Bioethics Forum Essay
Vaccine Mandates for Kids: It’s Not Whether, But When
States and school boards around the country are engaged in a debate about whether to require middle and high school students to be fully vaccinated against Covid-19. California has declared its intent to require students in kindergarten through 12th grade be vaccinated once a vaccine has received full approval for this age group by the Food and Drug Administration. Mandates from other states and school districts are likely now that the Pfizer-BioNTech vaccine is authorized for 5-to-11-year-olds.
In many ways, this is a one-sided debate. School vaccine mandates have long been part of our nation’s public health fabric. There is experience implementing and enforcing them for other vaccine-preventable diseases. School vaccine mandates have been effective in reducing the spread of diseases, as well as increasing vaccine coverage for diseases like polio, measles, and whooping cough. In addition, the health, economic, and educational impact of the current pandemic on kids all seem to converge in support of vaccine mandates for Covid.
So, what is there to debate? It is not so much about whether to mandate. It’s when to do so.
Two reasons justify restraint at this time. The first relates to our level of certainty around Covid vaccine safety. Given the lower risk of Covid-19 disease in children compared to adults, a vaccine mandate for schoolchildren will be most effective when there is a high level of certainty that the vaccine is very safe. Data collected through active surveillance (proactively obtaining health care data from individuals to identify adverse events) can help achieve this high level of certainty more reliably than can data from passive surveillance systems, like Vaccine Adverse Event Reporting Surveillance (VAERS), which rely on people reporting an event and are subject to under-reporting and reporting bias.
We might reach this level of certainty when the vaccine receives full FDA approval for a particular pediatric age group. But it can take several years from when an approved vaccine is recommended for disease prevention in children to when U.S. schools mandate the vaccine—the median time was four-to-six years, one study found. We can’t wait that long now, but we also cannot afford to be too hasty.
The collection of adverse event data after Covid vaccination through active surveillance has long been under way. The results, however, are just arriving. More analyses are needed. In stating in September that universal Covid vaccination of otherwise healthy 12-to-15-year-olds was premature, the United Kingdom’s Joint Committee on Vaccination and Immunization cited “uncertainty regarding the magnitude of the potential harms.”
The second reason is a lack of clarity surrounding the risk of school-based transmission. The rationale originally used for requiring vaccines for school attendance was the ability of this strategy to disrupt the transmission of highly infectious diseases, such as measles, between children in a setting that creates the type of close contact that can facilitate spread. School vaccine mandates remain most justifiable for vaccines that reduce school-based transmission of disease.
Before the Delta variant, school-based transmission of Covid-19 was low, particularly in states that required masks and other mitigation strategies in schools. This information was the basis for reopening schools. We need to reassess school-based transmission in the presence of the Delta variant and other variants that emerge. We also need to be prepared for the possibility that the incremental benefit of mandatory vaccination in reducing school-based transmission over and above what is being achieved by existing strategies–like vaccine mandates for school personnel, voluntary vaccination among schoolchildren, and other mitigation measures (like masks, physical distancing, and improved ventilation)–may not currently justify mandates for children. It is also not the time to relax use of these other mitigation measures in our schools given what we know about the risk of being infected with the Delta variant or transmitting it to others, even among those who are vaccinated. When that time arrives, the call for vaccine mandates for schoolchildren will be stronger.
School vaccine mandates have been a critical component of our nation’s vaccination policy for decades. It’s not a question of whether a Covid-19 vaccine should be added to the list of required vaccines for school attendance, but when to enact those mandates. That time has not yet arrived.
Douglas J. Opel MD, MPH, is an associate professor of pediatrics at the University of Washington School of Medicine and the interim director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute. Doug Diekema (@ddiekema1) is professor of pediatrics at the University of Washington School of Medicine and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute, and a Hastings Center fellow. Lainie Ross (@LainieRoss) is the Carolyn and Matthew Bucksbaum Professor of Clinical Ethics and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, and a Hastings Center fellow.