Borrowing Proven Policy Strategies to Vaccinate Kids Against Seas

COVID-19: Lessons from Past Successes can Provide a et

(selidimea Cll Across States

Roadmap for Ensuring Equity in Immunization Efforts Seacl ss

Prepared by the State Health Access Data Assistance Center, University of Minnesota Wr COalaeccealcceM niconzelaesion

November 2021

 

Introduction

With the authorization of COVID-19 vaccines for children ages five and older, focus is shifting to how the United States
can deploy those shots widely and equitably. The country has yet to hone its approach to immunizing adults, as shown
by low vaccination rates and persistent disparities in COVID-19 and other vaccines, such as flu shots."

For vaccinating children against COVID-19, however, there is reason for optimism if policymakers and healthcare
providers apply lessons from prior vaccination challenges and successes. The United States generally performs
admirably in most children's immunizations, reaching more than 90 percent of kids for some vaccines, such as polio and
chickenpox, and greatly reducing vaccination disparities in the past few decades.°

However, there also is cause for concern. For instance, disinformation and concerns about safety have made COVID-19
vaccines contentious for some people, and the United States has underperformed in the delivery of other similarly
controversial vaccines. Rates of vaccination against human papillomavirus (HPV) -an infection that can cause cancer-
remain well below other vaccines more than a decade after it was first approved and recommended, with controversy
around the immunization relating to HPV being a sexually transmitted infection.* Those low vaccination rates also come
with disparities in which lower-income and Black and Hispanic children experience lower HPV vaccination rates.>®

Additionally, even though one COVID-19 vaccine has been authorized for children ages 12-17 for months, vaccination
rates for those children fall behind even the lackluster rates for adults." Recent survey data also indicate that many
parents remain hesitant to vaccinate younger children against COVID-19, as well.®

This does not necessarily mean that COVID-19 vaccination campaigns for U.S. children cannot be successful. By
borrowing from strategies that have worked historically, states can develop strong playbooks for protecting children from
COVID-19, turning another page in the fight against the pandemic.

Leveraging Health Insurance Coverage to Improve Healthcare Access

One indispensable asset in the effort to vaccinate kids against COVID-19 is the high health insurance rate for children

as compared to adults, which came as a result of decades of health policy innovations (e.g., the Children's Health
Insurance Program [CHIP]) and hard work to enroll kids in coverage. This is key because uninsurance is a notable barrier
to healthcare- including vaccinations-as data show that people without insurance are less likely to get immunizations.°

Similarly, studies demonstrate that people with health insurance are more likely to have a regular source of healthcare,
where physicians and other healthcare professionals can recommend and administer vaccinations.'° That opportunity
is important because research also shows that when providers recommend certain, sometimes controversial vaccines
(e.g., the HPV vaccine) and administer them on-site, rather than referring the patient elsewhere, kids are more likely to
get the immunization."

Borrowing the Vaccines for Children Program Infrastructure

Even with their lower rates of uninsurance compared to adults, millions of kids in this country remain without health
insurance. Additionally, despite efforts in recent years to expand coverage of routine vaccinations and other preventive
healthcare, some children remain "under-insured" - enrolled in health coverage that poses cost barriers to needed care.
Historically, uninsured and under-insured children have had lower vaccination rates. And because children of color-
such as American Indian and Alaska Native (AI/AN), Black, and Hispanic or Latino kids-disproportionately experience
uninsurance and under-insurance, they also experience stark vaccination disparities. °
However, the federal Vaccines for Children (VFC) program is credited with a major role in boosting vaccination rates
and narrowing childhood vaccination inequities since its inception in 1994."45'6 The program offers free vaccinations
to uninsured and under-insured children through healthcare providers enrolled in the VFC program, such as Federally
Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and public health clinics. The federal government has
already taken steps in that direction by pre-purchasing COVID-19 vaccinations for the entire U.S. population and
requiring they be administered at no cost to individuals. To further build on that strength, states could leverage VFC-
enrolled providers as key hubs for outreach and provision of COVID-19 vaccines to children, especially since many
families already know them as trusted places where their kids have received free vaccines in the past.

Employing COVID-19 Vaccination Quality Measures in Medicaid

Nationally, one-third of children receive health insurance through Medicaid, and that rate ranges up to about one-
half of kids in states such as New Mexico, Mississippi, Louisiana, and Arkansas.'" Because lower-income children
such as those enrolled in Medicaid also tend to have lower vaccination rates, states should consider how to use their
Medicaid programs to reach more kids with COVID-19 vaccines.

