The case for school mandates of Covid-19 vaccines

All of America’s school-aged children can now get the Covid-19 vaccine. But should kids be required to get it?

Schools in every state, after all, already mandate vaccines for a range of diseases. These mandates have a long history in the US, with some states requiring immunization in schools as early as the 19th century. One goal of the mandates is to stop the spread of potentially deadly diseases, but another is to prevent outbreaks from disrupting the classroom as kids get sick and stay home.

Covid-19 has very much disrupted schools in the past year and a half. And while the coronavirus’s risk to kids is relatively low, it’s still killed nearly 600 children in the US, according to federal data. Kids can also spread the virus to people who are more vulnerable, including parents, grandparents, teachers, and other school staff.

The research on past school and other mandates, meanwhile, suggests that mandates successfully increase vaccination rates among children. More than 80 percent of kids are inoculated for other diseases, including polio, measles, and chickenpox, by age 2 — so serious outbreaks are very rare and almost never disrupt schools.

All of that, plus the high effectiveness of the Covid-19 vaccines, adds up to a compelling case that schools should require Covid-19 vaccines for students.

Yet there are reasons that schools might want to wait. The Pfizer/BioNTech Covid-19 vaccine is authorized for kids only for emergency use. It’s not fully approved, which creates some legal uncertainty around school mandates. There are also legitimate questions about the possible side effects for kids, including myocarditis (inflammation of the heart muscle). And while the research generally supports mandates, it also suggests that mandates are less effective if there’s not sufficient public buy-in.

To date, only California has said it will require Covid-19 vaccines for schoolchildren once the vaccines get full approval from the Food and Drug Administration.

“I don’t expect schools to move totally in this direction until [full approval],” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me. “Some may, but they’ll get pushback.”

The process could ultimately work like an expedited version of what we saw earlier this year: When the shots were approved for adults, officials, by and large, relied on enthusiasm for the inoculations and persuasion to get people vaccinated. Then they tried to incentivize shots through financial payouts and other benefits, albeit with disappointing results. Only once those measures proved to be not enough (about 70 percent of people 18 and older in the US are fully vaccinated) did employers, businesses, and different levels of government start mandating the vaccines.

Schools should be ready for this same chain of events. They should want to get kids vaccinated — it’s the best way to guarantee Covid-19 will stop disrupting the classroom. Chances are, though, that persuasion and incentives won’t be enough. And if that’s the case, mandates are a proven way to get vaccination rates up.

School mandates work

The empirical research on school vaccine mandates isn’t very expansive. But there are some studies, and they’re consistently positive for vaccination requirements.

A review of the research published in CMAJ Open in 2019 found that school mandates are “largely associated with increased vaccination coverage.” The review called for more studies, particularly with methodology that can better discern causation from correlation. But the studies reviewed, in elementary and middle school settings, showed that mandates seem to boost vaccination rates.

The chickenpox vaccine offers a recent example. The vaccine was approved in 1995, but initial uptake among children wasn’t great — in part because, like the coronavirus in kids, chickenpox carries a relatively low risk of death or serious complications for younger children. So in the late 1990s and 2000s, as vaccination rates stagnated, states began mandating the shot.

It worked. A 2005 study in Vaccine found that states with chickenpox vaccination requirements for day cares and school entry had greater coverage: 85 percent in the states with mandates compared to 77 percent for those without. The researchers also found that states with mandates didn’t appear to have higher vaccination rates prior to the requirements, suggesting the mandate is what made the difference.

A 2011 study in the Journal of Health Economics looked at the impact of school and day care mandates, broken down year by year. They found that the mandates increased vaccination rates, with the strongest effect in the second year after the mandate began.

German Lopez/Vox

Studies have also found evidence for mandates in other settings. A 2015 review of the research in Human Vaccines and Immunotherapeutics found that mandates in health care settings were the most effective intervention for boosting vaccination rates compared to softer requirements, increased awareness, and better access.

In recent weeks, there’s also been real-world evidence that Covid-19 vaccine mandates in particular are effective. As more workplaces and government agencies have mandated the shots, the requirements have consistently pushed up vaccination rates — to 90 percent or more in specific settings — while leading to very few, if any, resignations.

One telling example: Novant Health in North Carolina initially suspended 1 percent of its workforce — nearly 400 people — for not getting the vaccine, only for more than half of those workers to get the shot and go back to work within a week. What was once vaccine hesitancy and apathy quickly melted away as people got immunized.

Schools might want to wait

Despite the evidence, some experts remain skeptical that schools nationwide will embrace mandates — and note that there are some legitimate reasons to wait.

First, there’s the legal concerns. Since the vaccines are only authorized for emergency use for kids and lack full approval, there’s a worry that mandates now would fall to legal challenges.

Second, there are genuine concerns about the side effects of the vaccines. While all the experts I spoke to said they would get their kids vaccinated, they acknowledged legitimate concerns about the Pfizer vaccine causing myocarditis, particularly in boys. Coupled with the data showing that kids are at relatively low risk of Covid-19 to begin with, it’s not unreasonable for parents to wonder if the benefits of vaccines outweigh the risks.

An analysis by the Food and Drug Administration estimated that once Covid-19 is under greater control — which is not the case today but will be in the future — the vaccine could lead to higher hospitalization rates for children than the SARS-CoV-2 virus itself. The FDA suggested that the vaccine would still be worth it even in that scenario; the vaccine-linked myocarditis cases are almost all minor and resolve with very few, if any, lasting problems, while Covid-19 is far more likely to cause serious myocarditis and other significant health issues, including death, in the first place.

Still, the data presents a genuine challenge for school mandates. “You’re going to get pushback from parents that you’re actually putting their child at more risk by requiring them to be vaccinated,” Céline Gounder, an epidemiologist at New York University, told me.

The experts I spoke to said their own concerns were addressed by Pfizer moving to use a smaller vaccine dose for kids — those ages 5 to 11 get one-third of the dose given to people 12 and up. But myocarditis cases and other side effects continue to be something to watch for as vaccines are administered and more real-world data comes in.

Finally, there’s public buy-in. A recent survey from the Kaiser Family Foundation found just 27 percent of parents of kids 5 to 11 are eager to get their kids vaccinated, with 33 percent planning to wait and how the vaccines work and 30 percent saying they “definitely won’t” get their kids vaccinated. That’s more than six in 10 parents unwilling to get their kids vaccinated right away.

The level of skepticism can make mandates less effective. CMAJ Open’s 2019 research review found that mandates for HPV vaccines — which, like the Covid-19 vaccines, have been caught up in political controversy and safety concerns — “were notably ineffective.”

One way to build public support may be to tie vaccination rates or access to the vaccines — after a certain period of time — to the end of Covid-related restrictions, such as closures and masking. Some research suggests people are more likely to get vaccinated if it allows them to ease up on restrictions.

Monica Gandhi, a doctor and an infectious disease expert at UC San Francisco, told me that she rescinded her support for California’s school vaccine mandate after finding out it wasn’t linked to the end of school masking requirements. But she’d support a vaccine mandate if it came with an off-ramp for other restrictions.

“It’s not that I think children shouldn’t be vaccinated, because I do,” Gandhi said. But “there needs to be an off-ramp for children masking in schools.”

The vaccines are still the way out of the pandemic, and the ability to vaccinate kids is a crucial step to getting the world back to something closer to the pre-Covid normal. But the authorization of vaccines for kids is only the first part of that final step — and mandates will very likely be needed to finish the job.

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