When a COVID-19 vaccine is finalized and approved, schools will serve a key role in administering it, and educators may be among those to receive the earliest available doses, a new federal plan says.
That plan positions U.S. schools, which have experienced unprecedented disruption because of the pandemic, as a crucial partner in one of the largest public health operations in recent memory.
Public health officials compared the scale of the plan to the U.S. campaign to inoculate millions of children for polio in the 1950s. More recently, schools helped distribute millions of vaccine doses for H1N1, also known as swine flu, in 2009.
“In normal circumstances [school] is where children and adolescents are every day,” said Suzanne Mackey, policy director for the School-Based Health Alliance, an organization that advocates for medical care in school settings. “It removes many barriers,” such as transportation, for hard-to-reach students, and families trust schools as a place for their children to receive care, she said.
And, even as some schools remain in remote-learning mode, their experience in administering health screenings and more routine inoculations makes them an effective partner, she said. Schools often hold drive-through clinics and pop-up events to provide mandatory vaccines for illnesses like measles.
But education and public health officials may face some hurdles before children and their families are vaccinated for COVID-19 on a large scale. A financial crisis has led to downsizing of some school-based health centers, public opinion polling shows concerns about the safety of the vaccines, and scientific trials have largely focused on adults, who are more likely to grow severely ill from the virus than children.
A Federal Distribution Plan
Four pharmaceutical companies have been cleared for large-scale U.S. trials of potential COVID-19 vaccines. The U.S. Department of Health and Human Services released a plan Sept. 16 that outlines how it will quickly work with states to distribute doses when an effective vaccine is identified.
The 57-page plan leaves many blanks for states to fill in. Testifying before a Senate committee Sept. 23, Robert Redfield, director of the Centers for Disease Control and Prevention, said he expects states to develop their own plans by Oct. 16.
The national plan anticipates an unspecified lag time before production will ramp up to the point that doses will be broadly available to the general public. Depending on the specific characteristics of the vaccine that is ultimately selected, initial doses will be provided first to “critical populations,” the plan says.
The first wave of critical populations, which will be identified by the CDC’s Advisory Committee on Immunization Practices, may include people with health vulnerabilities, the elderly, and health care providers who work with COVID-19 patients.
Educators on the Priority List?
The second wave may include people at increased risk of acquiring or transmitting COVID-19, which includes employees of schools, child-care centers, colleges, and universities, the plan says.
That may help address concerns of educators in some areas who’ve expressed hesitation about returning to in-person learning while virus rates remain high.
But a vaccine won’t likely eliminate all risk. Anthony Fauci, the nation’s chief epidemiologist, told a Senate committee Sept. 23 that it’s not yet clear whether the eventual vaccine will function like a polio vaccine, which eliminates the risk of contracting the illness, or like a flu vaccine, which reduces risk of severe illness but does not necessarily eliminate it. Also unclear is how long the effects of the vaccine will last, whether multiple doses will be required, and whether booster shots will be required in subsequent years.
Reaching Herd Immunity
There is still value in treating all the adults in a school building, said Oscar Alleyne, an epidemiologist who serves as chief of programs and operations for the National Association of County and City Health Officials. But because children can contract and spread the virus without showing symptoms, it will take a much higher rate of vaccination before schools will be able to ease mitigation strategies, like wearing masks and spacing desks far apart.
“If you are in a setting where you do not have enough individuals vaccinated … there isn’t really that great protection that’s going to be offered if there are still asymptomatic and presymptomatic individuals who are spreading this disease,” he said.
Public health officials generally say a population reaches herd immunity, the condition in which enough individuals been vaccinated to limit community spread of an illness, when 70 percent to 80 percent have been inoculated, Alleyne said.
But late-phase clinical trials have focused on adults, leading a group of pediatricians to publish a commentary in the journal Clinical Infectious Diseases calling for increased attention to the needs of children so that there is not a delay identifying a dose that meets their needs. One member of the Food and Drug Administration’s vaccine advisory panel told The New York Times that trials for children may not begin until the first doses of the adult vaccine are administered.
Also of concern: Growing public hesitancy about vaccines in general and a polarized political climate may lead some to resist receiving the inoculation. In a Sept. 20 Axios-Ipsos poll, just 39 percent of respondents said they are likely to get the first generation COVID-19 vaccine as soon as the initial doses become available.
The federal plan focuses on providing the vaccine to “those who want it.” And, because the vaccine is still under development, no state has said it will be required for school attendance.
The Role of Schools
As enough vaccine becomes available for the general public, states and local health officials should work with a variety of organizations, including schools, to provide it broadly as quickly as possible, the federal plan says.
School buildings could serve as locations for pop-up clinics administered by hospitals or other health-care providers. Or school-based health centers, which are full-service primary care providers that serve students, may alter their operations to quickly vaccinate children with their parents’ consent.
“The opportunity is there because most parts of the country are at least in hybrid learning,” said Viju Jacob, the associate medical director for school-based health centers at Urban Health Plan, a New York-based provider that administers clinics in about 280 public schools. “If, even conservatively, I get 30 percent of the population immunized at school, that’s 30 percent that I don’t have to serve at an alternative location.”
In response to H1N1, the organization’s school-based health centers quickly shifted operations, developing one-page consent and information sheets for parents, Jacob said. While other countries may be more familiar with “conveyor belt”-style mass vaccine delivery, it’s less common in the United States, he said, making public education efforts important.
Another limitation: Some school-based health centers have shuttered while school buildings are closed. And some have closed permanently, said Mackey, of the School-Based Health Alliance. About half of the country’s 3,000 school-based health centers are operated by federally qualified health centers, charitable medical providers that receive enhanced Medicaid reimbursement rates for serving low-income patients.
But the rest are operated by hospitals, school districts, and states, leaving them vulnerable to cuts in operations and personnel as the economy suffers. In some places, that may mean experienced personnel won’t be available to provide school-based vaccine clinics. The School-Based Health Alliance plans to survey its members to determine the size of the cutbacks.
Plans Not Finalized
So when will a final vaccine be identified, sending public health officials scrambling to execute a massive campaign? The timing is still unclear.
Some public health officials reacted with skepticism after President Donald Trump pledged a vaccine would be ready around the Nov. 3 election.
Fauci told lawmakers recently that U.S. authorities would likely know “by the end of this year” if one of the vaccine candidates is safe and effective. Even now, the federal government is ramping up production of the finalists so that initial doses can be provided quickly after one is approved.
But it may be April 2021 before doses are provided on a larger scale, Fauci said.
Alleyne, of the National Association of County and City Health Officials, said local health officials want much more communication with state and federal health authorities so that they can be prepared to play a role.
As a county epidemiologist in New York during the H1N1 outbreak, Alleyne saw firsthand how complicated it can be to quickly distribute a vaccine at a large scale. In some cases, large shipments were sent to dentists rather than targeted health providers, like pediatricians and obstetricians. In some cases, hospitals received double shipments after their initial orders were long delayed.
“There are some of us who still have PTSD from that,” Alleyne said. “I literally was driving around my county with dry ice units collecting vaccines from hospitals. You know, horse trading.”
And COVID-19 vaccine distribution may be more complicated. It may require storage at lower temperatures than other medications. Some finalists require multiple doses, which will make administration more complicated.
Whatever the timeline, schools won’t be able to change their operations overnight, public health officials agreed. It will still be necessary to track cases and take precautions in response to rising rates of the virus until the vaccine has been distributed widely enough to drive down community spread.
“It’s a multipronged approach,” Alleyne said. “Vaccines themselves aren’t going to be the panacea. It’s a mixture of all of the above.”
