Priorities And Policy Levers To Support School-Located Vaccination

As political leaders and pundits alike debate mask mandates and what a post-Omicron “new normal” might look like, school officials across the country continue to confront the daily practical challenges of keeping their doors open and their students safe. Vaccination remains our first line of defense to reduce transmission in schools. However, we are far from reaching our goals nationally, with only 31.8 percent of 5- to 11-year-olds receiving at least one dose of a COVID-19 vaccine as of early February. Although this work is far from over, one key lesson learned so far from the COVID-19 vaccination effort is the importance of ensuring that vaccines are available in places that are accessible, convenient, and safe. Throughout the pandemic, school-located vaccination (SLV) has played a critical role in expanding access to COVID-19 vaccines for students, their families, and school staff across the country. Continuing this momentum and reaching unvaccinated populations that may still face barriers to accessing the vaccine in traditional health care settings will require school, state, and federal leaders to both double down on successful strategies for engaging communities and increase investments in schools to optimize their potential as a vital part of public health infrastructure.   

Efforts to vaccinate adolescents and children against COVID-19 have catalyzed innovations and partnerships among public health departments, health care providers, schools, and communities that have increased the availability of, and access to, COVID-19 vaccines. These school-based public health efforts, along with other approaches such as community vaccination sites, can play an important role in increasing COVID-19 vaccination rates among children and adolescents and can also connect children to local health care providers for well-child visits and routine pediatric vaccinations that have lagged during the pandemic. Despite this progress, school leaders and their partners have faced a variety of challenges that have hindered their efforts to establish and sustain SLV efforts, including staffing shortages, limited reimbursement, logistical challenges, and pressures related to the politicization of science and public health.

Addressing these and other challenges to SLV will be essential to strengthening the role of schools in both improving vaccination rates and connecting students to other critical preventive services. Establishing, scaling, sustaining, and continuously improving these efforts beyond the current public health emergency, however, requires assessing and sharing which SLV approaches have been successful, addressing barriers that make vaccination in schools difficult, and building long-term vaccination infrastructure that can support vital partnerships between educators and public health. To this end, this article highlights priorities and strategies for enabling, strengthening, and sustaining SLV models during the COVID-19 pandemic and beyond, and the policy levers that can help increase equitable access to childhood vaccinations.

Schools As Critical Public Health Infrastructure

For decades, schools in the US have provided an important public health service by vaccinating children against both once-deadly childhood illnesses, such as smallpox and polio, as well as seasonal illnesses such as influenza. As vaccine misinformation continues to circulate, school administrators, teachers, and staff are important messengers who convey the importance of vaccination to parents and families. Recent polling shows that parents and guardians who report that their school has encouraged them to get their children vaccinated against COVID-19 are four times as likely to report that their child has been vaccinated as compared to parents and guardians whose child’s school did not encourage vaccination. As trusted sources of health information and services for many families, schools provide especially critical services to students from the most medically underserved and historically marginalized groups and geographies who often have limited access to a regular primary care provider or pharmacies. In particular, the health and vaccination services that schools provide can help address disparities in routine pediatric vaccination rates that have widened during the COVID-19 pandemic.

Priorities And Policy Levers To Enable, Strengthen, And Sustain SLV Models

In September 2021, the Duke-Margolis Center for Health Policy and the Association of Immunization Managers, with support from the Rockefeller Foundation, convened school leaders, state health officials, pediatric providers, and other immunization stakeholders for a symposium discussing promising practices to increase routine and COVID-19 vaccination rates in school settings. Participants described success in vaccinating students in school settings, but they also encountered challenges in maintaining SLV efforts, including a lack of staffing to support clinic logistics and operations, inadequate reimbursement for providers, misinformation and parental pushback. In response to these identified challenges, we propose numerous policy changes and investments at the state and federal levels to strengthen the role of schools as critical access points for childhood vaccinations. These policies include investing in the infrastructure, training, and resources that increase individual and organizational capacities to offer vaccinations to entire school communities.

Strengthen Collaborations Among Public Health, K-12 Education, And Health Care Systems

Stakeholders highlighted the important role of establishing and strengthening collaborations among state and local public health departments, school administrators and staff, health care and vaccine providers, and community leaders in standing up SLV efforts during the pandemic. With many schools already facing workforce shortages and other pandemic-related demands related to COVID-19 testing and contact tracing, these collaborations can potentially supplement a school’s workforce and provide expert guidance on logistical challenges such as mapping out workflows, staffing clinics, managing operations, procuring supplies, and continuously engaging with families. As clinical experts in educational settings, school nurses also play a unique and critical role in facilitating partnerships with public health departments, school administrators, and parents as well as communicating across the school community about how SLV can help keep everyone healthy and safe. Partnerships with trusted leaders and organizations embedded in the community can further assist schools with raising awareness about SLV clinics and conducting vital outreach to families and the community.

Participants also highlighted the importance of close collaboration with pediatric providers, noting that such partnerships can be critical for delivering trusted information about vaccines to parents and encouraging well-child visits. With many schools opting to combine SLV clinics with existing community events—such as  back-to-school events, summer meal programs, or the delivery of other social or health services—vaccination augments the many health and social supports that schools deliver to students and families. As we look to the future, state and federal leaders should sustain the funding and effort required to continue these collaborations and institutionalize SLV as part of schools’ broader efforts to promote students’ health and well-being.   

Strengthen Data Infrastructure To Support Information Exchange And Targeted Vaccination Efforts

Officials from many school districts described the challenges of accessing and reporting student immunization data, making it difficult for schools to understand vaccination coverage rates across student subpopulations, target resources toward communities with low vaccination rates, and conduct outreach to students and families. School access to state immunization information systems (IISs) can vary according to state law, and bidirectional information exchange between schools and IISs can be stymied by limited technological capacity that prevents school systems and IISs from “talking” to each other.

