As many schools prepare to welcome students—and their updated vaccination records—back for the new academic year, President Donald Trump signed an executive order modifying federal vaccine policy.
The order recommends reducing the number of childhood vaccines from 17 to 11 for all children, and separating the measles, mumps, and rubella (MMR) vaccine into separate shots. It also threatens legal action against states that don’t provide religious or medical exemptions from childhood and adolescent immunization requirements.
The order comes as the effects of heightened parental vaccine hesitancy have taken hold nationwide. So far this year, health officials have confirmed 2,566 measles cases in the U.S.—the highest annual case count since the disease was declared eliminated nationally in 2000.
Education Week spoke to Lynn Nelson, president of the National Association of School Nurses (NASN), about the executive order, its potential effects on families with school-age children, and how school nurses are planning to respond. NASN, with nearly 20,000 members and 49 affiliates, supports the American Academy of Pediatrics’ child and adolescent immunization schedule.
The interview has been edited for length and clarity.
How concerning is this new executive order?
It’s not going to change practice. But it’s concerning from the point of view that it’s just more misinformation out there, and it’s going to sow more confusion right as school starts up. Parents are going to hear what they hear and interpret it how they interpret it, and it’s just going to create more confusion and more distrust of public health and of vaccines in general.
What do you think of the recommendation to separate the MMR vaccine into three separate shots?
It’s problematic on so many levels. But the bottom line is that those vaccines aren’t being manufactured individually, and haven’t been for decades. They’re not available that way... it could potentially take years before they’re even available, and then there’s the issue of which providers are going to recommend them, even if they’re available. And I wonder if they will be available at all, because I don’t know that vaccine manufacturers are going to go out on that limb, because in three or four years that executive order is going to be gone.
And I don’t think this is going to impact parents who choose not to vaccinate their children one way or the other. And for parents who do vaccinate their children, who’s going to do three to five appointments for each vaccine and everything that entails? Nobody wants to have their child get six injections when they could have one, or five injections, or three. And then there are the additional appointments, the copays, the insurance costs, the time off work, all those things.
Does this executive order change the advice school nurses should share with families?
Nothing has changed in terms of our stance on vaccines. We still want to point our families toward evidence-based practice. We want to encourage them to collaborate with their healthcare provider to get the best recommendations and make the decisions that are best for their families.
School nurses are required to follow state laws around things like vaccine exemptions. Right?
Yes. The interesting thing about this executive order is that it talks about requiring medical exemptions, but all 50 states probably always have had medical exemptions. That’s never been an issue. So I honestly don’t know why that’s called out in the executive order. The other one that’s called out is religious exemptions, and that does vary a lot by state. Some states don’t have them. Some states have very broad religious exemptions.
Do variations in states’ vaccine exemptions affect how school nurses communicate to families about vaccines?
School nurses deliver messages to parents that are based in science and that support information from both the American Academy of Pediatrics and the American Public Health Association, because we know those are two evidence-based sources that families can trust. That information may or may not align with [state] exemptions. We don’t take a stand on exemptions, necessarily, because they’re different in every state.
The beginning of the school year is a busy time for school nurses, anyway. What now?
In the fall, school nurses are really prioritizing creating safety plans and emergency plans and doing staff teaching around those students who have chronic health conditions, especially those that can lead to emergencies in schools, so safety around that is our number one priority.
Right behind that, and all around the edges, are reviewing those immunization records and helping families understand the state requirements and identifying those students who might need catch-up vaccines, or who are out of date on some of them, or who haven’t been vaccinated at all.
At the same time, there’s a huge and necessary push for schools to recognize and plan for the probability of infectious disease outbreaks. I won’t even say the possibility anymore because as kids come back together after traveling, you know, any number of infectious diseases can and will rear up in different places, and so there’s a whole lot. This executive order just adds another layer, and it especially adds a layer to helping parents understand what’s required and what’s not.
Have you heard from any school nurses about how they’re handling this?
I think it’s a little early. It’s only been out a couple of days, and across the country, a lot of schools are not even back yet. So I haven’t heard much at this point, but I think I will.
Are school nurses prepared for possible pushback from parents about vaccinating their children because of this new order?
We’re always prepared for pushback. It’s always the nurse who’s making those phone calls to the parent. And it’s the vocal minority that push back. Most parents, even those who are hesitant about vaccinating their children, generally speaking, once they get good information from a school nurse or a healthcare provider that they trust, they go ahead and vaccinate. But it is that minority of parents who are going to push back no matter what.
This just gives them more to push back with, and so it’s going to be just more educating that nurses are going to have to do, and we’re all kind of bracing for that. It’s just not pushback [we’re anticipating], but trying to help parents understand the importance of vaccines. To be honest, some of them don’t want to understand. They just want more ammunition for not vaccinating their children, which is a choice they can make. But we always recommend they make it in conjunction with their own healthcare provider.
Are school nurses worried that outbreaks of preventable diseases could escalate with this order?
School nurses are worried, maybe resigned, to the fact that outbreaks of communicable diseases are increasing, kind of exponentially at this point, and we just have to be prepared for that.
Do you have other concerns about this executive order?
When you change long-standing vaccine recommendations, you really need to be transparent, and you need to know the clinical and scientific processes, and be transparent with people. And that’s lacking here, and so that’s what’s adding to confusion.
I don’t see this order having much practical impact on anybody other than just increasing confusion with parents and adding or increasing that layer of work we as school nurses need to do to help parents understand that state guidelines are still what they need to follow, and that the conversations that need to happen around vaccines should be evidence-based.
