This brief was coauthored by Ashley Hill and Hayley Benson of the State and Territory Alliance for Testing (STAT). STAT is a peer-to-peer network of state tactical leaders that emerged during the pandemic as a bi-partisan space for problem-solving and solution-sharing and is currently hosted by the Brown University School of Public Health.

On June 18, 2022, CDC Director Dr. Rochelle Walensky endorsed the Advisory Committee on Immunization Practices’ (ACIP) recommendation that all children 6 months and older should receive a COVID-19 vaccine. The inclusion of children ages 6 months through 4 years of age, who had previously been ineligible for COVID-19 vaccination, expands vaccine eligibility to approximately 20 million additional children in the U.S., according to the U.S. Census Bureau.

Currently, COVID-19 vaccines are purchased directly by the federal government from the manufacturers and distributed through states, as well as major pharmacy chains and other federally-supported sites. States are responsible for making sure vaccines are available across their jurisdictions, especially to historically marginalized populations. States also have an important role in communicating the importance of vaccines to those eligible to be vaccinated (or their parents and caregivers) and to potential vaccinators (pediatricians, family doctors, pharmacists).  States will need to adapt to the unique challenges of vaccinating young children, address harmful vaccine misinformation, and expand upon effective strategies to improve immunization access among older children and adolescents.

The Vaccination Landscape for 6-Month to 5-Year-Olds

Distribution and Access Challenges

While pharmacies have played a major role in administering COVID-19 vaccines to older children, they are often not an option for all children in this age group. Current federal law allows pharmacists nationwide to administer vaccines to children as young as 3 years old, but states differ as to whether pharmacists are allowed to vaccinate children ages 6-35 months. There are also additional logistical challenges to vaccinating young children (e.g., children under age 4 years are typically vaccinated in the thigh, rather than in the arm) that may lead some pharmacies not to offer the option altogether.

As states continue to scale back mass vaccination clinics, states have prioritized vaccinating young children at their pediatrician or family doctor’s office, which have long been central to providing childhood vaccinations. However, with pediatric capacity challenges resulting from high levels of burnout and more than half (53.8%) of all children without a medical home, local health departments, children’s hospitals, and federally qualified health centers (FQHCs) have stepped up to fill the access gaps.

Public Opinion Challenges

Despite reassurances to parents that COVID-19 vaccines have undergone the most intensive vaccine safety monitoring in history and support from the American Academy of Pediatrics (AAP), many parents are unsure about getting their young children vaccinated. According to the Kaiser Family Foundation’s COVID-19 Vaccine Monitor, as of May 2022, only 18 percent of parents surveyed indicated they would get their young child vaccinated right away, with 38 percent stating they plan to wait and see how the vaccine is working for others before getting their own children vaccinated. More than a third (38%) of parents indicated they will only get their child vaccinated if required to do so (11%) or will definitely not get their child vaccinated (27%). Challenges in boosting vaccine confidence among parents and the desire to wait and see before vaccinating their young children are likely to mirror trends in attitudes and uptake for older children and adolescents. According to the AAP, as of June 22, 2022, 36 percent of children ages 5-11 years and 69 percent of children ages 12-17 have received at least one dose of a COVID-19 vaccine, despite the vaccines having been authorized for these ages in October and May of 2021, respectively.

State Approaches to Vaccinating 6-Month to 5-Year-Olds

How States Are Addressing Access

States face an uphill climb when it comes to protecting young children against COVID-19 low parental confidence in the vaccines paired with reduced access across settings means even parents who are interested in getting their child vaccinated may have a more difficult time finding a vaccine provider. As of June 17, 2022, jurisdictions had pre-ordered approximately half of the available Pfizer vaccines and approximately a quarter of the available Moderna vaccines for this age group. Despite these challenges, many states are finding innovative ways to improve vaccine uptake among young children by making vaccination more accessible to parents. Strategies for addressing barriers to vaccine access for young children include:

• Expanding Access in Community Settings: States are expanding opportunities to vaccinate younger children in existing community-based clinics, many of which offer night and weekend hours. Minnesota has added vaccinations for children 6 months to 5 years to its long-standing COVID-19 vaccination site at the Mall of America. The site is operated afternoons, evenings, and weekends to help accommodate parent schedules. Additionally, Minnesota mobilized a network of providers, including 320 pediatric and family medicine offices, FQHCs, local public health agencies, tribal health offices, and Indian Health Service locations. Michigan’s largest school system in Detroit is enrolled as a vaccine provider and is planning a back-to-school campaign encouraging vaccinations. As part of this effort, the state immunization program is meeting with the superintendent and principals from each school to align goals and encourage each school’s participation.
• Addressing Provider Barriers: States are working with pediatric providers and associations to remove perceived barriers from participation in COVID-19 vaccination efforts. For example, the Virginia Department of Health is hosting a series of webinars with state chapters of the American Academy of Pediatricians (AAP) and  American Academy of Family Physicians (AAFP), as well as the Virginia Pharmacists Association (VPhA), to educate providers on the new vaccine preparations. In Illinois, the state responded to provider concerns about low demand and waste (particularly in more rural areas of the state) by encouraging practices to order small quantities of vaccine and reassuring them that reasonable vaccine wastage was expected. States can also consider incentivizing providers to enroll in the COVID-19 vaccination program by providing funding to offset the costs of enrollment and infrastructure (storage equipment, personnel costs, etc.).
• Expanding Partnerships with Social Service Providers: States can explore opportunities to partner with K-12 schools, childcare centers, early childhood education providers, summer feeding programs, and Women, Infant, and Children (WIC) program offices to provide education and vaccination opportunities when children and families are present. For example, Maine is working on partnerships with their WIC and Head Start programs to expand access to COVID-19 vaccinations for young children. Kansas is actively engaging with grassroots community partners to expand vaccine access for young children, especially in rural areas of the state. Traditional and non-traditional grassroots community partners are eligible and actively applying for grants to support these vaccine efforts.

How State Are Addressing Public Opinion

Many states have identified strategies to connect parents and caregivers to trusted sources of information, including:

• Developing communications resources for pediatric providers: Healthcare professionals, especially pediatricians, continue to be regarded as trusted sources of information when it comes to vaccinating children, with many states working closely with pediatric providers and associations to support efforts to encourage vaccination. Illinois Department of Health is supporting the Illinois Chapter of the American Academy of Pediatrics (ICAAP) in its effort to carry out a robust COVID-19 vaccination campaign for the under-5 population. ICAAP distributed a toolkit to pediatricians and other healthcare providers to assist them with incorporating COVID-19 vaccinations into their regular office routine and communicating with parents about COVID-19 vaccine safety.
• Developing toolkits and communications resources across platforms: New York publishes a webpage, Combatting Misinformation About the COVID-19 Vaccines, which includes a list of frequently asked questions, myths and facts. The state also publishes an online toolkit that provides posters, flyers, and social media graphics that promote science and combat misinformation. California was the first state to launch a bilingual WhatsApp chatbot to combat COVID-19 vaccine misinformation as part of its SMARTER (Shots, Masks, Awareness, Readiness, Testing, Education, and Rx) Plan. The chatbot provides English and Spanish-speakers with up-to-date information on vaccine safety, how to book an appointment, and how to obtain digital records of vaccinations.
• Partnering with schools on messaging: According to KFF, parents who are encouraged by schools to get their children vaccinated are more likely to vaccinate their children. It will be important to continue to provide vaccine safety messaging to parents in the remaining weeks before school adjourns for the summer, and to begin planning to hold school-based vaccination clinics as soon as students return to school in the fall.

Conclusion

As with the rollout of COVID-19 vaccines for older age groups, the initial rush of eager-to-vaccinate parents is likely to quickly subside, leaving a larger population of parents and caregivers that may have access challenges or questions about whether to vaccinate their young children against COVID-19. States and pediatric providers will need to continue their efforts to build vaccine confidence and improve equitable vaccine access, especially given the ongoing development of new SARS-CoV-2 virus mutations which threaten to cause new surges in cases. As has been seen throughout the pandemic, vaccination strategies are not one-size-fits-all, and states will need to continue to innovate and share best practices to ensure the most successful vaccination campaign possible, while also working to integrate COVID-19 vaccination into the routine pediatric immunization schedule.