It is estimated that immunizations prevent approximately 6 million deaths each year from vaccine-preventable diseases such as polio, measles, and pertussis. While routine childhood immunization requirements for schools and childcare centers have long existed in every state, COVID-19 vaccine requirements are very rare. Instead, state and local leaders are employing a variety of strategies to reduce barriers to access for COVID-19 and develop partnerships to communicate the importance of vaccines to parents and caregivers.
Only Washington, DC has a COVID-19 vaccine mandate for the 2022-2023 academic year, requiring all students ages 12 and older to be fully vaccinated for school entry. Originally that mandate was to become effective this fall but has been delayed until January 2023. California has a pending statewide COVID-19 vaccine requirement that will not take effect until at least July 2023. Both DC and California require COVID-19 vaccines only in age groups where the vaccines have full approval by the U.S. Food and Drug Administration (FDA). Louisiana, which had been the first state to implement a COVID-19 vaccination mandate for school entry for the 2022-2023 school year, retracted its mandate in May 2022.
Over the past year, DC has employed a variety of strategies to increase vaccination rates across children and youth, in addition to requiring COVID-19 vaccines for school entry. Such efforts have resulted in increasing vaccination rates that greatly exceed the national rates for these populations. Below is a summary of some of these strategies.
The vast majority of states are not requiring COVID-19 vaccination for school entry.
Only Washington , DC and California require COVID-19 vaccines for age groups where there is full FDA approval for the vaccine (12 years and older), and neither will be enforced until 2023.
COVID-19 Vaccines for DC Children Ages 12-15
On May 12, 2021, DC Health announced the availability of COVID-19 vaccines for individuals 12-15 years old at walk-up sites, health centers, and pharmacies. Vaccines were available on weekends and evenings, and locations were available throughout the District. Children’s National Hospital, George Washington University Hospital, Howard University Hospital, and MedStar Georgetown University Hospital, as well as One Medical sites, federally qualified health centers, and chain grocery stores and pharmacies, also made vaccines available for this age group.
DC is divided into eight wards. As was seen with the initial COVID-19 vaccine roll-out, youth living in wards with larger Black and Hispanic populations were much less likely to be vaccinated than youth living in wards with primarily white populations. Ward 3, in the upper Northwest quadrant of DC, is 80 percent white and 95 percent insured. Ward 8, however, located at the southernmost tip of the District, is 92 percent Black, 88 percent insured, with 23 percent of families living in poverty. As of August 7, 2021, just 8 percent of Ward 8 children ages 12-17 had been fully vaccinated, compared to 57 percent of the youth in Ward 3.
In June 2021, with interest in the vaccine steadily decreasing among the population at large, Mayor Muriel Bower’s administration rolled out its “Take the Shot, DC Giveaway” program, incentivizing vaccination with $51 VISA gift cards and entries into raffles for various prizes. When the program was evaluated, it was found that a vaccination site in Ward 8 saw a 100 percent increase in vaccinations and a site in Ward 7 saw a 17 percent increase. Further, 70 percent of those vaccinated at those sites lived in that ward. As of early June 2021, 70 percent of the adult population in DC was at least partially vaccinated. It would take the U.S. until August to achieve that rate.
Similarly, in an effort to improve vaccination rates among youth in wards with disproportionately low vaccination rates, the District initiated several programs to incentivize youth vaccination. VISA gift cards were given to youth (and their accompanying parent) who were vaccinated at five schools and one public library in Wards 4, 5, 7, and 8, and AirPods were given to the first 400 youth vaccinated at each of three schools. By March 23, 2022, the vaccination rate among youth ages 12-17 in DC was 100 percent, according to data from the American Academy of Pediatrics.* It remains the highest in the country.
Vaccinating DC’s 5-11-year-olds
On October 29, 2021, Mayor Bowser and DC Health announced the vaccination plan for children ages 5-11, with plans to have vaccines available in more than 60 hospitals, pharmacies, and health centers, as well as at District pop-up sites set up specifically for 5-11-year-olds. DC Health posted pop-up vaccination site dates on their website and offered a way for community groups to request a pop-up event. DC Public Schools tweeted about the announced plans writing, “The COVID-19 vaccine is safe, effective & free.” Children’s National Hospital offered vaccinations at its eight primary care locations and via their mobile vaccination unit. Children’s National also proactively contacted parents of children who were at higher risk of developing severe COVID-19 disease and encouraged them to schedule an appointment for vaccination. Within two weeks of offering vaccinations to this population, DC’s vaccination rate (8%) was two and a half times that of the U.S (3%).
In one DC community, a principal of an elementary school with a Black and Hispanic population of about 80 percent coordinated with a DC program to hold vaccination clinics in the school’s cafeteria in the afternoons and evenings. The school’s principal, Mr. Kiplinger, was “calling the school’s parents, texting, nagging, cajoling daily,” and eventually achieved an 80 percent vaccination rate in his school’s kindergarten through fifth graders. Mr. Kiplinger recruited Black pediatricians to provide medical information and endorsements to help encourage parents to vaccinate their children. As of August 24, 2022, DC’s vaccination rate for children ages 5-11 was 68 percent, second only to that of Vermont (69%) and 31 percentage points above the national rate of 37 percent.
Applying Lessons Learned to Efforts to Vaccinate Children 6 months-4 years
While DC’s efforts to vaccinate children ages 5 and older have been notably successful compared to the national rate, vaccinating young children, especially those under age 3, is a greater challenge. The Public Readiness and Emergency Preparedness (PREP) Act provides immunity from liability to vaccinating pharmacists and other health care professionals who do not commonly provide vaccinations, but only when vaccinating patients older than age 3. That restriction severely limits vaccine access for young children, although some pharmacists will vaccinate children younger than age 3 with a physician’s prescription. When vaccines became available for those under age 5 on June 21, 2022, DC Health recommended parents first call their child’s primary care provider. DC Health’s Immunization Division Chief, Heather Burris, estimates 80-90 percent of DC pediatricians are enrolled in the Vaccines for Children program and saw even those that aren’t in the program sign up to provide COVID-19 vaccinations. Ms. Burris stated, “DC is not hesitant as a city. There’s a vaccine mandate for healthcare workers, District government employees, and for schools.” In addition to having robust pediatric provider participation, the District also made vaccines available in COVID Centers located in each of its eight wards. COVID Centers attempt to remove every barrier to vaccination — they vaccinate all ages, without appointments, weekends and evenings, in every ward of the District. They even post a Trusted Party Consent and Verification Form on their website in case a parent needs to send their child with another adult. Children have received a “goodie bag” with a stuffed animal, a onesie decorated with Band-Aids in the shape of Superman’s logo, and items to pass the time while waiting the required 15 minutes after receiving a vaccination. As of August 24, 2022, DC had vaccinated 25% of its under 5 population — the highest vaccination rate in the country and 18 percentage points above the national rate of 7 percent.
Conclusions
Vaccination requirements for school entry exist in all 50 states and are positively correlated with vaccination rates. While school vaccination requirements are one option, public-private partnerships that prioritize vaccine accessibility and efforts to build community trust are also critical strategies for improving immunization rates for children. Public health, hospitals, pediatricians, pharmacists, federally qualified health centers, and schools all play a role in championing the importance of protecting children from COVID-19 and addressing disparities in access and uptake.
*Data from the American Academy of Pediatrics may differ from that reported by DC Health.
