December 18, 2019
4 min read

Q&A: Few child care centers require flu vaccination in kids, caregivers

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Timothy R. Shope, MD, MPH
Timothy R. Shope

Despite a CDC recommendation that everyone aged 6 months or older receive a seasonal influenza vaccine, only 24.5% of child care centers reported having a child influenza vaccine requirement, and even fewer centers required caregivers to be vaccinated, according to a study published in the Journal of the Pediatric Infectious Diseases Society.

Timothy R. Shope, MD, MPH, professor of pediatrics at UPMC Children’s Hospital of Pittsburgh, and colleagues performed a telephone-based survey of 518 randomly selected U.S. child care center directors in 2016. They used four indexes — use of health consultants, childcare quality, general infection control and pandemic influenza preparedness — and other director and center characteristics to predict director-reported influenza vaccine requirements.

Of the directors surveyed, only 24.5% and 13.1% reported influenza vaccine requirements for children and adults, respectively. Neither center nor director characteristics or indexes were associated with director-reported vaccine requirements, and only state influenza vaccine laws for children and adult influenza vaccine requirements predicted having a child influenza vaccine requirement.

Research published earlier this year showed that reports about seasonal severity and vaccine effectiveness have no association with influenza vaccination rates overall.

“Director-reported influenza vaccine requirements for children and adult caregivers were influenced primarily by state influenza vaccine laws,” Shope and colleagues wrote. “Given the high risk of children in childcare and low director-reported influenza vaccine requirements, more states should pass laws requiring influenza vaccine for children and adult caregivers at childcare programs.”

Healio spoke with Shope about the study and the role that pediatricians play in improving influenza vaccination rates. – by Eamon Dreisbach

Q: What are the clinical implications, if any, of these results?

A: State vaccination laws for children entering child care and schools greatly assist clinicians in promoting vaccinations to parents, many of whom are hesitant for a variety of reasons. However, few states have an influenza vaccination law, despite an Advisory Committee on Immunization Practices (ACIP) recommendation for it since 2004.

The lack of laws makes it harder for clinicians to convince parents to give their children the influenza vaccine, which has clear individual and public health benefit, especially for the youngest children who are often in group childcare settings. Our study showed that clinicians will not get much reinforcement from child care center directors because few of them required the vaccine for entry.


Q: The study found that just under 25% of childcare center directors report having an influenza vaccine requirement for children. What social and clinical factors contribute to this relatively low rate of vaccine requirements?

A: The only factor among many that we studied (childcare center and director characteristics, a variety of quality indicators, director experience, etc.) that positively influenced the director-reported influenza vaccine requirements was having a state law. Child care center directors must comply with many requirements set by state childcare regulations to maintain licensure. If the state vaccination laws do not include a requirement for influenza vaccine, the child care licensing regulations are also unlikely to contain the requirement. It is understandable that if directors are not seeing laws or requirements for influenza vaccine but are for other vaccines, it may send an unintended message that influenza vaccine is not as important and they may feel it is not their place to require this vaccination.

Q: What can be done to improve vaccination rates at the pediatrician’s level?

A: I think a variety of techniques are important, and no single strategy works for each family. We need to have ongoing and open conversations to address myths about vaccine side effects, vaccine efficacy and influenza disease severity. Many parents are not aware that on average, in the United States today, influenza causes more deaths annually than all the other vaccine-preventable diseases combined. Building trusting relationships with families may be the single biggest factor in overcoming vaccine hesitancy.

Also, we need to regard influenza vaccine on the same level as all the other vaccines because it is an equal ACIP “recommendation.” Typically, ACIP recommendations quickly become state laws. However, in the case of influenza vaccine, there has been a prolonged lag in which states have not adopted laws for this vaccine.

Q: What influence do state and local laws have on improving vaccination requirements?

A: State vaccination laws give child care center directors and school administrators, who are not medical providers, firm footing to stand on in enforcing entry requirements. In the case of child care centers, state laws are necessary but not sufficient for increasing vaccination rates. The state laws need to be incorporated into childcare licensing regulations and enforced by regular inspection of vaccination records of children in licensed child care programs.


Q: What is the take-home message for clinicians?

A: Young children attending child care settings are at the highest risk for acquiring influenza and suffering influenza morbidity and mortality. We should place extra energy and emphasis on convincing parents of these children to immunize against influenza. Our study shows that we are unlikely to get much assistance from state laws or from childcare center directors.

Q: How do these results compare to similar studies?

A: This is the first national study of licensed U.S. child care center directors’ reported influenza vaccine requirements. Prior studies of child care centers show that immunization rates, including influenza vaccine rates, among children and child care providers can be increased by state laws.

Studies of adults who work in child care settings show that their influenza vaccine rates are low. Studies in health care settings demonstrate that employer-mandated influenza vaccine programs can dramatically increase influenza vaccine rates. Studies also show a large proportion of parents support mandatory vaccination of child care providers because, similar to health care settings, they expect their children to be protected from acquiring this disease from caregivers.

Q: Were there results from this study that surprised you?

A: Unfortunately, no, these results were not surprising. When states do not consider this an important enough public health problem to legislate, it is not surprising that childcare center directors are hesitant to implement a requirement for vaccination of children and adult caregivers.

Q: What limitations were there for this study, and how can they be addressed for future analysis?

A: The biggest limitation was that we measured director-reported requirements for influenza vaccination but were not able to measure actual vaccination rates in children or adult caregivers. Despite not having a requirement, some directors may have actively promoted influenza vaccination, based on their personal knowledge or beliefs. Actual vaccination rates for children and adult caregivers are likely higher than the director-reported influenza vaccine requirements.


CDC. Frequently asked influenza (flu) questions: 2019-2020 season. Accessed December 17, 2019.

Disclosures: The authors report no relevant financial disclosures.