For instance, states that use managed care organizations (MCOs) to administer their Medicaid programs could require
those MCOs to meet vaccination rate benchmarks for ensuring the children enrolled in their plans have sufficient
access to COVID-19 immunizations. And states with payment and delivery system reforms such as patient-centered
medical home (PCMH) programs that reward healthcare providers that meet quality measures could implement similar
requirements in those programs.

Such steps would be a logical extension of existing initiatives that require MCOs and PCMHs to meet vaccination
benchmarks for other vaccinations, as in the Childhood Immunization Status (NQF 38) already included in the 2021
Core Set of Children's Health Care Quality Measures for Medicaid and CHIP. Furthermore, states with multipayer
quality measure alignment efforts could include COVID-19 vaccination measures in those measure sets, as well, to
encourage private insurers to follow suit.

Encouraging Best Practices Among Providers

States can encourage healthcare providers to adopt immunization best practices. For instance, the "4 Pillars
Immunization Toolkit" is a strategic framework designed for healthcare providers, and research has shown it can
increase vaccination rates and reduce racial and ethnic disparities.'*'° Though initially designed to improve flu
vaccination rates, the same approaches- making vaccination services convenient, education of parents and patients
about vaccines, and improved clinic systems, for example-could be adopted for COVID-19 vaccinations.

 

4 Pillars Immunization Toolkit

Originally developed to improve children's flu vaccination rates and decrease disparities, the immunization toolkit strategies
could be applied to COVID-19 vaccinations, as well.

Pillar 1: Make vaccination services convenient for families
e eg., offer walk-in vaccinations without appointments

 

Pillar 2: Educate parents and patients about vaccine
e e.g., conduct outreach via mail, email, phone, text messaging

Pillar 3: Improve clinic systems to simplify vaccination
e e.g., determine vaccination eligibility for each scheduled patient at start of day

Pillar 4: Motivate staff to meet immunization goals
e e.g., chart progress toward vaccination goals and provide regular feedback to staff

Source: Lin, C.J., Nowalk, M.P., Zimmerman R.K., Moehling, K.K., Conti, T., Allred, N.J., & Reis, E.C. (May/June 2016). Reducing Racial
Disparities in Influenza Vaccination among Children With Asthma. J Pediatric Health Care, 30 (8), 208-215. doi: 10.1016/j.pedhc.2015.06.006

 

 

 

BORROWING PROVEN POLICY STRATEGIES TO VACCINATE KIDS AGAINST COVID-19: 2
LESSONS FROM PAST SUCCESSES CAN PROVIDE A ROADMAP FOR ENSURING EQUITY IN IMMUNIZATION EFFORTS
Requiring Immunization for Daycare and School Enrollment

Although the details vary, all 50 states require children to receive certain vaccinations to attend public schools, and
some even require vaccination for kids to attend private schools or other childcare settings.2° Research has identified
those strategies as an important component of multilayered approaches that have increased vaccination rates and
reduced disparities.2' States could lean on those existing policies and infrastructure to achieve COVID-19 vaccination
goals by adding the immunization to existing lists of other required vaccines. And they could further simplify the process
for children to get vaccinated with school-located vaccination clinics. Research from other vaccine-preventable
contagious diseases, such as measles and pertussis, suggests that communities that decline to require COVID-19
immunizations or that offer broad exemption policies are likely to experience continued outbreaks well into the

future 2324.25.26

Conclusion

In contrast with the challenge of vaccinating adults against COVID-19-for which the United States does not have

a recent example of widespread success-states have proven strategies and policies that work for improving
immunization rates among children. Rates of childhood vaccination against diseases such as chickenpox, measles

and others have increased in recent decades, and racial and ethnic inequities have narrowed dramatically, with the
implementation of those strategies. To protect children against COVID-19 and to protect their larger communities, states
should borrow those evidence-based strategies. If not, they risk seeing child COVID-19 vaccination rates languish at
disappointingly low levels and with notable disparities, as the United States has seen for HPV vaccines in recent years -
and seeing the largely preventable consequences of the pandemic persist within under-vaccinated communities.

