That means thousands of youth already disproportionately at risk for chronic health conditions, and many without regular access to health care, could be last in line for a vaccine the Biden administration has said is essential to returning children to school and ending the pandemic.

The dilemma poses a major test for the Administration for Children and Families, a little-known part of the Health and Human Services Department that is responsible for keeping unaccompanied minors at the border safe along with overseeing programs for childcare, foster children and family services. The Biden administration has already redirected more than $2 billion from health programs to address a record influx of migrant children into its custody, hoping to avoid the kind of scrutiny over children in its care that beset the Trump administration.

It’s critical that these children and their guardians have easy access to information about the vaccines, said JooYeun Chang, the acting Administration for Children and Families secretary tapped by Biden in February to lead the agency. “We are educating their parents, their caregivers — whoever has legal authority to make that decision for them so that we don’t leave any child or family behind as these vaccines become available.”

But that is easier said than done. The pandemic broke down normal foster care practices such as on-site visits from government officials, while at the border the number of unaccompanied children swelled this year even as government officials made strides to connect children quickly with U.S.-based guardians.

It is increasingly difficult to check on a child’s welfare and ensure they are getting the care they need, let alone a Covid-19 vaccination, said Susan Punnett, founder of Washington D.C.’s Family and Youth Initiative.

Local public health workers “had to pivot on things like court hearings and social workers visiting the children” when both practices turned virtual, Punnett said. While it was a necessity during the pandemic, the move had repercussions — many vulnerable children only saw officials over a computer camera, without assurance that they were alone to discuss concerns, said Punnett.

Typically the Centers for Disease Control and Prevention recommends approved vaccinations for use in certain age groups, a move that requires insurers to cover those shots and makes them part of routine health services administered to minors. A CDC spokesperson said that its expert panel is not prohibited from recommending unlicensed shots for use and that currently authorized Covid-19 vaccines are included in its schedule, a federally-recommended series of shots. But while the CDC has encouraged coronavirus vaccination, the way the shots are being given under an emergency authorization puts them in unchartered territory, subjecting them to a patchwork of state responses and special considerations on consent and access.

Pfizer’s vaccine is authorized for children as young as 12, and teens who live with their parents or other legal guardians are already getting the shot, opening the door for on-site schooling, summer camps, sports and other activities. The company filed this month for full approval in people 16 and over — a higher regulatory bar than the emergency authorization that would allow it to market the vaccine.

Pfizer and other vaccine developers meanwhile are studying immunizations in young children and infants, but results are not expected until the fall at earliest.

Vaccine consent laws vary across states. Most state welfare agencies let current guardians make decisions for routine care such as federally approved and recommended vaccines; in some areas, such as Washington D.C., children above the age of 11 can make vaccination decisions themselves. But the vast majority of states require parental consent.

The Administration for Children and Families is “currently reviewing ways to increase access to vaccines for all eligible children, per CDC guidance, and collaborating with our state partners to determine implementation plans,” according to the agency’s policy.

But the ACF’s Children’s Bureau has no jurisdiction over vaccination of foster children, a spokesperson for the agency said. “Decisions and policies related to vaccines for these children are under the jurisdiction of the states.”

Meanwhile at the border, thousands of children, many of them teens, have cycled through emergency shelters in recent months, a surge that has left federal agencies scrambling for more resources. Regulators authorized the Pfizer vaccine for young teens in early May, but it is still unclear whether unaccompanied minors can receive the shot while in U.S. custody. ACF declined to comment on the status of the policy.

HHS has the authority to make routine health decisions and administer a range of vaccines to unaccompanied minors in its care, but coronavirus shots’ status plus misinformation about the pandemic and vaccine development could put federal health officials in a bind when it comes to disadvantaged minors.

“We need to think about the flip side of it, to make sure that there is no coercion is getting people to get the vaccine because they are in federal custody,” said Ranit Mishori, senior medical advisor for Physicians for Human Rights and Georgetown University’s public health officer. “This is unique to this vaccine; no one is pushing you to get, say, the Hepatitis A vaccine.”

Legal consent for coronavirus vaccinations could be just half the struggle as health officials turn towards broad vaccination efforts among young people.

Foster children and those who age out of the system are prone to distrust government entities and other authorities, said Punnett, who oversees a program aiding teens and young adults that have transitioned out of foster care. She and and other health experts say many young people who were in foster care also worked in service industries that saw layoffs during the pandemic, and struggled with steady incomes and finding shelter.

“We know that youth who age out of the foster care system are already vulnerable to so many things like being victims of criminal behavior, homelessness, joblessness and domestic violence. All the stressors that Covid-19 brought to the environment made them that much more vulnerable, because the community was struggling,” said ACF’s Chang, who oversaw child welfare programs in Michigan before joining Biden’s administration.

A late December relief package allotted $344 million to the ACF to help former foster youth and families and children in the welfare systems with some of these pandemic losses and challenges. But more might be needed to boost vaccine outreach and instill confidence as federal and state governments embark on the next chapter of immunizations.

“There are so many issues for young people who are in, or have aged out of, foster care in the last year and a half — compounding the stressors and complications that any young person would face, outside of a pandemic,” Punnett said.

From foster care to border shelters, targeted dialogue to help teens, children and their guardians understand the coronavirus vaccines will be essential — and should start now, before broad childhood access, said Mishori. “Consent goes hand in hand with a person having their questions and concerns answered.”



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