To date, there have been more than 2 million COVID-19 infections in US children and 8,000 pediatric hospitalizations. As states begin vaccinating those age 16 and older, many are drafting plans and applying lessons learned from their existing vaccination initiatives for the day when a vaccine is authorized for younger children.
As the Biden Administration rolls out its comprehensive plan to vaccinate 100 million American adults in the next 100 days and reopen schools in 100 days, states are already taking actions to include children in their vaccine distribution plans and tackling issues, such as:
- Should schools require students to get the COVID-19 vaccine, similar to other immunization requirements?
- How should they prioritize children with medical conditions or living in congregate settings that put them at higher risk of infection?
Children are at lower risk of illness from COVID-19 than adults, yet this population can still develop symptoms and spread the virus to others. Though children have experienced fewer severe physical illness than adults, the pandemic has significantly impacted their emotional and social development. Children and their families have been stressed by social distancing, disruptions in schooling, unemployment, and loss of family members due to COVID-19.
Last October, states submitted COVID-19 vaccine distribution plans to the Centers for Disease Control and Prevention (CDC) that outlined their approaches, including how they will collaborate with stakeholders, enroll providers, and track vaccinations. The federal Advisory Committee on Immunization Practices (ACIP) has recommended vaccinations first for health care personnel and long-term care facility residents, people 65 and older, essential workers, and those with high-risk medial conditions. States are using these recommendations to guide their approaches to prioritizing populations for vaccine distribution.
ACIP is currently discussing vaccine trials in pediatric populations and has indicated it may update its recommendations once a vaccine is authorized for children under age 16. Meanwhile, several states have already identified a distribution phase for children in their current plans.
Youth age 12 and older have just begun enrolling in vaccine trials. If the vaccine is authorized for this age group, it will next be tested in a younger pediatric population. While there have been barriers to clinical trials for the vaccine in this population and the timeline is unclear, it will be months before any children under age 16 are eligible for vaccination. As states grapple with challenges in distributing the vaccine to currently eligible populations, they may be able to leverage the lessons they are now learning to improve distribution for younger children in the future.
Additionally, there are already systems in place to deliver vaccines to children, and many states plan to use the Vaccines for Children (VFC) infrastructure for enrolling and verifying providers, distributing, and tracking COVID-19 vaccine administration for all populations, including adults. States may find that these established protocols will facilitate vaccinating children.
States differ in how they have – or have not yet – included children in their vaccine distribution plans while the vaccine undergoes pediatric clinical trials. State approaches include:
- Incorporating child health agency representatives in COVID-19 vaccination planning teams;
- Designating roles for child health programs and providers to facilitate distribution; and
- Prioritizing children or subpopulations of children for when the vaccine is authorized.
Several states have indicated their pediatric vaccination plans may be updated once the vaccine is authorized for children. (See the table for a list of states that have included pediatric-specific approaches in their vaccine distribution plans.)
Including Child Health Stakeholders in Vaccination Planning
States have developed organizational structures that include internal and external agency representation to facilitate COVID-19 vaccination planning. At least 31 states have included child health stakeholders on their vaccine planning teams and advisory councils. These stakeholders include state chapters of the American Academy of Pediatrics (AAP) and other provider groups, children’s hospitals, other pediatric providers, state education agencies, local school districts, and others. Including these representatives in vaccine distribution planning early offers an important perspective for distributing the vaccine when it is authorized for children.
- Washington, DC’s vaccine planning team includes representatives from the District’s chapter of the American Academy of Pediatrics, pediatric providers, public schools, Families USA, and March of Dimes.
- Ohio’s vaccine planning team includes representatives from Ohio Children’s Hospital Association, Ohio Department of Education, and select local school districts.
Designating Roles for Child Health Programs and Providers
Beyond their vaccine planning teams, states have identified and partnered with child health programs and providers to support implementation of their distribution plans. These partners include pediatric practices, local school districts, and state public health agencies, including Title V Maternal and Child Health programs. Forming partnerships with these entities early in the planning process can facilitate rapid vaccine deployment once it is authorized. The specific roles designated to these partners include promoting the vaccine, facilitating communication with children and their families, identifying eligible children, and administering the vaccine.
