Amidst changes in the COVID-19 landscape, including navigating surges due to new variants, states are working with local partners to prepare for and implement back-to-school plans, while also anticipating the need to adapt as the school year progresses.
These factors along with an evolving set of vaccine mandates and mandate bans complicates public health mitigation plans, not only for vaccinating but for the full complement of tools that reduce spread, including health education, masking requirements, testing, and contact tracing. Additionally, intention to vaccinate and access to vaccines vary widely across the unvaccinated, with vaccination status of eligible children closely mirroring that of their parents.
Health and education officials simultaneously are planning for flu vaccinations and prioritizing catch up for routine childhood immunizations, required in many states for school, which lagged significantly during the pandemic as families followed social isolation and socially distanced recommendations.
NASHP convened a group of state officials from across the country to exchange strategies and creative approaches to navigating this environment in various demographic, political and policy environments. This brief summarizes key themes around accelerating routine vaccination rates and increasing access to the COVID-19 vaccine among eligible youth, including making vaccines convenient, using data to target resources and effectively engage partners, partnering to increase access and address intent, and prioritizing equity.
Making Vaccines Convenient for Families
Making vaccines available at locations that align with individuals’ daily routines enables those who may have limited time or resources due to childcare responsibilities, transportation, and other barriers to become vaccinated against COVID-19. Such convenience is critical to promoting widespread access generally and is an important tool in advancing equitable access for school-age children who rely on caregivers.
Convenience can be achieved by making vaccines available in community settings. To target adolescents and their families, some states are offering vaccine clinics at schools, ensuring that families can have ready access in a community hub and trusted location. Several states are pursuing strategies to ensure people “stumble into” opportunities to vaccinate, through pop up clinics in highly populated places (such as transit centers), on school grounds, or other at popular community events to allow for families to get vaccinated together, like at state fairs (such as Wyoming’s Frontier Days), or sporting events. This type of broad access in community enjoys the benefit of enhanced vaccine confidence when delivered in collaboration with trusted sources.
Another key method for reaching unvaccinated populations is to engage community providers and ensure they are willing and able to administer COVID-19 vaccines, which is particularly important for those living in underserved or rural areas. Most Americans trust doctors, nurses, and pharmacists, especially their own, and states are leveraging this trust and engaging these providers in both COVID-19 and routine vaccination efforts. Early in the pandemic, Kentucky state officials partnered with the Kentucky Board of Pharmacy to encourage pharmacist participation in delivering COVID-19 and routine vaccines. The Department of Public Health, the Kentucky Immunization Registry Coordinator, and the Emergency Preparedness Pharmacist from the Kentucky Pharmacists Association enrolled community and independent pharmacies to participate in the state’s vaccination program to reach underserved populations. Pharmacies are now one third of enrolled COVID-19 vaccine providers in the state, with 482 participating locations.
Prior to the delta surge, states had closed most mass vaccine sites in favor of local clinics, individual demand for vaccines had plateaued, and officials began managing excess doses about to expire. However, many community providers remained reluctant to provide COVID-19 vaccines for several reasons, including being unable to use large quantities of vaccines. To address these challenges, a number of state health officials established distribution programs – breaking down large palettes of vaccine sent by the federal government into small quantities to be distributed to providers. This approach is key to reaching underserved populations through trusted health care providers. For example, the Virginia Department of Health (VDH) federally funded Small Shipment Redistribution Program allows medical providers to order doses using VDH’s vaccine management platform, and a network of distribution centers across the state are used to store and distribute doses to clinics. Mississippi set up a Pfizer vaccine distribution site at County Health Departments using CDC supplemental funds and deployed pharmacists to distribute smaller doses (minimum of 6) to local providers, clinics, pharmacies, and homeless shelters, allowing for broader access to individuals. Kentucky doubled the size of their COVID-19 Vaccine and VFC (Vaccines For Children) program field representative workforce to redistribute doses around the state directly to providers.
Partnerships to Increase Access and Address Intent
Engaging trusted community leaders as messengers is essential to increasing vaccine intent. States are enlisting various community partners to help them engage more individuals in vaccination efforts. Vaccine intent varies across different demographic groups, and states can partner with school staff, healthcare professionals, and community and faith leaders to tailor vaccination engagement approaches.
Schools are important partners when it comes to hosting vaccine clinics and educating families about the importance of getting vaccinated. Mississippi and Kentucky designed school-based programs that bring vaccines to students who are eligible for the COVID-19 vaccine. Mississippi’s Adopt-a-School model incentivizes medical providers to coordinate on-site vaccination clinics at schools by paying participating providers $75 per shot. The Adopt-a-School program is part of Mississippi’s Covid-19 Community Vaccination Program, which is funded through a Center for Disease Control and Prevention (CDC) immunizations grant. The Kentucky Department for Public Health is contracting with a private vendor to host mobile vaccine clinics at schools. The state reimburses this vendor $80 per shot using FEMA (Federal Emergency Management Agency) funding. Other states are exploring partnerships between FQHCs and schools as well as public health and school nurses to organize school-based vaccine clinics.
