Vaccinating Children Ages 5-11: Policy Considerations for COVID-19 Vaccine Rollout

Introduction

It is widely expected that children, ages 5-11, will soon become the latest group to be eligible for COVID-19 vaccination in the United States. The Food and Drug Administration (FDA)’s advisory committee is meeting on October 26 to vote on Pfizer’s request to authorize its vaccine for children, which would be followed by an FDA decision. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) is meeting on November 2-3 to make its recommendation, which would be followed by a CDC Director recommendation. As such, children could become eligible as soon as November 3 or 4. In anticipation, the White House and CDC have engaged in operational planning with state and local jurisdictions. However, when the doses for children become available and how rapidly the rollout translates into shots getting into kids’ arms nationwide remain to be seen. At least in the near term, there could be some unique challenges to this new vaccination effort as well as a repeat of some of the difficulties faced during previous COVID-19 vaccination phases. This brief highlights key issues to consider for the vaccination rollout to younger children.

Scale-up and Supply

Access to vaccines for children will likely vary across the country in the short run. While the federal government has been working with state and local jurisdictions to prepare to administer vaccines, as in the early days of the vaccine effort, much of the rollout will depend on jurisdictional decisions, and implementation will likely vary across the country. Local vaccination efforts will reflect decisions about pre-ordering supplies, choosing vaccination sites and providers, the adequacy of provider networks, and communication and outreach plans. While this vaccination effort will rely on existing COVID-19 vaccination providers (pharmacies, Community Health Centers/Rural Health Clinics, hospitals), other providers will have an expanded role in the rollout to younger kids, including pediatricians, primary care providers, schools, and children’s hospitals. New providers will need to be registered, trained, and certified, a process which likely to occur at different speeds and with different levels of completeness across jurisdictions. As a result, vaccine availability for children will likely vary depending on where they live.

Demand for pediatric vaccinations could initially outstrip supply, as providers wait for delivery of children’s vaccines and update processes to administer them. Up until now, when a new group has been prioritized or authorized for COVID-19 vaccination, providers could simply use existing supply to administer the vaccine. However, Pfizer’s COVID-19 vaccines for children will have different dosing, formulation, and packaging requirements compared to vaccines for adults. The new product and packaging have advantages, including a smaller number of vials per carton (compared to the much large number of adult doses distributed) that may make it easier for physicians’ offices and other locations to store and manage; these differences will also keep pediatric vaccines easily distinct from adult vaccines. However, existing vaccination providers – including physicians’ offices, pharmacies, clinics, and other sites – will have to wait for delivery of these new vials to begin vaccinating this age group and may have to update processes to reflect these differences.

The speed of scale-up will likely vary across the country, partially dependent on state ordering and assessments. The White House has said that the federal government has enough vaccine supply for the estimated 28 million children ages 5-11, who will become eligible for vaccination. Initially, a large, one-time allotment of 15 million doses will be made available to jurisdictions for pre-order, on a pro-rata basis based on the distribution of the child population. This initial allotment will be distributed in three waves, and began October 20. States will be responsible for planning and ordering first and second doses and distributing doses to participating providers and sites (although pharmacies will also receive doses directly from the federal government as part of the federal pharmacy program). At least initially, unpredictable and shifting levels of demand could result in mismatches between demand and supply across and within states.

Vaccination Providers

Pediatricians and children’s hospitals will play an expanded role in vaccinating younger children. The White House has indicated that the COVID-19 vaccine will be available at over 25,000 pediatrician offices and primary care sites. As trusted sources of care for children, and regular providers of routine immunizations, pediatricians can help provide parents/caregivers with the information needed to make a decision about the vaccine for their children. While many pediatricians are already providing COVID-19 vaccinations (an American Association of Pediatrics survey found that most pediatricians in primary care had enrolled as COVID-19 vaccine providers and many had started administering to adolescents), states are working to enroll more doctors to meet the increased demand and ensure caregivers can access the vaccine where they are used to seeking care for their children. Still, enrollment is likely uneven across the country, and some pediatricians, especially those in smaller practices, may face barriers to participating at least initially, as they wait to receive doses or, despite the smaller number of vials per carton, run into challenges with administering their supply within a set period to avoid running into expiration dates. In addition, given how trusted pediatricians are, the success of vaccination efforts may in part hinge on whether they are able to proactively reach out to parents/caregivers or if they wait to hear from them. The federal government is also partnering with over 100 children’s hospitals across the country to set up vaccination clinics through the end of the year.

While schools are positioned to play an important role in vaccinating children and educating families, their role will likely play out differently across the country given the localized nature of school decision-making and politicization of COVID-19 vaccines. The White House has said it will work with state and local jurisdictions to make vaccination sites available at schools, including setting up and supplying sites as well as supporting logistics and communications. However, school decisions are highly localized, whether that be relating to mask or vaccine requirements, screening, or offering on-site vaccine clinics. Decisions about whether schools will provide on-site clinics will be up to jurisdictions, as was the case for 12-17 year-olds. For 12-17 year-olds, some states, such as Mississippi, encouraged vaccine providers to partner with schools to offer on-site vaccination and others, including California and DC, set such clinics up. At the same time, others have resisted putting any school-based COVID-19 requirements in place, including for masking and testing, and some have been reluctant to offer COVID-19 vaccine clinics on site. In preparation for authorization of vaccines for those 5-11, California and Maryland have already indicated their intention to offer school-based vaccination clinics, but whether others follow suit remains to be seen.

