No vaccine, no school?

(UNWR) – With the Food and Drug Administration poised to approve the first coronavirus vaccine for use in the U.S. – the start of a major national effort to blunt the spread of a pandemic that’s taken the lives of nearly 300,000 Americans, paralyzed the economy and shuttered schools for millions of children – pediatricians and school and public health officials are bracing themselves for and bristling against the onslaught of questioners asking the one thing they don’t want to talk about. At least not yet, anyway.

Will children be required to get vaccinated against COVID-19 to return to school?

“The questions to be asking right now are, ‘Is it effective? Is it going to be free? Is it widely accessible?'” she says. “What we’re not doing right now – regardless of what I personally think – we’re not weighing in on whether a vaccine should be mandatory or not right now because that’s not an appropriate question right now.”

The caveats of “right now,” “yet” and “at this moment” do a lot of heavy lifting in conversations about immunization requirements, and that’s because the answer is complicated and not as straightforward as parents would probably like. Not only does it depend on where families live, as different states have different vaccination requirements for schools, but it also depends on drug companies enrolling more children in their trials in order to amass enough data to show – as most pediatricians and public health experts fully expect – that it’s efficacious and safe in children.

“We can’t get ahead of ourselves and start asking about whether we’re going to require it,” agrees Becky Pringle, president of the National Education Association. “We don’t know that yet. So let’s not say that yet.”

So while few are publicly advocating for the forthcoming vaccines to be mandatory for school – at least not yet, anyway – most agree that a majority of states probably will require children to be immunized against COVID-19 at some point. Some states may adopt the requirement as early as the 2021-22 academic year, but many more will punt to the following year.

“What is often the focus of making a requirement is: Do we think this vaccine will make schools a safer, healthier learning environment for our children?” says Dr. Kelly Moore, associate director for immunization education at the Immunization Action Coalition.

While the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is responsible for adding vaccines to the recommended schedule of childhood immunizations, individual state legislatures mandate which vaccinations are required for school.

Most states mandate vaccinations for diseases easily transmitted in school settings, like polio and measles, while others may not require vaccinations for things like Hepatitis B or HPV, which are most often transmitted through intimate contact – even though such diseases are no less serious and the CDC recommends them for all children.

“One of the misunderstandings people have is that if it’s not required for school then it must not be important. And that couldn’t be further from the truth,” Moore says. “There may be a lot of societal reasons why a vaccine is recommended but not required. People need to remember, the CDC doesn’t make requirements. They only ever recommend it. The choice to require something is done at the state level between school officials and public health officials.”

Complicating the landscape further, states allow for various exemptions from mandatory school immunizations. According to the Immunization Action Coalition, 45 states and Washington, D.C., allow parents to exempt their children from vaccination if it contradicts their religious beliefs, and 15 of those states also allow for personal or philosophical exemptions. Only five states – California, Maine, Mississippi, New York and West Virginia – do not allow either exemption.

Each state establishes its own thresholds for what it considers to be a genuine religious exemption And in states that offer a personal or philosophical exemption, almost any reason provided is acceptable – though some states make parents get an official sign-off from a doctor and fill out additional paperwork.

In recent years, as the anti-vaccination movement expanded and general vaccination hesitancy grew, causing schools in some communities to experience dangerously low levels of important immunizations among elementary school students, state legislatures have been modifying existing exemptions. Since 2015, at least 13 states have altered the language for exemptions to make them more difficult to obtain or to eliminate them altogether, as was the case in Maine in 2019.

What many pediatricians and school and public health officials worry about with the forthcoming coronavirus vaccines is that the warranted rush to approve them for emergency use to curb a deadly pandemic – a shortened timeline that doesn’t allow for the thorough education campaigns that typically accompany the rollout of important vaccines – may spook some parents, and going a step further to require the vaccination may backfire.

For those very reasons, Moore, who spent 14 years directing Tennessee’s state immunization program, has written immunization requirements for school children and oversaw a modernization and overhaul of Tennessee’s immunization requirements in 2009, cautions that moving to require the vaccine now is premature – though perhaps not far off.

“We are going ahead and authorizing its use before we have gone ahead and checked all the boxes we normally would,” she says of the forthcoming Pfizer and Moderna vaccines. “In a situation like that, you don’t want to all of a sudden require a vaccine. From a public health and public policy standpoint, we are saying, ‘We are willing to move forward with more uncertainty than usual because we are in the midst of a terrible crisis.’ And in the middle of an emergency you don’t ask as many questions. You can’t wait for all the answers. You have to go right now because 3,000 people died yesterday.”

For now, the American Academy of Pediatrics and school and health officials are urging drug companies to enroll more children in trials, underscoring the importance of collecting efficacy and safety data in younger populations as they are increasingly being infected by COVID-19.

As it stands, more than 1 million children in the U.S. have been infected with COVID-19 since the start of the pandemic, according to the American Academy of Pediatrics and the Children’s Hospital Association. And while it’s rare for children to become severely ill – though they can and do – the bigger concern is that they are more likely to be silent spreaders who may not know they are infected because they are asymptomatic.

That’s a big hurdle to overcome when trying to reopen schools, especially considering many school districts are attempting to reopen without the proper personal protective and sanitizing equipment and in buildings with poor ventilation. Moreover, while school staff are hoping to secure priority for the vaccination, nearly a third of the educator workforce is over the age of 55 and a quarter of the workforce has medical issues, like heart disease or diabetes, placing them at higher risk for a more serious infection if they were to contract the coronavirus.

“This disease is so unique in the fact that it is a silent disease,” says Dr. Laura Blaisdell, a practicing pediatrician in Portland, Maine, and a vaccine policy advocate and researcher. “Measles was never silent. Polio was never silent. Here we have a silent disease that is transmitted in children and we are not including them in vaccine trials yet. We need to include children in these trials and do so urgently so we can consider sending children to school, vaccinated.”

Blaisdell, who helped lead the effort to eliminate Maine’s exemptions for school immunizations in 2019, says it’s imperative for pediatricians and public health and school officials to be as proactive as possible about educating parents and patients on the benefits of the vaccine, just as it’s important for state legislators to understand they have the ability to mandate the immunization for schools should they need to.

“As a physician, I am pro-vaccine and I will be sticking my arm out and getting myself vaccinated. And at the same time, by working in vaccine hesitancy, I know we need to continue to be nuanced in how we approach everything,” she says. “We can’t be either pro-vaccine or anti-vaccine.”

Still, it’s unclear how the public will respond to the forthcoming vaccinations – especially their use and potential requirement in children.

Most pediatricians, school and public health officials report feeling stuck between a rock and a hard place: They worry about the searing backlash that requiring the vaccine may prompt, yet they also worry that misinformation and disinformation campaigns, including the rise of conspiracy theory groups like QAnon that have latched on to the anti-vaccination movement, may drive down vaccination rates and stymie efforts to reopen schools safely.

“I think that there is a dialogue to be had about the social contract we have with one another in America,” Blaisdell says. “There is no way to get back to normal unless we take care of one another by becoming vaccinated ourselves, and that is not without personal sacrifice and risk. But that common goal of getting back to an open society is something I hear mentioned and it is implied, but I don’t think we are hitting it head on.”

“I don’t want to get to a point of mandate,” she says. “I would love for my neighbor to look at me and say, ‘I will protect you,’ and I look at them and say, ‘I will protect you as well.'”


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