Little more than 1 in 3 elementary-age students are on track to be fully vaccinated against COVID-19 by the end of the school year, with rates flat even amid rising cases of omicron and its newer subvariants.
With most masking and other mitigation mandates relaxed, school and district leaders face uncertain options for what to do to prevent more pandemic outbreaks in the fall.
“I think the risk perception has shifted quite a bit,” said Rupali Limaye, an associate scientist at the Center on Immunization Research at Johns Hopkins University who studies vaccination behavior.
After states and school districts dropped mask mandates and allowed those who are infected to leave quarantine after five days, “the perception now amongst most people is that COVID is not a big deal anymore,” Limaye said. “So what you’re essentially dealing with here is you have households that are either extremely protected—meaning the adults not only are fully vaccinated, but are boosted, and they’ve gotten their children vaccinated—or you kind of have the flip side...big swaths of people who are completely unprotected.”
That’s a problem, because studies of school mitigation strategies during the pandemic generally found that the most-effective approaches for keeping infections low used multiple, simultaneous interventions, including masking, vaccination, ventilation, physical distancing, hygiene, and tracing the contacts of those who are infected. Experts say many schools have rolled back several different strategies at the same time as vaccinations became more widely available. That can leave campuses more vulnerable to outbreaks if families don’t follow through on getting the shots for their children.
Vaccination rates may get a boost this summer if the Food and Drug Administration approves emergency authorization for that last large age group of unvaccinated children, those who are ages 6 months to 5 years. Moderna has asked for emergency approval for its two-injection vaccine series, and Pfizer-BioNTech has done so for a three-injection series.
However, the FDA’s focus on emergency use authorization also delays its process for full approval of the Pfizer vaccine for older children, which is now also used under emergency status. Emergency use authorization means the FDA can expedite the process to allow a drug to be used during a public health emergency when there are no other fully approved options available. While companies still have to provide studies showing a vaccine’s safety and effectiveness for emergency use, the lack of full approval can make vaccines a harder sell, according to Dr. Tina Tan, a pediatric infectious disease specialist at the Ann & Robert H. Lurie Children’s Hospital of Chicago and a pediatrics professor at Northwestern University’s Feinberg School of Medicine.
“The problem is there’s been a plateau but the vaccination rates overall are fairly low,” Tan said. “When you look at the 5- to 11-year-old population, less than 30 percent of them have gotten [fully vaccinated], so that really means over 18 and a half million kids in that age group [are] unvaccinated.”
Potentially greater access, but less will
Last week, the Centers for Disease Control and Prevention expanded its guidelines to recommend children ages 5 through 11 receive a booster shot five months after completing their original vaccination series. (So far, only the two-injection Pfizer-BioNTech series has been approved for emergency use for this age group, and no vaccine has received full approval.)
Yet in expanding booster availability, CDC Director Dr. Rochelle Walensky acknowledged the vaccination rate for elementary-age children has lagged that of older Americans.
When the vaccine for 5- to 11-year-olds was first approved late last fall, vaccination spiked, first from pent-up demand and then the winter emergence of the highly infectious omicron strain of the pandemic. But vaccination rates slowed to a crawl by the end of January, and Tan said many who were worried about getting their children vaccinated from the start haven’t changed their minds.
“From a lot of parents, we’re still hearing the same thing we heard at the beginning of the pandemic: You know, ‘The vaccine hasn’t been out very long. It’s experimental.’ Or, ‘I don’t believe in the vaccine.’ And a lot of it still is misinformation on social media ...[such as] ‘Kids don’t get COVID.’ We’ve not been able to get away from any of that,” Tan said.
While omicron and its related variants of the pandemic coronavirus have caused less severe illness on the whole than delta, the newer strains tend to cause more upper-respiratory illness than their predecessors, which Tan said has caused more children to develop croup-like symptoms that have required hospitalizations.
The lack of full approval and parent and community pushback has made it politically unfeasible for states to add COVID-19 vaccines to the list of those required to attend public school, although many private schools have done so, said Gretchen Chapman, professor and head of social and decision sciences at Carnegie Mellon University, who studies vaccine decision-making. Even California, the first state to announce it would add COVID-19 to its required school immunizations, announced last month that it would delay the mandate until at least the summer of 2023.
Even without a mandate, studies have found schools can boost immunization rates by holding vaccination clinics during the school day with easy or automatic ways for parents to give consent, and particularly with guaranteed financial incentives, such as a gift card for each child vaccinated.
Sponsoring on-site vaccinations and boosters may help even after a school has had an outbreak, Tan said, because natural infection does not provide immunity for as long or to as many different strains of the virus as vaccines do. Moreover, parents may be more likely to have children immunized if there is an immediate threat.
However, Limaye argued that schools that have been unable to boost vaccination or masking should plan for environmental mitigation strategies next year, such as ventilation and physical distancing, that “don’t depend on individuals to do the right thing.”
For example, public health advocates have posted directions for teachers and students to build low-cost classroom air filters known as Corsi-Rosenthal cubes, which can be integrated into science or engineering lessons.
“That, to me, is a better sort of investment right now—instead of trying to encourage people to wear a mask or get a vaccine—because honestly I think we’ve hit the people that we’re going to hit [with vaccine communications campaigns] now,” Limaye said. “From now on, it’s going to be really using a lot of persuasion, and it’s going to be a long game, to get people to get a vaccine.”