The Children’s COVID-19 Vaccine Rollout Requires a Different Playbook

Now that the FDA approved emergency-use authorization of the Pfizer-BioNTech COVID-19 vaccine for children 5 to 11 years old, it’s essential for as many as possible to get vaccinated. But successfully rolling out the vaccine to young children will require a different approach than for adults.

The FDA approval represents a watershed moment in the fight against COVID-19, yet many parents, even those who are vaccinated themselves, are hesitant to vaccinate their children. The FDA granted an emergency authorization for the Pfizer vaccine for those 16 and older on December 11, 2020, and expanded it to 12-15 year-olds on May 10, 2021, yet just 32 percent of 12-17-year-olds are fully vaccinated. Worryingly, 3 in 10 parents say they will “definitely not” get their 5- to 11-year-olds vaccinated.

In a CDC-funded simulation released in August of this year, researchers reported that the predicted share of infection among unvaccinated and not previously infected elementary students within the first three months of the fall 2021 school semester would be more than 75 percent. In addition to protecting children’s health, boosting vaccinations can help avoid severe school disruptions.

Successfully rolling out the vaccine to young children will require a different approach than for adults.

Full FDA approval of COVID-19 vaccines for children under 12 may help address some parental concerns—there were moderate rate increases associated with full approval of the adult vaccine—but this may not come until later this winter at the earliest.

Why are so many parents skeptical about the pediatric COVID-19 vaccines and hesitant to get their child vaccinated?

For one, parents often make different decisions for their children than they would make for themselves. Among vaccinated parents, less than half say they will vaccinate their child as soon as they’re eligible. A recent study found that when it comes to decisions around vaccinating their children, parents are commonly influenced by omission bias—the natural tendency to weigh any harm resulting from our actions (such as a child experiencing side effects) more heavily than harm resulting from something we didn’t do (a child getting sick from COVID-19 because they weren’t vaccinated). While omission bias is also a factor in parental decision-making for their own vaccines, it’s likely exacerbated in decision-making for their children due to two key features of childhood COVID-19 vaccines: first, there’s a greater perception of potential harm from action for kids compared to adults, given the salience of extremely rare but severe side effects among young people. And second, there’s a lessened perception of potential harm from inaction, given CDC findings that children and adolescents have fewer severe COVID-19 outcomes compared to adults.

These differences illustrate that those looking to boost vaccine uptake can’t just use the same messaging and tactics used to get parents to vaccinate themselves—the approach needs to be adjusted to address the particular barriers that arise for parents deciding to vaccinate their children. However, that doesn’t mean starting entirely from scratch.

We can help parents overcome many of these barriers by drawing from tried-and-true strategies that increased use of other childhood vaccines. Vaccination is a key role for pediatricians, so it’s important to leverage pediatricians as trusted messengers and normalize receiving the COVID-19 vaccine and information at pediatric visits. Childhood vaccines are a routine part of care, and parents usually don’t have to proactively seek vaccines for their children. Instead, their doctor prompts them when their child is due for a specific shot—removing the burden of remembering to ask. For children without access to pediatric care, alternative channels for vaccine outreach such as schools, day cares, and community centers are possible options.

Should (and will) schools mandate the COVID vaccine? An early White House estimate that about 900,000 U.S. children ages 5 to 11 received their first COVID-19 shot within the first week of eligibility is encouraging but only represents 3 percent of the nearly 28 million eligible children in that age range. School mandates already play a large role in boosting childhood vaccination rates for many vaccine-preventable diseases, like measles, tetanus, and whooping cough. Mandates have helped reduce the rates of these diseases. Yet mandating COVID-19 vaccines for children, like many things associated with the pandemic, will likely be highly politicized.  While some states like California have already announced plans to require student COVID vaccinations, others will likely move to implement legislation to prevent this from happening. 

Vaccination is a key role for pediatricians, so it’s important to leverage pediatricians as trusted messengers and normalize receiving the COVID-19 vaccine and information at pediatric visits.

Even masking, which has been recommended by the CDC for unvaccinated people for over a year now, faces pushback in many states and school districts. While widespread COVID vaccine mandates for younger children likely won’t come for many months (for most, at least not until the vaccine has been fully approved by the FDA for that age group), potential mandates are already being debated. Mandates are supported by a majority in many places like New York City and Washington state, though there have also been many high-profile media stories about parent protests and lawsuits challenging potential mandates, as well as some pushback from health officials voicing equity concerns related to COVID-19 vaccine mandates.

Even if schools don’t mandate the COVID-19 vaccine, they can serve as a site for vaccine drives and a channel for delivering vaccine recommendations—especially as many pediatrician offices may be overwhelmed by the sudden influx of vaccinations.

Learning from the challenges during the early days of vaccine availability, the decision-making (and follow-through) processes for vaccinating children needs to be as easy as possible. Federal, state, and local officials should use consistent categorical eligibility to make it clear that every child 5 and older (with only very narrow exceptions) should get the vaccine, instead of grouping people into a patchwork of inconsistent, complex tiers varying by state. Then, communications or vaccine search portals must clearly state when and where kids can get the vaccine—creating a credible, seamless experience accessible to everyone, especially those without tech savvy or without reliable internet access.

Also, there should be less attention paid to any minor differences that may exist between individual vaccine manufacturers like Pfizer and Moderna (when it becomes available for children) and more focus on the urgent call to action for parents to get their children vaccinated as soon as possible. Most people aren’t making these kinds of brand decisions when considering other types of pediatric vaccines.

And specific efforts should be made to counteract the psychological mechanisms germane to parents. To counter omission bias, messaging should frame nonvaccination as an active, deliberate decision: parents can either choose to protect their child or choose to leave their child unprotected from harm. We at ideas42 have learned from conducting surveys that parents tend to overestimate the level of vaccine hesitancy among other parents, so we should highlight those who are early adopters of the recently authorized Pfizer-BioNTech vaccine instead of giving the relatively few anti-vax communities outsized media attention that promotes the false perception of a social norm. 

To successfully vaccinate our children against COVID-19, we must learn from and go beyond the initial approach used for adults. Schools, governments, and health care providers should tailor efforts to the specific barriers and channels children and parents encounter. If coordinated, purposeful steps are taken now, applying insights from behavioral science to vaccine uptake can support ongoing efforts to keep our children safe and prevent further disruptions to their education.

Disclosure: Ricardo LaGrange and Lee-Sien Kao are employees of ideas42, which provides financial support to Behavioral Scientist as a Founding Partner. Founding Partners do not play a role in the editorial decisions of the magazine.