Pharmacies have been one of the major sites for COVID-19 vaccination, particularly since the spring, but it is unclear how many will offer vaccination for young children. HHS has invoked the PREP Act under the COVID-19 public health emergency to allow pharmacists to vaccinate younger children for routine immunizations as well as COVID-19 (upon authorization). This action pre-empts state laws that might have age limits on pharmacist administration of vaccines. However, not all pharmacies have chosen to take up this option, thereby potentially limiting what could be an extensive avenue for access to vaccination nationwide. Outreach to major pharmacy chains and independent pharmacies about their ability to administer vaccines to younger children during the public health emergency by the federal government or individual jurisdictions could further increase their participation.

Community vaccination clinics that were vital to vaccinating large numbers of people early in the vaccination effort could provide additional access points for children. However, local health departments have scaled back community-based vaccination efforts as demand for the vaccine slowed over the past few months. Reestablishing these clinics in community-based settings to specifically reach younger children or increasing the capacity of existing clinics will require additional resources. These sites may also face logistical challenges vaccinating younger children because of the special dosing requirements. Federal support and funding can assist with staffing and supply needs to ramp up capacity as well as the community outreach needed to inform parents/caregivers of the availability of these clinics.

Vaccination Uptake and Equity

Parental/caregiver support and confidence will be paramount to achieving high vaccination rates over time, yet many have concerns or questions about getting their younger children vaccinated against COVID-19. KFF polling has found that overall, about one-third of parents (34%) with children in the 5-11 age group are eager to get them vaccinated as soon as their kids are eligible (with some parents more likely to say they want to get their children vaccinated right away, including those who are older, have college degrees, and have been vaccinated themselves). This means there initially will likely be high demand for vaccines, when scale up and distribution issues noted above may pose challenges. After this initial surge, however, the primary challenge is likely to shift to addressing concerns or questions that contribute to reluctance to vaccinating younger children. As of September 2021, a majority of parents reported being either unsure about vaccinating their children in this age group (32% say they will wait and see) or say they will not get them vaccinated or only do so if required (31%). These shares will likely decline once the vaccines are approved for younger children and there is increased outreach and education. However, data show some remaining reluctance among parents of 12-17 year-olds, with a quarter still saying they will not get their child vaccinated or will only do so if required, even though children in this age group have been eligible for vaccination for months. CDC data show that as of October 21, 63% of 16-17 year-olds had received at least one vaccine dose as had 56% of 12-15 year-olds, compared to 79% of those 18 and older. Parental/caregiver consent will be a major factor in vaccinating those under age 12 since consent is required in all states (though DC and Philadelphia allow 11-year-olds to self-consent for the COVID-19 vaccine). Therefore, outreach and education to parents/caregivers will be important to achieving high vaccination rates in younger children, and pediatricians will play an especially important role in this regard.

Trusted and diverse messengers matter, and outreach will be even more important, but more challenging, over time. As part of its plan, the White House has said HHS will conduct a national public education campaign, relying on trusted messengers and multiple stakeholders (e.g., schools, health departments, faith leaders, and community organizations, local organizers). This will include popular media and social media campaigns, such as one that we recently launched with the American Academy of Pediatrics to reach parents and caregivers. The news media – particularly local news media – will also be key messengers about COVID-19 vaccines for children and the extent to which they are actively and regularly providing information will likely have an important impact on vaccine uptake

Finally, it will be important to prioritize equity as vaccination efforts extend to younger children. Of the estimated 28 million children in the U.S. ages 5-11, more than half are children of color, including approximately 26% who are Hispanic and 14% who are Black (Figure 1). The racial ethnic distribution of children varies across states, which higher shares of children of color in many states, particularly in Hawaii and the District of Columbia (Table 1). Almost four in ten (39%) children between the ages of 5-11 live in households with incomes below 200% of the Federal Poverty Level (FPL) (Figure 1). Over the course of the COVID-19 vaccination rollout, Black and Hispanic people have been less likely to be vaccinated compared to their White counterparts, although these disparities have narrowed over time. To mitigate similar disparities in vaccination rates among children, it will be important to address potential access barriers and ensure vaccinations are available through trusted sites in the community. Engaging trusted community members to provide outreach and education and address parent/caregiver concerns and questions about the vaccine will also be key. In addition, increasing the availability of data will be vital for being able to identify and address disparities in vaccination rates among children. At the federal level, data currently are not available on vaccinations by race/ethnicity and age, and very few states report these data. Without these data, disparities will remain unseen and more difficult to address.