Data exchange is further hindered by variable interpretations of federal laws such as the Family Education Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) and concerns about data privacy. FERPA limits school districts’ ability to share student immunization data with IISs when these data are considered to be part of students’ educational records. Furthermore, pursuant to FERPA, parental consent must also be granted for school staff to access children’s IIS records outside of an emergency. Despite these challenges, state health and education leaders, immunization program staff, and legal experts can work together to facilitate bidirectional data exchange. For example, in Washington State and Tennessee, agreements between some school districts and state health departments enable state IISs and student electronic health records to exchange immunization data. Lastly, state officials can simplify these processes by increasing technical assistance and coordinated and sustained investment in technology solutions to manage common challenges to SLV, such as consent and data reporting.

Align Reimbursement Policies To Support Vaccine Access

Many state Medicaid programs have increased the reimbursement rate for COVID-19 vaccine administration, a move that has not only encouraged more providers to offer COVID-19 vaccines but also highlighted  the need to reexamine reimbursement rates for routine vaccinations. The Vaccines for Children (VFC) program enables enrolled providers to deliver recommended vaccines at no cost to children who qualify for Medicaid, are uninsured or underinsured, and/or are Native American or Alaskan Native. Reimbursement to VFC providers for administering vaccines, however, varies by state and facility type. In many states, the cost of administering vaccines has outpaced reimbursement amounts, posing a major disincentive for vaccine providers and creating significant barriers to access among medically underserved populations. The pandemic has further stretched financially strained provider practices, making cost-related barriers to vaccination even more important to address. In a recent national survey of providers, more than 80 percent of respondents reported that increased reimbursement for vaccine administration fees would help them overcome barriers to administering routine and seasonal immunizations.

Some school districts have made offering SLV more financially feasible by expanding school-based Medicaid billing. Through the reversal of the “free care” rule in 2014, the Centers for Medicare and Medicaid Services (CMS) allowed schools to bill Medicaid for school-based health services provided to all students enrolled in Medicaid. Prior to this reversal, schools could only bill medical services provided to students who were enrolled in Medicaid and had medical services included in an Individualized Education Plan or Individualized Family Service Plan. After this reversal, the state of Kentucky amended its state Medicaid plan to allow school districts to bill Medicaid for vaccines administered to all students enrolled in Medicaid. States can explore expanding school-based Medicaid billing to support SLV by amending their state Medicaid plans.

Additionally, some types of providers, such as pharmacists, are authorized to order and administer COVID-19 and childhood vaccines by the Public Readiness and Emergency Preparedness Act (PREP Act). Not all of these providers, however, are recognized by state Medicaid programs as providers whose services can be reimbursed through mechanisms such as “other licensed practitioners” (OLPs). In these cases, providers who administer vaccines in SLV clinics may be ineligible for reimbursement for the cost of vaccine administration. Some states, including Arkansas, Louisiana, and Maine, have received approval from CMS to amend their Medicaid plans to temporarily cover pharmacist-provided COVID-19 services during the public health emergency. State officials should consider amending their Medicaid plans to permanently establish pharmacists and other non-traditional vaccinators as OLPs to help address workforce shortages, financial barriers for providers, and barriers to vaccine access.

Build And Sustain School Infrastructure For Vaccination

While COVID-19 stimulus funding awarded to state and local education and public health agencies has helped jumpstart many SLV efforts for COVID-19, they need sustained funding beyond the pandemic to support broader vaccination efforts in schools. Although school nurses continue to play an integral role in establishing and organizing SLV efforts, their expanding responsibilities and a nationwide shortage of school nurses, both of which predated and were exacerbated by the COVID-19 pandemic, may impede the sustainability of SLV. To support short-term efforts to build SLV infrastructure in schools, some school districts have used funding from the Education Stabilization Fund to build capacity and workforce for vaccination and other student health needs. Schools should also leverage Elementary and Secondary School Emergency Relief (ESSER) funds and/or Governor’s Emergency Education Relief (GEER) Funds to provide COVID-19 vaccination to teachers, staff, and eligible students; facilitate clinics; conduct vaccination outreach efforts and activities to create awareness and build vaccine confidence; and provide incentives for vaccination. For example, Georgia and North Carolina used portions of ESSER and GEER funds to hire additional school nurses and other student health staff. Schools may also consider using current federal funding to make broad, longer-term investments in infrastructure that supports school-based vaccination and the broader provision of health services, such as school-based health centers or mobile health clinics, .

Expanding Equitable Access

COVID-19 has not only highlighted significant needs and gaps in the delivery of health and social services but also spurred creativity, innovation, and accelerated collaboration with the diverse stakeholders needed to systematically address these needs. These partnerships will remain especially important as public health leaders increasingly look toward addressing COVID-19 as an endemic and seasonal phenomenon. In such a scenario, vaccination will be an important strategy for mitigating the impact of seasonal influenza and other respiratory diseases. Lastly, building bridges among school officials, pediatric providers, parents and guardians, and the community will be increasingly important to push back against misinformation and combat the politicization of vaccination that threatens to slow progress toward reducing outbreaks of vaccine-preventable diseases. Schools, public health partners, state education and health leaders, and policy makers have important roles to play in expanding equitable access to vaccination. School, district, state, and federal policy changes are critical to improving health outcomes for students and their families now and in the future.

Authors’ Note

The Rockefeller Foundation provided funding to the Duke-Margolis Center for Health Policy for this work. When this article was drafted, Leah Perkinson was employed by the Rockefeller Foundation. All views expressed are solely those of the authors.