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Bioethics Forum Essay

California U-Turn on Vaccine Mandates for Schoolchildren

The California legislature appears to have caved to pressure from opponents of a Covid vaccine mandate for schoolkids. I’d prefer to think of it as a wise and strategic retreat from a battle that mandate advocates could not win.

Mandate advocates in California are a savvy bunch. Led by State Senator Richard Pan, a pediatrician, they eliminated the personal belief exemption from California’s mandate for routine pre-Covid childhood immunizations.  After that fight, it seemed that a Covid vaccine mandate would be easy. After all, we were in the middle of a pandemic. Kids were dying or getting strange inflammatory illnesses, missing school, and forced to wear masks. The vaccine studies in adults showed that vaccines were astoundingly safe and effective. Everyone was just impatiently waiting for similarly upbeat results from pediatric studies. Governor Gavin Newson announced in the fall that, as soon as the Food and Drug Administration approved vaccines for children, they would be mandated for children attending public schools. California was on track to proudly be first in the nation to implement such a mandate. In January, Pan introduced a bill to add a Covid-19 vaccine to the panel of vaccines mandated for school entry.  

Opposition to the proposed Covid vaccine mandate was immediate and fierce. Many California school districts took official stands against vaccine mandates and publicly stated that they would not comply.  

The stage seemed set for a showdown.

But the plot was too tidy. Kids, it turns out, are not just small adults. It wasn’t enough to just give them a lower dose of vaccine for them to get the same results as adults. Furthermore, the virus itself wasn’t static. Vaccines were less effective against the new Omicron variant than against prior strains. 

Data from an observational study done by the New York Health Department showed that, prior to Omicron, the Pfizer-BioNTech vaccine was 67% effective in preventing infections in children. Once Omicron hit, its efficacy fell to 51% in teens and 12% in children ages 5 to 11. Furthermore, vaccine efficacy waned quickly in children. For children ages 5 to 11, the vaccine’s efficacy in preventing infections fell from 65% two weeks after the second jab to 12% at a month. Because of rapidly waning immunity, these vaccines  will likely require frequent boosters to be effective. The efficacy of each booster may change as new variants emerge. Nobody knows how often boosters will be needed.

Given the muddy data, nearly 40% of parents across the country say that they would not want their children immunized.  Another 40% wanted to wait and see more data before deciding. Parents’ choices reflect these attitudes.

Pan’s colleague, State Senator Connie Leyva, who chairs the Senate Education Committee and also serves on the Senate Health Committee with Dr. Pan, came out against the Covid-vaccine mandate for schoolchildren. She said,  “We’re too divided as a community. This bill is just too divisive.” 

Senator Pan could see the writing on the wall. Last month he withdrew his proposed bill. He tried to put the best spin on it, shifting the focus to improving the rates of voluntary immunization. “People have questions,” he noted, “and want to get them answered.” 

The reasons for the U-Turn suggest a way of assessing the likelihood that a mandate will be politically feasible. It would seem that mandates are only possible when most people are convinced that the vaccines are safe, effective, and easy to use. But there is an irony here. When most people are convinced that a vaccine is safe and effective, they are likely to voluntarily seek the vaccine. For example, there is no mandate for adults to receive a Covid vaccine, but more than 80% of adults in the United States have had at least one dose of vaccine. Fewer than 40% of children have.

When the public is skeptical about vaccines, mandates may actually hinder efforts to achieve high immunization rates by exacerbating distrust and angering vaccine-hesitant parents and those who support parental choice.  To counter such a backlash, our mandates have always been soft and porous. Most states allow religious exemptions. Many others allow exemptions based on personal beliefs. Such policies say, in essence, that you only need to be immunized if you are not willing to fight against it. Even in the landmark Supreme Court case in which the Justices upheld the rights of states to mandate immunization, the penalty for refusing smallpox vaccine was a $5 fine. Our vaccine policies have always been more like a strong suggestion than a true mandate. That is where California ended up on Covid vaccine for kids. For now,  that is the right place to be. 

California’s U-turn is politically wise and ethically appropriate. Existing Covid vaccines can give some protection to children. But 50% protection is not good enough to justify a mandate. Mandated childhood vaccines generally have efficacy rates above 90%.   Furthermore, for children, we don’t yet know the best dose or schedule for optimum protection from Covid, lowest levels of risk, and most cost-effectiveness. We do now know that studies in adults cannot simply be extrapolated to children. We need to do the studies in kids. Even then, uncertainty will remain. Given the uncertainty, a voluntary program is preferable to a mandate. As parents evaluate the evidence and make decisions, more data will accumulate. 

(Last week, a prospective randomized trial of the Moderna vaccine published in the New England Journal of Medicine reported that, for 6-to-11-year-olds, two doses led to high levels of antibodies that persisted for two months. The study was too small to draw meaningful conclusions about actual infection rates but the authors speculated that, with those antibody levels, it would be 88% effective at preventing disease.)

The skeptical public is right on this one. Until there is stronger evidence that Covid vaccines are highly effective in children, the decision about whether to immunize children should remain with parents.

John D. Lantos, MD, is President of JDLConsulting, LLC and a Hastings Center fellow.; @johnlantos

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