarian is also an alumna of the school, and although it makes me sound terribly old, she's also a former student of mine, so it's an absolute delight to reconnect with her today.

0:02:57.0 N.B.: Thank you for having me on.

0:02:58.0 M.B.: Before we jump into our main topic for the day, childhood vaccinations in Michigan, I wanna talk a bit about your experience as Chief Medical Executive for the state of Michigan. As you know Natasha, I held that same position some 20 years ago under Governor Jennifer Granholm, and it's a tough job but also a vital one. The role of Chief Medical Executive entered the spotlight prominently during the COVID pandemic, and you took the job in 2021 in the second year of the pandemic. I wonder if you could tell our audience what the experience has been like so far.

0:03:33.4 N.B.: Well, I have to say, Matt, it's been incredibly rewarding. I've had a chance to meet folks from around the state, hear what folks problems, and questions, and public health issues are, and there's also been an incredible opportunity to raise awareness to some really important topics. Lately, we've been talking a lot about gun violence as a public health issue. That's something that for a long time public health and healthcare providers weren't really talking about as a public health topic. And now we can, and we are. When the Dobbs ruling came out, we talked a lot about reproductive health as a vital component of healthcare. So I've been able to raise some important awareness around some of these topics, and I think that has been incredibly rewarding.

0:04:22.4 M.B.: Thank you. If I could put you in a time machine and have you transport back in time to being an epidemiology student at Michigan Public Health, did you see yourself at that time holding a role like Chief Medical Executive? 

0:04:37.6 N.B.: Well, Matt, I think I've told you this story, but I took one of your classes in probably 1999 and at the time you were talking about outbreaks you'd investigated and all kinds of exciting news from around the state, and I thought to myself, that seems like a really cool job. I like to have a job like that someday. So I think in large part you were the inspiration for this part of my career. How I got here, a lot of it had to do with right place, right time. I'm an infectious disease physician by training and all of my education and preparation was in terms of outbreak preparedness and pandemic preparedness. I worked in Singapore for about five years before the pandemic and during the early days of the pandemic, I ended up moving back to Michigan in July of 2020 just as things were really heating up here.

0:05:31.0 N.B.: And the state of Michigan was really looking for someone who had my background because it related so closely to COVID-19. And I thought it would be a great way to have a seat at the table and really advocate for positive things. So that's how I started working for the state. And when this position became available, they offered it to me based on, again, some of that experience that I brought to the state level. So a lot of it is luck and being in the right place at the right time, but you were definitely an inspiration.

0:06:00.0 M.B.: Well, thank you Natasha. Yeah, I mean, I agree my own trajectory in getting there involved both luck and pluck as they say. And I'm sure your international experience brought a lot to the table 'cause I think that's relatively unique for chief medical executives around the country. That's a really nice segue to my next question. So for any current or perspective public health student listening, what advice would you offer them as they think about launching their careers or building their careers in public health? 

0:06:29.7 N.B.: I think that rarely do they unfold in a straight line. And my career has definitely taken some turns and twists along the way. And there have been a few times at which I've said, "Well, gosh, is this the end of my career? Am I going to do anything meaningful after this twist and turn of fate?" And I think that rather than being focused on a goal or an endpoint, it's important to really enjoy the experiences that come along the way and different opportunities that are offered to you. I really maximized some of my breadth of experience by saying, "Yes," when various opportunities have come my way, that allowed me to take the leap and move to Singapore. I took a position with the World Health Organization again, because I remained open to having those types of experiences.

0:07:16.2 M.B.: You made some really good points. One of the things I tell students is that opportunities come along. Oftentimes they don't come along at the right time, but they're there for you to potentially take and it can really open new doors up. And I think that's a common experience both of us have had on our pathway through our careers. I wanna shift gears now and transition into our today's main topic, childhood vaccination in Michigan. I wonder if you could tell our audience about the childhood vaccination trends you're seeing in the state of Michigan right now and and how does Michigan compare with trends we're seeing nationwide? 

