Ask PolitiFact: Why is the COVID-19 vaccine not among required school vaccinations?

Nationwide, before parents drop off their children at the start of the school year, one important task on their to-do list is to submit the required proof of vaccinations. 

But one vaccine is noticeably absent from the list of state-mandated vaccines for school enrollment: the COVID-19 vaccine, which has been available to children ages 12 and older for months. Some states have taken the opposite approach by passing legislation that restricts schools from requiring the vaccine.

We wondered, why have states not required the COVID-19 vaccine for most middle and high school students? 

The short answer is that states could choose to mandate the vaccine for school students ages 12 and up, but they haven’t gone down that path. The obstacles are that the vaccine has not yet received full authorization status, and it isn’t available to all ages of school children.

"Mandating a vaccine in school is always a struggle. It takes political capital to succeed, and I expect school districts and states would rather not have to fight this twice, once for 12 and up, once for 5 and up," said Dorit Reiss, an expert on vaccine mandates at UC Hastings law school. "That said, with the delay in relation to five and up, and with the increase in cases through delta, that calculus might change."

Pfizer’s vaccine received emergency use approval by the Food and Drug Administration in May for children ages 12-15 . Vaccine trials for younger children by multiple companies remain underway, and industry experts predict that a vaccine will be available for ages 5-11 sometime this winter.  

Although severe illness from COVID-19 for children is rare, an increasing number of children have caught COVID-19 this summer as the delta variant spread. About 121,000 children were reported as testing positive for COVID-19 for the week ending Aug. 12, representing about 18 percent of all cases, according to the American Academy of Pediatrics. In total since the start of the pandmeic, about 4.4 million children have tested positive.

States are responsible for setting required vaccination schedules for school attendance. 

Many states choose to align their rules with recommendations by the U.S. Centers for Disease Control and Prevention, which seeks input from their Advisory Committee on Immunization Practices, a panel made up of medical and public health professionals. (One exception is the HPV vaccine, which the committee has long recommended, but few states mandate.) The committee has in general recommended the COVID-19 vaccine for everyone ages 12 and older — and so has the American Academy of Pediatrics.

Each state has its own procedure for setting the required vaccination schedule, which can involve decisions by state health officials, the Legislature or both. 

"This is a fairly elaborate process," said William Schaffner, a health policy professor at Vanderbilt University in Tennessee. 

States commonly require school children to be vaccinated to protect them from various diseases including polio, measles/mumps and rubella (MMR), diphtheria/tetanus/pertussis (DTaP), varicella (chicken pox), haemophilus influenzae type b (Hib) disease and hepatitis B. 

Many states allow religious or philosophical exemptions, but the majority of students get vaccinated. Nationwide during the 2019-2020 school year, 94% or more of kindergarteners received their required vaccinations.

Medical experts say vaccinating children is part of the strategy to mitigate transmission of COVID-19. But we found no state has yet to require the vaccine for students ages 12 and older.

A database of 100 large urban districts by The Center for Reinventing Public Education shows the only major district to require the vaccine for students is in Hawaii and only for athletes. The database tracks various pandemic prevention strategies for schools such as mask rules and vaccination mandates for staff. (These numbers remain in flux and may change as more schools open their doors or experience case spikes.)

The Justice Department’s Office of Legal Counsel, which advises the president, issued an opinion in July that emergency use authorization does not prohibit public or private entities from mandating the vaccine. But that opinion alone may not move states, which generally appear to be waiting for full authorization.

"Although this opinion is well-reasoned and persuasive, it carries little legal authority outside the federal government, and would likely get limited deference in court," wrote Reiss, the UC Hastings law professor, and Arthur Caplan, a bioethics professor at New York University.

Despite benefits of childhood vaccination, the COVID vaccines are still relatively new and lack long term safety data. That means mandating the vaccine for children would be premature, Georgetown law professor Lawrence Gostin and other experts wrote in a viewpoint piece for The Journal of the American Medical Association in June. 

"Using incentives instead of mandates would avoid public backlash that could undermine the SARS-CoV-2 vaccine rollout," they wrote.

Also, multiple states have already taken action via legislation or executive order to prohibit COVID vaccine mandates, said James G. Hodge, an expert on health law at Arizona State University.

Pediatricians, however, have urged parents to get their children vaccinated once they are eligible. University of Minnesota professor of pediatrics Mark Schleiss along with colleagues wrote an article arguing that the vaccine will help protect children from disease, protect their families and community contacts and allow for safe in-person schooling. (Schleiss is a paid advisor for a Moderna program for a different virus but does not have any role in the Moderna COVID vaccine program.) 

"Ultimately the control of SARS-CoV-2 infection in children will not only protect their health, but will represent the ‘endgame’ in enabling long-term control of the COVID-19 pandemic for all age groups," they wrote.

Past efforts to add a vaccine to the list of mandates have brought out vocal opponents. So approving a COVID vaccine requirement is a process that states may not want to go through twice: once now and then again when the vaccine is available to elementary school students or when it gets full authorization.

"If you look at the hullabaloo over masks and low vaccination rates ages 12-17, I think (vaccination mandates) would not go over well at the present time," Schaffner said. "There would be a huge uproar in my state. We are debating with embarrassing intensity kids wearing masks."

Many parents have shown resistance to vaccinating their teenagers. Slightly less than half of people ages 12-17 have received at least one shot as of mid-August. Slightly less than half of parents of K-12 students support requiring vaccines for high school students, and that number drops to 43% for parents of middle school students, according to a Gallup poll.

Overall, school vaccination mandates have been key to getting the vast majority of children in the United States vaccinated. Cities and states started to mandate vaccinations for school in the 19th century, although "enforcement was complicated by active resistance and apathy," according to a 2002 article in the Kentucky Law Journal by Hodge and Gostin.  

In more recent decades, many school vaccination laws were enacted in response to the transmission of measles in schools in the 1960s and 1970s, they wrote. "State legislatures at that time were influenced by the significantly lower incidence rates of measles among school children in states with comprehensive immunization laws," they wrote.

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