Differences in State COVID-19 Vaccine Mandates for Schoolteachers and Childcare Professionals

Abstract

This case series examines the differences in COVID-19 vaccine mandates for schoolteachers vs childcare professionals from US states that have implemented them.

On August 11, 2021, California became the first state to require COVID-19 vaccination of schoolteachers. Childcare professionals, despite comparable occupational risk of contracting COVID-19, were excluded. To better understand this emerging disparity, we characterize state vaccine mandates for childcare professionals vs schoolteachers.

Methods

To determine which states had issued legislative or regulatory directives or both requiring vaccination of childcare or school personnel (as of November 1, 2021), we reviewed official archives of executive orders for all 50 states and DC and COVID-19 state databases maintained by the National Conference of State Legislatures¹ and the National Academy for State Health Policy.² For each identified state, we collected issue date, compliance deadline, type (eg, executive order, public health order), issuer (eg, governor, public health officer), availability of vaccine exemptions and testing alternatives, and acceptable proofs of vaccination. The current study is not research involving human subjects and is therefore not subject to institutional review board approval, per US Department of Health and Human Services regulation 45 CFR 46.101.

Results

Eleven states (including DC) had issued executive-branch directives requiring either COVID-19 vaccination or routine testing for schoolteachers, of which only 5 included childcare professionals (Table). No states had issued directives for childcare professionals alone. No states had passed legislation requiring COVID-19 vaccination. Three states required COVID-19 vaccination without a routine testing alternative, 7 allowed either vaccination or routine testing, and 1 (New York) required routine testing with opt-out vaccination for those unwilling to undergo weekly screening. Six of 11 states did not specify any vaccination exemptions, with the rest allowing medical or religious belief exemptions or both and none allowing personal belief exemptions. All states required formal proof of vaccination either in the form of health care professional attestation, signed Centers for Disease Control and Prevention (CDC) vaccination card, or entry in a state immunization registry; no states allowed for personal attestation to support receipt of vaccination.

Table. States Mandating COVID-19 Vaccination, Testing, or Both for Childcare and School Settings.

State	Type of congregate setting		Directive				Provision of exemptions and/or alternatives to vaccination				Acceptable proof of vaccination
	Childcare	K-12 school	Issuer	Type	Date issued	Deadline to comply	Medical exemption	Religious belief exemption	Personal belief exemption	Routine testing alternative	Personal attestation	Attestation from health care professional	Signed CDC vaccination card	Record from state’s vaccination registry
California	No	Yes	State health agency	Public health order	8/11/21	10/15/21	Not specifieda	Not specifieda	Not specifieda	Yes	No	Yes	Yes	No
Connecticut	Yes	Yes	Governor	Executive order	8/19/21	9/27/21	Yes	Yes	No	Yes	No	Yes	Yes	Yes
DC	Yes	Yes	Mayor	Executive order	9/20/21	11/1/21	Yes	Yes	No	No	No	No	Yes	Yes
Delaware	No	Yes	State health agency	Emergency secretary’s order	10/15/21	11/1/21	Not specifieda	Not specifieda	Not specifieda	Yes	Nob	Nob	Yesb	Yesb
Hawaiic	No	Yes	Governor	Proclamation	8/5/21	8/16/21	Not specifieda	Not specifieda	Not specifieda	Yes	Not specifiedd	Not specifiedd	Not specifiedd	Not specifiedd
Illinoise	Yes	Yes	Governor	Executive order	Schools: 9/3/21; childcare: 10/22/21e	Schools: 9/19/21; childcare: 12/3/21	Yes	Yes	No	Yes	No	Yes	Yes	Yes
New Jerseye	Yes	Yes	Governor	Executive order	Schools: 8/23/21; childcare: 9/20/21e	Schools: 10/18/21; childcare: 11/1/21	Not specifieda	Not specifieda	Not specifieda	Yes	No	Yes	Yes	Yes
New Mexico	No	Yes	State health agency	Public health order	9/5/21	Not specifiedf	Not specifieda	Not specifieda	Not specifieda	Yes	Not specifiedd	Not specifiedd	Not specifiedd	Not specifiedd
New York Stateg	No	Yes	State health agency	Determination	9/2/21	9/2/21	Not specifieda	Not specifieda	Not specifieda	Yesd	No	Yes	Yes	Yes
Oregon	No	Yes	State health agency	Temporary administrative order	8/19/21	10/18/21	Yes	Yes	No	No	No	Yes	Yes	Yes
Washington State	Yes	Yes	Governor	Proclamation	8/18/21	10/18/21	Yes	Yes	No	No	No	Yes	Yes	Yes

Abbreviations: CDC, Centers for Disease Control and Prevention; K-12, kindergarten through 12th grade.

^a Many state directives did not list whether they allowed for medical, personal belief, or religious belief exemptions to vaccination; given that all these states allowed for a routine testing alternative to vaccination, this is likely because the expectation was for unvaccinated individuals to simply undergo routine testing (in place of pursuing an exemption to vaccination).

^b Delaware does not explicitly state acceptable proof of vaccination; however, it does specify that vaccinated staff must “show proof of vaccination in a manner consistent with Division of Public Health Guidance.” The Division of Public Health website mentions the acceptability of the CDC vaccination cards and state immunization registry to verify vaccination status.

^c Hawaii requires public employees to vaccinate or undergo routine testing, which would include only public-school teachers (private-school teachers would presumably be excluded).

^d Hawaii and New Mexico require “proof of vaccination” but do not specify acceptable proof.

^e Illinois and New Jersey initially issued directives covering only schoolteachers but later issued additional directives that included childcare professionals.

^f New Mexico does not specify a compliance deadline, perhaps because the unvaccinated would simply undergo routine testing until they are vaccinated.

^g New York is unique and mandates weekly testing with opt-out vaccination, unlike the rest, which mandate vaccination either with or without a routine testing alternative.

Discussion

Less than about half of states requiring COVID-19 vaccination or routine testing of schoolteachers included childcare professionals, suggesting an unwarranted disparity between childcare and school settings in states’ efforts to promote vaccination. Several arguments favor vaccinating childcare professionals. First, both staff and children in childcare programs may be at higher risk for contracting COVID-19 than those in schools, because very young children are currently ineligible for vaccination and possibly less adherent to nonpharmaceutical interventions (eg, masking, social distancing). Second, childcare professionals have lower COVID-19 vaccine uptake compared with schoolteachers (78% vs 90% as of late spring 2021³). Third, childcare professionals are disproportionately more racial and ethnic minority individuals, and therefore may be at greater risk for COVID-19–related morbidity and mortality (17.3% and 19.3% are Black and Hispanic individuals vs 12.1% and 13.0% of school personnel, respectively⁴).

The most obvious study limitation is that there was no way to determine why some regulatory directives included childcare professionals and others did not. One possibility is that state policy makers were under greater political pressure to get schoolteachers vaccinated, given significant national attention devoted to safely reopening schools and resuming in-person learning. Another possibility is the ease of implementing and enforcing mandates among schoolteachers relative to childcare professionals: Most schools are publicly funded and required to adhere to state requirements or risk losing funding.⁵ Conversely, most childcare programs are privately owned and operated and may not be subject to the same risks for noncompliance (1 exception is the federally funded Head Start, for which a federal vaccine mandate exists⁶). Regardless, 5 states were able to mandate childcare professional vaccination, testing, or both, supporting the feasibility of this approach. To ensure equitable consideration for the health and safety of childcare professionals and the children and families in their care, states should consider expanding directives to include childcare professionals to bridge the COVID-19 vaccination gap between childcare professionals and schoolteachers.