0:07:57.8 N.B.: Great questions, Matt. So first of all, when we're talking about Michigan compared to other states, Michigan's actually doing pretty well. Our vaccination uptake for children under the age of 35 months is really quite good when we compare ourselves to other states, especially some states in the south. Now, what happened during the pandemic is unfortunate because when we look at that same age group, so children between the ages of 19 to 35 months, we saw a very clear decline in recommended childhood immunizations. So prior to the pandemic uptake in that age group of vaccines like measles, mumps, rubella was about 75%. And then through the pandemic we saw continual declines and post pandemic in that age group for routine childhood immunizations, not including things like COVID-19 and influenza, we are at 66% uptake. So we've seen a very clear decline and I think there are a few reasons for that, but I don't think we can discount the impact of COVID-19 and some of the political rhetoric around health and public health that came out of the pandemic.

0:09:06.3 M.B.: You make some great points there. It's true that we saw declines in virtually all clinical preventive services. So mammograms, colonoscopies, cervical cancer screening during the pandemic and including immunizations as you point out for a combination of reasons like lack of access and disrupted services. One of the interesting things about childhood vaccination though is that we've seen a lot of these clinical preventive services bounce back to some degree post pandemic, but we haven't seen that to nearly that degree with childhood immunizations, which seem to have had greater durability in terms of that downturn. And I wonder if you could speak to what that might be about, immunizations relative to these other important clinical preventive services.

0:09:55.2 N.B.: I think that's an excellent point, Matt. I think all of these services have been impacted by a decline in folks going to see their primary care provider during the pandemic. But what specifically harmed vaccinations that didn't touch those other areas was the misinformation and disinformation that was really specific to vaccines. And it was an overflow effect from COVID-19. We started with misinformation and disinformation about the COVID-19 vaccine, and then I think that started to impact other vaccinations as well. But I do have to say there is some good news and we do have some evidence that there are still things that work in terms of encouraging vaccination. So while the vaccination rates for children between the ages of 19 and 35 months declined, we actually didn't see a severe decline for childhood vaccinations for those entering kindergarten. And so what's interesting there is that those vaccination rates have remained at about 90%. And so there is some positive impact on school requirements for vaccination. Those still seem to have an effect. So while I think the misinformation and disinformation have impacted vaccinations, there are still things that work and those school requirements are one of those things that still work.

0:11:21.4 M.B.: So do you think time is on our side, Natasha, as we move out further from the pandemic, we'll continue to see potentially increases in childhood vaccination, maybe returning to pre-pandemic levels? 

0:11:36.9 N.B.: I hope so, Matt, but I think there's a lot of work that needs to be done in this area. One of the things that we've been talking a lot about at the state level and also with local health departments is how do we rebuild trust? How do we regain the trust that was lost during the pandemic? And this was really, I think across the board, people lost trust in government. They lost trust in agencies that are supposed to be looking out for them. And I think it's gonna take us some time to rebuild that trust in a very deliberate way. But we have to leverage on areas where trust still exists. And we know that from focus groups and from research that people still have trust in individuals who care for them. So they may not have trust in these larger entities like the state health department or local public health departments, but they still have trust in their doctors, and in their nurses, and maybe their pastor or their community leader. And so there is still trust out there and we need to leverage that trust as we think about how to rebuild public health and rebuild these relationships.

0:12:45.7 M.B.: Yeah, I'd like to expand a bit and think at the family level. And if you could say more about what are the barriers preventing caretakers and parents from vaccinating their children or causing them to delay vaccination? 