- Connecticut has identified vaccine administration locations that will specifically serve children. These include school-based health centers and pediatric medical practices.
- North Carolina plans to partner with schools to help identify children for vaccination once it is authorized. The state is also engaged with the state’s AAP and the Pediatric Society to support education and communication about the vaccine.
Children at higher risk of illness due to COVID-19: While the distribution phase differs, most states have categorized people with chronic conditions that increase their risk for illness due to COVID-19 as a priority group for vaccine receipt. Because most states do not specify the age range for this prioritized group in their distribution plans, some of these states may implicitly plan to include children, including children and youth with special health care needs (CYSHCN) who are at increased risk of COVID-19 illness, within this group when the vaccine is authorized for pediatric populations. However, five states (HI, KY, ME, NY, and OK) have specifically included children at higher risk as a prioritized population.
- Oklahoma has prioritized students including those in K-12 schools, childcare facilities, and early childhood facilities for Phase 3 of their vaccination distribution. Within their distribution plans, they specify that students at higher risk due to comorbid conditions will be prioritized among all students.
- Maine’s distribution plan specifies that “people of all ages” with conditions that put them at higher risk will be prioritized for earlier phases of vaccination. Anyone with a condition that puts them at significantly higher risk will be prioritized for Phase 1b, and those with conditions that put them at moderately high risk will be prioritized for Phase 2.
As the vaccine is tested for safety in the pediatric population, states are considering how they will further incorporate children into their distribution plans if it is authorized.
- Including child health stakeholders in planning for the vaccine for children. Many states have leveraged the existing VFC infrastructure and partnered with child health agencies to support planning and implementation for distribution of the currently available vaccine. This important perspective will be increasingly critical if the vaccine is authorized for use in children. States can consider collaborating with additional stakeholders that represent the broad range of child health services to effectively support vaccine administration for the pediatric population.
- Leveraging lessons learned from distribution of the adult vaccine. States have faced various challenges in distributing the vaccine to those who are currently eligible. Given that children under age 16 will not be eligible for the vaccine for at least several months, states may be able to draw from their experiences to improve their strategies for distributing the vaccine to children while also considering the challenges and opportunities that are unique to the pediatric population.
- Prioritizing caregivers of children with underlying conditions. Many CYSHCN who may have underlying conditions that increase their susceptibility to COVID-19 symptoms are cared for by family members. To reduce the risk for CYSHCN, states can prioritize vaccinating these family members by classifying them as health care workers.
- Prioritizing sub-populations of children. Children who are at higher risk of COVID-19 due to underlying medical conditions and/or those in congregate facilities are important populations for states to consider for prioritization. Additionally, states can consider how to distribute the vaccine to minimize learning losses due to school closures. CYSHCN may face unique challenges in accessing virtual learning compared to other children, whether or not they are at greater risk of COVID-19 illness. This is particularly true for children of color, those with high socioeconomic needs, and those with limited access to technology. Prioritizing children with greater virtual learning challenges could more equitably facilitate a safe return to in-person learning.
- Determining whether the vaccine will be a school requirement. Several state vaccine distribution plans include language about their state statutes that currently require certain vaccines for children to enter schools. While these plans do not specify that the COVID-19 vaccine is a school requirement, this will be an important consideration for states if the vaccine is authorized for use in pediatric populations.
- Distributing the vaccine across pediatric age groups. Vaccination authorization in children will likely be authorized in stages, with current trials for those ages 12 and older, and subsequent trials for younger age groups. This may impact states’ decisions governing how they prioritize vaccine distribution, when and which schools reopen for in-person instruction, and who, if anyone, is required to have received the vaccine to attend school in person.
The National Academy for State Health Policy will continue to monitor states’ COVID-19 vaccine distribution plans, and how states’ plans change once the vaccine is authorized for children under age 16.
Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials co-operative agreement. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the US government.