Less than a month away from the start of school, a quarter of D.C. students are behind on routine childhood vaccinations, and city officials are in the final push of a summer-long campaign to get shots in arms.

A problem that predated the pandemic and worsened as a result of it, children in D.C. are missing routine vaccinations against illnesses including measles, mumps, and pertussis – vaccinations that by city law, are required in order to attend school. As of July 27, the city’s compliance rate for student vaccinations was 73% – far below the national average of 93%.

In the final weeks of summer, officials are doubling down on outreach to bring the roughly 27% of unvaccinated students into compliance with the city’s vaccination requirements, which now include a COVID-19 vaccine for children 12 and older. Adopting a “no shots, no school” mantra, city officials have said they intend to enforce the mandate, meaning unvaccinated children would be barred from attending school .

“If you haven’t been back to your primary care in a while, whether you’ve been delaying for COVID reasons or other reasons, now is the time to go back, to get back to your medical home to catch up on immunizations,” said Dr. Asad Bandealy, Chief of DC Healths’ Healthcare Access Bureau, at a press conference last week, encouraging parents to get their children vaccinated outside of the community health provider, Mary’s Center. “Our goal is that no child should miss a single day of school.”

According to DC Health, nearly half of high school students in the District are missing a routine vaccination, while one third of middle schoolers are behind on shots, and about 20% of elementary students.

This isn’t the first time a public health crisis forced the city to confront a lack of childhood vaccinations. In 2019, amid a measles outbreak in New York, then-DC Health Director LaQuandra Nesbitt warned school officials that the city’s childhood vaccination rate – around 93% at the time in public schools – left the system vulnerable to an outbreak. Vaccination rates only dropped further in 2020, as residents avoided hospitals and doctor’s offices during the coronavirus pandemic. For example, between January and August of 2018, the city recorded more than 14,000 vaccinations in children under three years old. That number dropped to roughly 9,600 over that same period in 2020, according to DC Health data.

And D.C. isn’t alone: Rates of childhood vaccination dropped across the globe during the pandemic, a decrease fueled by several factors, including missed doctor’s appointments, misinformation around vaccines, and mistrust of public health and government. According to a July 2022 Unicef report, it’s the largest backslide of vaccination rates in nearly 30 years. Recently, New York state reported its first polio case in nearly a decade, and New York City wastewater samples suggest that the illness is circulating in the community.

“You can die from these diseases, and I think that’s what people don’t usually realize, because we’ve been protected for so long,” says Dr. Gabrina Dixon, a pediatrician and associate medical education director at Children’s National Hospital, speaking about childhood illnesses like measles and pertussis, or whooping cough. “The reason you haven’t seen these illnesses is because of vaccines, so when we have these lower vaccination rates that we’ve seen, our fear [as public health people] reemerges of these illnesses, that can lead to death in children.”

It’s possible, Bandealy said last week, that some students, especially those who do not live in D.C. but attend a school within the District, are vaccinated and their guardians have not reported that information to the school system.

“It’s important to note that our data are incomplete because many children are vaccinated outside of the District,” Bandealy said. “In many cases, the child may be fully vaccinated, but we just don’t have that proof. We need that proof to be able to ensure that we protect kids against outbreaks in schools.”

In order to prevent an outbreak of a highly contagious disease like measles, 95% of the population needs to be vaccinated. Dixon says that it’s important to think about vaccinations in terms of herd immunity and their ability to protect the surrounding community from a disease. Even just a few non-vaccinated individuals can put a population at-risk of an outbreak.

For example, Dixon says if two kids in a classroom are unvaccinated against a disease like measles, one of those children could develop the illness and expose others in the class. A vaccinated classmate, once exposed, may only develop mild symptoms, but that vaccinated classmate could go on to expose, say, a six-month-old sibling at home, who could become very ill.

“That’s the big picture,” Dixon says. “It’s not just like ‘I’m not going to get my child vaccinated.’ It really does affect the community that you live with.”

At the start of the summer, D.C. Mayor Muriel Bowser announced a push for required vaccinations that included months of phone calls, mailed letters, mobile vaccination vans, and school-based vaccine pop-ups. Last week, Bandealy explained a slew of options for residents to get their children vaccinated – from walk-in appointments at health centers like Mary’s Center, to vaccination clinics at the schools themselves. Every Saturday in August and September, the Mary’s Center will be opening vaccine-only visits, and Children’s National has vaccine-only appointments Monday through Friday. Unity Health Center, a federally qualified health center, will host walk-in vaccine clinics every Saturday morning at the Anacostia, Brentwood, and Upper Cardozo locations.

DC Health is also coordinating with schools where compliance is particularly low to stage mobile vaccination clinics, which residents can sign up for ahead of time online. The vaccines are completely free, and a student can get a vaccine at any mobile clinic, regardless of where they attend school. According to Bandealy, the city recently sent out 22,000 personalized letters for families, and over the month of August will be conducting 29,000 phone calls to families.

“If you get one of these letters, if you get one of these calls, please heed the message, please take your child in to be immunized,” he said.

In addition to routine vaccinations, students ages 12 and older are also now required to have a full COVID-19 vaccine, following the passage of a D.C. Council bill late last year. One of the only cities in the U.S. to do so, D.C. will require that every student receive a COVID-19 vaccine, if the vaccine has been fully approved – not just emergency authorized – for their age group. (The U.S. Food and Drug Administration fully approved the COVID vaccine for ages 12 to 15 in July.)

According to DC Health, roughly 87% of children between 12 and 15 years old are at least partially vaccinated, and 76% of 16- and 17-year-olds are partially vaccinated.

“We did tremendous work led by DC Health over the past two years to provide access to the COVID vaccines, and we now have a very high, I would say, compliance rate with COVID vaccinations,” Deputy Mayor for Education Paul Kihn said at the press conference last week.

Before the COVID-19 vaccine mandate was passed, critics of the bill expressed concern that the requirement would further deepen racial inequities, given the gap in COVID vaccination rates between Black and white children in D.C. As of Aug. 4, DC Health reports that 1,873 Black children between the ages of 12-15 are up-to-date with their COVID-19 shots, compared to 3,379 white children in the same age range. DC Health did not provide racial demographic data on other routine childhood vaccination rates.

Kihn, the Deputy Mayor for Education, said that the city has “every intention of following the law,” when it comes to enforcing the vaccine mandate – which would mean removing a child from school if proof of vaccination is not presented within 20 days.

According to Dixon of Children’s National, addressing the vaccine gap requires getting to the “root of the problem.”

“Don’t just put a bandaid on it, find the root cause of why this population is not getting vaccinated,” Dixon says. “Is it the distribution of it? Is it transportation? Is it fear of vaccinations in certain communities? Do we need to talk to community leaders to see how we can reinforce people getting vaccinated? We need to talk to the people and really get why they’re not getting the vaccinations.”

She says that the Children’s National mobile clinics are one way to help address these issues.

“We bring it to the community,” Dixon says. “People who aren’t able to come to the doctors’ offices or clinics to get vaccines, we bring the vaccines to the community.”

It appears DC Health is taking a similar approach in its outreach and vaccine pop-ups in order to avoid sending any children home from school, but time is running out.

“Our goal is that no child should miss a single day of school,” Bandealy said. “And that means that we need to get started now.”