Several other states are partnering with schools to circulate vaccine messaging and encourage students to get vaccinated. One state is collaborating with the American Academy of Pediatrics (AAP) chapters, school nurse organizations, and health and education departments to distribute information to students and families about vaccines. Other state officials from Kentucky and Maryland emphasized the important role of athletic departments in incentivizing vaccinations, as some schools do not allow unvaccinated students to participate in sports and ensuring the ability to take part in school athletic events is highly motivating.
State public health agencies can also engage more individuals by integrating vaccine efforts into the healthcare system. State health departments partner with primary care providers (PCPs), pharmacists, Medicaid agencies, and managed care organizations (MCOs) to educate individuals about COVID-19 vaccines and incentivize vaccinations. For example, one state’s Medicaid agency sent a fax blast to Medicaid-participating pharmacies to help encourage vaccinations. Another state official cited their state’s partnership with MCOs, where the MCOs helped organize community vaccination events and partnered with providers to increase vaccine availability. Other MCOs are offering financial incentives to their patients who get the COVID-19 vaccine. Trusted medical providers have a unique role in counseling and educating individuals about the safety of vaccines. Several states are leveraging this trust in doctors and creating initiatives that encourage providers to administer both COVID-19 and routine immunizations at doctor’s visits. For example, Wyoming is organizing a series of webinars for providers, giving them the opportunity to ask questions and work through challenges together.
Consistent Outreach and Messaging is Critical
States highlighted the value of a governor’s role in messaging through use of the bully pulpit including publicly vaccinating their eligible children. Still, most noted that effective outreach to those who remain unvaccinated requires tailored messaging to specific audiences and thoughtful assessment of population-specific barriers to vaccine information and uptake. Wyoming, for example, launched a multi-pronged messaging campaign to address vaccination holistically (including COVID, influenza and routine vaccinations). The campaign is tailored to the needs of various populations such as American Indians and residents in the most rural parts of the state. Intentional use of “choice” language through their provider and consumers educational campaigns has been key. Notably, early in the pandemic, some individuals were getting information about vaccine (and testing) opportunities across state lines which challenged state-specific messages around resources. The state responded through multiple messaging media to bring the right information to state residents.
Maryland is focusing outreach efforts to pockets of the state with a high rate of unvaccinated individuals. They are rolling out a voluntary screening/testing program at schools (reaching approximately 80% to date) with the hope of integrating mobile vaccination clinic opportunities into the program. The state is also aiming to reach areas with high need by leveraging multiple messaging strategies, such as door-to-door canvassing, pop up activities, digital communications, and partnerships with local employers and court systems.
Using an Equity-driven Approach
Given the disparate impact of the pandemic on communities of color, specifically Black, LatinX, and Indigenous groups, states are working to make sure their vaccine distribution strategy is equitable to these populations. Research shows that even though children may not have been impacted by the pandemic at the same rates as adults, the socio-emotional and developmental implications are staggering. And, children are experiencing similarly disproportionate levels of vaccine distribution, highlighting the importance of using an equity-driven approach to close the gaps in vaccine distribution in advance of and during the school year, and to mitigate the effects of the COVID-19 virus, especially with the emergence of the highly contagious Delta variant.
State officials cited their focus on areas with high numbers of unvaccinated people, as well as those vulnerable to infection. States use various data, such as the CDC’s Social Vulnerability Index (SVI), to identify these pockets of need and bring vaccinations to these areas, using a combination of mobile vaccination teams and local providers. Ensuring providers have appropriate educational materials and support to build vaccine confidence with their patients is critical.
State officials acknowledged efforts to engage community-based organizations and faith leaders to support vaccine intent. Kentucky created a COVID-19 vaccine communication toolkit for local trusted leaders to use when engaging with community members. There has also been an increased push from the federal level to address equity in COVID-19 response, including vaccination efforts. For example, the White House has increased public messaging and created the COVID-19 Health Equity Task Force and there has been an increase in equity-related funding from the CDC and HRSA to aid states as they work to use an equity lens on targeted approaches to vaccinate individuals.
Considerations for the Evolving Landscape
Several key themes were discussed without clear policy solutions and represent areas of continued opportunity as the school year begins and the vaccine landscape will continue to evolve:
- Navigating the issue of parental consent: Maintaining policies around consent for vaccination emerged as a major challenge in some states. A small subset of states allows minors 14 and older to consent for their own medical care through policies developed in partnership with provider organizations, such as the American Academy of Pediatrics. Political and policy disagreements with respect to exercising this option around the COVID-19 vaccine has resulted in clearer guidance from some states that parental consent is needed for COVID-19 vaccination separate from routine use of the minor consent option for other services.
- Incentivizing provider participation: Provider reimbursement approaches continue to evolve to incentivize vaccination and engage various provider types and locations. State officials noted further that provider reimbursement approaches should reflect the extended counseling sessions often occurring with unvaccinated people uncertain about their intention.
- Planning for the next milestones in vaccine approval: Several anticipated milestones will renew discussions around vaccine intent, access, and planning, including emergency use authorizations (EUA) for use of vaccines in children under 12 as well as full approval of those vaccines under EUA for adults and older children.
- Integrating pharmacists into vaccination efforts: Many states were eager to identify ways to include pharmacists in the Vaccines for Children (VFC) program specifically (and new adult immunization programs) to broaden the network and reach of vaccine providers, particularly in rural, frontier and otherwise underserved areas.