0:13:00.6 N.B.: I think Matt, that's a, it's a complicated question and I think folks are dealing with just so much information out there and not knowing what is correct and what's not correct. During COVID-19, we heard from a lot of people that they believed that by vaccinating their children with the COVID vaccine, they could be causing sterility. They could be impacting their children's ability to have future babies. So that type of misinformation and disinformation is a barrier. And I think that for members of the public, it's sometimes hard to sort out the good information from the bad. I think with delaying vaccinations, we've also seen a lot of voices out there talking about not giving too many vaccinations at the same time. And there are bloggers and social media influencers who talk about not giving too many vaccines at the same time. Now we know medically there are many vaccines where it's perfectly safe and appropriate to give them together.

0:14:02.0 N.B.: And one of the things that delaying vaccinations does is it impacts people's follow up. They may not come back to get those same vaccines. We also know that aside from some of this misinformation and disinformation, there are very real physical barriers for some people. And what I mean by that is lack of transportation. So if you don't have access to reliable transportation, especially if it is bad weather, it becomes difficult to take your children to their provider's office to get these vaccinations. We know that lack of access to things like the Internet impacts people's ability both to reach reliable information and to do things like schedule telehealth visits to maybe talk to their healthcare provider about some concerns. And so I think that making sure that folks basic needs are met and that we're addressing those social determinants of health is very important in terms of making sure people are not facing these type of barriers.

0:15:04.4 M.B.: The term vaccine hesitancy was new for a lot of people and came to the fore during the pandemic, but actually vaccine hesitancy has been with us for quite some time. In fact, a few years ago, the US almost lost its measles elimination status because vaccination levels dropped so low, including in Michigan. But this was a national phenomena and there was sustained transmission from person to person of measles for almost a full year, which is one of the principle criteria for measles elimination. And thinking about that, do you think we're going to see that again with other childhood vaccine preventable diseases because of these changes that have occurred in childhood vaccination levels? 

0:15:49.0 N.B.: Matt, I am afraid we will, and I'll tell you that we've got very real examples of what can happen in low vaccine uptake communities. In 2022, there was a measles outbreak in Ohio that resulted in many children needing to be admitted to the hospital. And just last week we were seeing cases of measles in Philadelphia that resulted in mass exposures in places like daycares and in hospitals. And so one of the things we have to remember is that even though those routine childhood vaccinations, they go up to about 90% by entry to kindergarten, there are still pockets in our state with extremely low vaccination rates. And we have data in fact, where you can look up the vaccination rate by school building, and there are some schools out there in our state that have vaccination rates of 99%, and there are some schools out there that have vaccination rates of 10% or 20%.

0:16:51.3 N.B.: And so when we see introduction of a highly transmissible disease like measles in one of those low vaccine uptake environments, the potential for a large scale outbreak is huge. And there is more measles, for example, internationally, we're seeing more sporadic cases. And so it just takes one introduction into one of these very vulnerable communities for us to see a large scale outbreak. And I am worried and fearful that that's what we'll see even as we continue to encourage vaccination on a large scale effort, so long as there continue to be pockets of low vaccine uptake, the potential is there.

0:17:29.8 M.B.: That's very true, Natasha, because we do find that there's grouping or clustering of non vaccination, and it actually increases the risk of outbreaks when you get these clusters that they're not evenly spread across the population. I wonder if you could say a bit more with regard to these trends in the context of the risk of infection for both vaccinated and unvaccinated kids and their families.

0:18:00.6 N.B.: Great question, Matt, because we have to really think about this as not just something that has consequences for the individual, but something that has consequences for communities. So if you have a child and you choose not to get your child vaccinated, not only does it put your child at risk, but it also has implications for other kids in that environment. So there are children who can't get vaccinated, maybe because they're receiving chemotherapy for cancer, maybe because they've had an organ transplant and they're on immunosuppressive medications, maybe they have another underlying immune deficiency and even though they've been vaccinated, they have not responded perfectly. And so I think that one of the ways we need to start thinking about this is not only the implications to the individual, but what it means for the larger community. What it means for the very young, sometimes those who are too young to be vaccinated. What it means for the elderly, the immunocompromised. And I think we need to start thinking about vaccination as a public good rather than just an individual good.