BORROWING PROVEN POLICY STRATEGIES TO VACCINATE KIDS AGAINST COVID-19: 3
LESSONS FROM PAST SUCCESSES CAN PROVIDE A ROADMAP FOR ENSURING EQUITY IN IMMUNIZATION EFFORTS
 

BORROWING PROVEN POLICY STRATEGIES TO VACCINATE KIDS AGAINST COVID-19: 4
LESSONS FROM PAST SUCCESSES CAN PROVIDE A ROADMAP FOR ENSURING EQUITY IN IMMUNIZATION EFFORTS
 

 

 

ENDNOTES

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Ngep, J. (2021, July 19). COVID-19 Vaccination Rates: State-level and Subpopulation Evidence from the Household Pulse Survey. SHADAC Blog.
httos:/Awww.shadac.org/news/HPSVax-06.21

Planalp, C. & Hest, R. anuary 2021). Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns. State Health Access Data Assistance
Center (SHADAC). https://www.shadac.org/sites/default/files/Flu%20Vaccination%20Patterns%20Brief_ CHCF_Jan2021 .pdf

National Center for Health Statistics. (2021, August 3). /mmunization. Centers for Disease Control and Prevention (CDC).
https://www.cdc.gov/nchs/fastats/immunize.htm

Boersma, P. & Black, L.I. (January 2020). Human Papillomavirus Vaccination Among Adults Aged 18-26, 2013-2018 [NCHS Brief No. 354].
https://www.cdc.gov/nchs/data/databriefs/db354-h.pdf

Vadaparampil, S.T., Staras, S.A.S., Malo, T.L., Eddleton, K.Z., Christie, J., Rodriguez, M., Giuliano, A.R., & Shenkman, E.A. (2013, February 1). Provider Factors
Associated With Disparities in Human Papillomavirus Vaccination Among Low-Income 9- to 17-Year-Old Girls. Cancer, 179(3), 621-628. doi: 10.1002/cner.27735

Burdette, A.M., Webb, N.S., Hill, T.D., & Jokinen-Gordon, H. (January 2017). Race-specific trends in HPV vaccinations and provider recommendations: persistent
disparities or social progress? Public Health, 142, 167-176. doi: 10.1016/).9uhe.2016.07.009

Murthy, B.P,, Zell, E., Saelee, R., Murthy, N., Meng, L., Meador, S., Reed, K., Shaw, L., Gibbs-Scharf, L., McNaghten, A.D., Patel, A., Stokley, S., Flores, S., Yoder,
J.S., Black, C.L., & Harris, L.Q. (2021, September 3). COVID-19 Vaccination Coverage Among Adolescents Aged 12-17 Years - United States, December 14,
2020-July 31, 2021. MMWR, 70(35), 1206-1213. https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e1 .Atm

Brenan, M. (2021, September 28). In U.S., 55% Would Get COVID-19 Vaccine for Young Child. Gallup.
https://news.gallup.com/poll/354998/covid-vaccine-young-child.aspx

Planalp, C. & Hest, R. anuary 2021). Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns. State Health Access Data Assistance
Center (SHADAC). https://www.shadac.org/sites/default/files/Flu%20Vaccination%20Patterns%20Brief_CHCF_Jan2021 .pdf

State Health Compare. Had Usual Source of Medical Care; All Coverage Types; 2011-20177 [Data set]. State Health Access Data Assistance Center (SHADAC).
http://statehealthcompare.shadac.org/

Burdette, A.M., Webb, N.S., Hill, T.D., & Jokinen-Gordon, H. (January 2017). Race-specific trends in HPV vaccinations and provider recommendations: persistent
disparities or social progress? Public Health, 142, 167-176. doi: 10.1016/).9uhe.2016.07.009

Vadaparampil, S.T., Staras, S.A.S., Malo, T.L., Eddleton, K.Z., Christie, J., Rodriguez, M., Giuliano, A.R., & Shenkman, E.A. (2013, February 1). Provider Factors
Associated With Disparities in Human Papillomavirus Vaccination Among Low-Income 9- to 17-Year-Old Girls. Cancer, 179(3), 621-628. doi: 10.1002/cncer.27735

State Health Access Data Assistance Center (SHADAC). (May 2019). Children's Health Insurance Coverage Nationwide and in the States, 2016 to 2017.
https:/Awww.shadac.org/sites/default/files/publications/KidsCoverage_2016_2017_Chartbook_0.pdf

Walsh, B., Doherty, E., & O'Neill, C. (February 2016). Since The Start Of The Vaccines For Children Program, Uptake Has Increased, And Most Disparities Have
Decreased. Health Aff (Millwood), 35(2):356-364. doi: 10.1377/hithaff.2015.1019

Zhao, Z., & Smith, PJ. (2013, May 1). Trends in vaccination coverage disparities among children, United States, 2001-2010. Vaccine, 31(19), 2324-2327. doi:
10.1016/.vaccine.2013.03.018

Luman, E.T., Ching, P.L.Y.H., Jumaan, A.O., & Seward, J.F. (April 2006). Uptake of Varicella Vaccination Among Young Children in the United States: A Success
Story in Eliminating Racial and Ethnic Disparities. Pediatrics, 117(4), 999-1008. doi: 10.1542/peds.2005-1201

State Health Access Data Assistance Center (SHADAC). Health Insurance Coverage Type; Age 0-18; Medicaid/CHIP; 2019 [Data set]. State Health Compare.
http://statehealthcompare.shadac.org/

Lin, C.J., Nowalk, M.P., Zimmerman R.K., Moehling, K.K., Conti, T., Allred, N.J., & Reis, E.C. (May/June 2016). Reducing Racial Disparities in Influenza Vaccination
among Children with Asthma. J Pediatric Health Care, 30(8), 208-215. doi: 10.1016/j.0edhc.2015.06.006

Lin, C.J., Nowalk, M.P., Zimmerman R.K., Moehling, K.K., Conti, T., Allred, N.J., & Reis, E.C. (May/June 2016). Reducing Racial Disparities in Influenza Vaccination
among Children with Asthma. J Pediatric Health Care, 30(3), 208-215. doi: 10.1016/).0edhc.2015.06.006

Centers for Disease Control and Prevention (CDC). (2016, November 15). State Vaccination Requirements.
https://www.cde.gov/vaccines/imz-managers/laws/state-reqs.html

 

BORROWING PROVEN POLICY STRATEGIES TO VACCINATE KIDS AGAINST COVID-19:
LESSONS FROM PAST SUCCESSES CAN PROVIDE A ROADMAP FOR ENSURING EQUITY IN IMMUNIZATION EFFORTS

 
 

 

 

ENDNOTES

21.

22.

23.

24.

25.

26.

Hutchins, S.S., Jiles, R., & Bernier, R. (2004, May 1). Elimination of Measles and of Disparities in Measles Childhood Vaccine Coverage among Racial and Ethnic
Minority Populations in the United States. J Infect Dis, 789(Suppl 1), S146-152. doi: 10.1086/379651

Centers for Disease Control and Prevention (CDC). (2021, August 23). Considerations for Planning School-Located Vaccination Clinics.
https:/Awww.cdc.gov/vaccines/covid-19/planning/school-located-clinics.html

Omer, S.B., Enger, K.S., Moulton, L.H., Halsey, N.A., Stokley, S., & Salmon, D.A. (2008, December 15). Geographic clustering of nonmedical exemptions to
school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol, 168(12), 1389-1396. doi: 10.1093/aje/Kwn263

May, T &, Silverman. R.D. (2008, March 7). 'Clustering of exemptions' as a collective action threat to herd immunity. Vaccine, 21(11-12), 1048-1051. doi:
10.1016/s0264-410x(02)00627-8

Omer, S.B., Pan, W.K.Y., K.S., Halsey, N.A., Stokley, S., Moulton, L.H., Navar, A.M., Pierce, M., & Salmon, D.A. (2006, October 11). Nonmedical Exemptions to
School Immunization Requirements: Secular Trends and Association of State Policies with Pertussis. JAMA, 296(14), 1757-1763. doi:
10.1001/jama.296.14.1757

Feikin, D.R., Lezotte, D.C., Hamman, R.F., Salmon, D.A., Chen, R.T., & Hoffman, R.E. (2000, December 27). Individual and Community Risks of Measles and
Pertussis Associated With Personal Exemptions to Immunization. JAMA, 284(24), 3145-3150. doi: 10.1001/jama.284.24.3145

 

BORROWING PROVEN POLICY STRATEGIES TO VACCINATE KIDS AGAINST COVID-19:
LESSONS FROM PAST SUCCESSES CAN PROVIDE A ROADMAP FOR ENSURING EQUITY IN IMMUNIZATION EFFORTS