0:19:09.4 M.B.: From your seat, Natasha, do you feel that there's enough national dialogue and focus on childhood immunization with respect to these levels that dropped off during the pandemic or do we need to highlight it to a greater degree? 

0:19:26.4 N.B.: You know, Matt, I think we need to continue having these conversations and we need to highlight this topic as well as other public health issues. I find that we have access to so much data at the state level and folks are really unaware in communities about what's happening across the state or even what's happening in their community in terms of some of these public health topics. And I think that part of regaining trust and building additional trust with communities is by being completely transparent and sharing data. So the more we highlight these topics, the more we engage in dialogue, I think the better it is for rebuilding public health.

0:20:09.8 M.B.: That leads to my next question. You recently held a statewide multi-sector forum on vaccines. Can you share with our audience some of the findings from proposed solutions from that forum? 

0:20:21.0 N.B.: It was a great forum. It was really groundbreaking in that we brought people from all different backgrounds to talk together about this issue. So we had doctors and nurses and folks from local health departments, folks from the state, folks who thought about vaccines every day, and then folks who didn't. We had some people from community organizations that don't typically focus on vaccinations. We had folks from pharmaceutical companies and from the insurance payers. So it really was a multi-sector collaborative discussion. And number one, what I found was that people deeply care about this issue. So it was rewarding to be able to have this conversation with other folks who really care about vaccination and saw this as a real issue. The way that we talked about this topic was, number one, there is the communication and the messaging around vaccines, which we know has to be better, has to be stronger. And we need to start combating some of the misinformation and disinformation.

0:21:20.7 N.B.: But the other topic that we talked about and that I really focused on was access. And we know that access is a barrier. So if, for example, you go to your primary care doctor's office and you get your child their routine immunizations, but that office doesn't offer COVID-19 vaccine, that is an issue. Number one, you're less likely to go to another place and make an appointment and wait in line and get your child vaccinated. But it also sends the message that COVID-19 vaccine, for example, is something other and maybe something a little bit different. And that's why it's not offered by your doctor's office. We also talked about how many folks don't have primary care providers. And they may, for example, if you are a young, healthy female of reproductive age, you may only see a gynecologist or an OB. And so how do we get those folks involved in some of these conversations about vaccines? We came up with some really tangible ideas. For example, we talked a lot about dentists and how there are folks who go to the dentist but may not regularly go to other types of health care providers.

0:22:33.8 N.B.: And is there a way to get dentists involved in some of these vaccination efforts, particularly with HPV vaccine. So we know that the HPV vaccine can not only prevent cervical cancer, but it can prevent head and neck cancers. And while there are many parents who are reluctant to talk about their pre-teens or teens having sex or being at risk for a sexually transmitted infection, they may be more responsive to having a conversation about head and neck cancer and receiving that HPV vaccine at the dentist's office. So we talked a lot about getting other folks at the table and bringing in some folks who don't normally focus on vaccines because it is such a big issue.

0:23:16.7 M.B.: Yeah, there's been a trend, Natasha, with moving vaccines and vaccination into other venues. So, for example, a lot of us get some or all of our vaccinations at pharmacies. And now there's this effort for vaccines to be administered in the dentist's office. Do you see that as a continuing trend that we'll continue to see an expansion of the venues where individuals can go to receive their vaccines? 

0:23:44.3 N.B.: I would like to see an expansion in terms of where people can get vaccines because it's an access issue. There are folks out there who can't travel far, who can't take time off work. And so making vaccines as readily available as possible, I think, is really helpful. But I don't wanna lose what we have. I don't want to lose vaccines from primary care providers' offices because I think that having a conversation with your primary care provider, who we know are highly trusted by communities, and then having the opportunity to get vaccines there and then, that is a huge opportunity and would result in missed opportunities if those primary care providers then said, well, we don't have the vaccine, go to your local pharmacy. So I think what we're looking for is a both and type of solution and making vaccines available in as many places as possible for folks who have different needs.

0:24:39.8 M.B.: So what will you and the state health department be looking for in terms of assessing your success with these strategies that have been formulated as a result of this statewide multi-sector forum on vaccines? 

0:24:55.6 N.B.: Well, we'll continue to look at the childhood immunization rates, but we'll also continue to look at rates of uptake of COVID-19 vaccine among all age groups. We're now looking at the RSV vaccine to see who's getting the RSV vaccine. And we have seen that we've had great success in some age groups. So our over 65 year old age group, I call them absolute rock stars when it comes to vaccine uptake. And then vaccinations tend not to be as robust in younger demographics, particularly among those who are in their 20s or teens. And so we need to look at those rates specifically and see why we're not reaching those folks. We know that there are racial disparities in terms of vaccine uptake. And so we'll need to look at those metrics closely over time to see if we're reaching black and brown communities and to see if we're reaching different geographic communities around the state. So we'll continue to look at all of these trends.

0:25:55.2 M.B.: So Natasha, you're a medical doctor by training. So I'd like you to put your physician hat on while we focus in public health on keeping large populations healthy. I wonder what you would tell an individual parent or caregiver who had reservations about vaccinating their child if they were sitting across from you face to face in the clinic setting.

0:26:16.4 N.B.: Matt, I think that's an excellent question because we have a lot of data. We have a lot of data that we can share. But what I have found is sometimes the most powerful message, either when I'm talking to large groups or when I'm having a conversation with an individual in my clinic. Sometimes a story is more impactful and sometimes telling folks that I am vaccinated, that I made sure my nine-year-old son is vaccinated, that I made sure my mom got her RSV and COVID vaccines this year. Sometimes that's more impactful. And then also talking about the reasons why we choose to vaccinate in my family. And I think that for some folks, the data is helpful. But many people really like to hear that this is not something I'm recommending just for them, that I recommend this for myself and for my own family. And I think that personal connection is helpful for some people.

0:27:16.3 M.B.: My very last question here is, do you feel that physicians continue to be especially relevant in making recommendations to their patients and the patient's children for vaccination in this era where we're seeing an expansion of the places where you can receive vaccines like pharmacies? 

0:27:38.2 N.B.: Absolutely, Matt. We have done many focus groups and there are many studies out there looking at who people really think of as trusted messengers. And it varies a little bit by individual and by geography and by community. But overall, people trust their doctor, their health care provider, the nurse who takes care of them in their clinic or in an inpatient setting. People trust health care providers. And so I think we need to leverage on that trust. We need to provide clear and concise communication with nuance and with transparency. We need to learn better how to communicate uncertainty when there's a new product and we're not sure about it. And I think that health care providers are still very much a relevant part of these conversations.

0:28:23.6 M.B.: Well, I'd like to thank Dr. Natasha Bagdasarian, Chief Medical Executive of the State Health Department, for speaking with us today. I don't wanna brag, but when you took my class 25 years ago, I was almost positive that someday you would be the chief medical executive. So we seem to have come full circle.

0:28:45.7 N.B.: I'm quite convinced, Matt, that you did not. I'm not even sure that it was, it was a very big class. I think there were about 200 people in that class. So that's very kind of you to say, though. I appreciate it.

0:29:00.7 M.B.: Well, thank you very much, Natasha.

0:29:01.1 N.B.: Thanks for having me on.

0:29:11.0 Host: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. I'm glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcasts, Google Play, Stitcher, Spotify or wherever you listen to podcasts. Be sure to follow us at U-M-I-C-H-S-P-H on Twitter, Instagram and Facebook so you can share your perspectives on the issues we discuss. Learn more from Michigan public health experts and share episodes of the podcast with your friends on social media. You're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health. Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition where we'll dig in further to public health topics that affect all of us at a population level.