Policy Watch: Parental Consent for COVID-19 Vaccinations

November 8, 2021 | Kimberly Randall, Lister Hill Center Program Coordinator 

Teen girl after her vaccination
Photo courtesy of Getty Images


In 1975, Alabama Code § 22‐8‐4 went into affect, giving medical autonomy to minors. The law reads: 

When minor may give consent generally.

Any minor who is 14 years of age or older, or has graduated from high school, or is married, or having been married is divorced or is pregnant may give effective consent to any legally authorized medical, dental, health or mental health services for himself or herself, and the consent of no other person shall be necessary.

Alabama is one of only a few states to have such a law on file allowing for minors to make their own healthcare decisions. However, the Alabama Department of Public Health announced a challenge to this law in late June, stating that parental consent would be necessary for any child under the age of 19 to receive the Pfizer-Biotech COVID-19 vaccine at a state-run clinic. Earlier this fall, Representative Chip Brown (R-105) proposed legislation (HB19) during a special session to require parental permission for any vaccine, however it was not passed.

Proposed Legislation 

Presented to the Senate by Representative Arthur Orr and others, SB15 reads: 

Notwithstanding Section 22-8-4, Code of Alabama 1975, no minor may receive a vaccination without the written consent of the minor’s parent or, if applicable, legal guardian. Institutions of education may not inquire into the vaccination status of a minor student without the written consent of the minor’s parents or, if applicable, the legal guardian. The Attorney General may commence a civil action to enjoin a threatened or continuing violation of this section. 


Even with declining COVID cases, public health officials have continually stated the need for vaccinations. Dr. Nola Ernest, Legislative Chair for the Alabama Chapter of the American Academy of Pediatrics, told WPMI there is no medical reason vaccinations should require parental consent and the regulations are causing delays in the process. For example, teenagers who can legally drive may not have a parent present when they wish to get the vaccine, or a college freshman may not be able to return home for an appointment. 

Research has also encouraged giving enhanced medical autonomy in teenagers. Morgan, Schwartz, and Sisti (2021) report that “children and adolescents have the capacity to understand and reason about low-risk and high-benefit health care interventions. State laws should therefore authorize minors to consent to COVID-19 vaccination without parental permission.” The Society for Adolescent Health and Medicine (2013) states that “a requirement to obtain parental consent for vaccination can present a significant barrier to improving adolescent vaccine uptake across all health care settings in which adolescents access care. The ability of minors to consent to vaccination can influence whether adolescents receive indicated vaccines during adolescent health care visits when parents are absent and when adolescents are seen for confidential services.” 

Next Steps

Alabama Governor Kay Ivey signed SB 15, along with SB9, into law on Friday, November 5. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Stay Informed

Want to learn more about Alabama healthcare? Check out these organizations. 

Alabama Arise 

Alabama Hospital Association 

Alabama State Nurses Association 

Policy Works: US Launches At-Home Covid Testing Initiative

January 18, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator 

Photo Courtesy of Getty Images

Health policy can take many forms and impacts multiple parts of the public health sector. From housing reform to addressing nutrition in impoverished communities to climate change, legislation can have widespread impacts on the health of citizens. 

Following rising cases of the Omicron variant of the novel coronavirus, President Biden announced a series of executive actions on December 21st to assist hospitals and public health agencies. In addition to mobilizing 1,000 troops with medical experience to be dispersed to hospitals overrun with COVID-19 cases and launching distribution systems for PPE to hospitals, clinics, and the general public, the White House also announced an initiative to provide free at-home antigen testing kits to be delivered through the United States Postal Service

This initiative follows similar actions in the United Kingdom and Canada, where at-home test kits have been available to citizens free of charge for several months, either through mail delivery or at designated pharmacies. Tuesday, January 18th saw the launch of https://www.covidtests.gov/, the official website where US Citizens can request a set of four at-home test kits to be delivered via USPS. While the test kits are estimated to be delivered in late January, registration is open now. The federal government has purchased 1 billion test kits for this initiative, after doubling its original pledge of 500 million. 

In addition to the at-home delivery service, President Biden announced that private insurance companies will be required to reimburse expenses for at-home test kits purchased at local pharmacies. According to the Centers for Medicare and Medicaid Services, private insurance companies are required to reimburse over-the-counter COVID-19 tests purchased on or after January 15, 2022 at a cost of up to $12 per test. Health insurance providers must reimburse the cost of up to 8 at-home test kits per month, per person enrolled. According to Blue Cross Blue Shield Alabama, the largest health insurance provider in the state, “members who purchase a test kit should file a claim to be reimbursed. Claims can be filed electronically by logging in to your account or by submitting a Medical Expense Claim Form along with the test kit receipt.” A full list of reimbursable kits can be found on the FDA’s website. 

The Centers for Disease Control lists at-home testing as one of the key measures to reduce the spread of COVID-19. While at-home tests have a higher chance at a false-negative than a PCR test, it is suggested to utilize them prior to indoor social gatherings and other close-contact situations where the virus might be transmitted. According to the CDC, “a negative self-test result means that the test did not detect the virus and you may not have an infection, but it does not rule out infection. Repeating the test within a few days, with at least 24 hours between tests, will increase the confidence that you are not infected.” 

Want to register for your at-home test kits? It’s a simple, two-step process. 

Visit https://www.covidtests.gov


Select “Order Free At-Home Tests” which will direct you to the official page on the USPS website. 

Fill in the information as needed. Tests are estimated to ship starting in late January. 

Herd Immunity in Alabama

April 30, 2021 by Suzanne Judd, LHC Director

Herd immunity occurs when the level of immunity in a population is high enough to prevent the spread of an infectious disease. In other words, when the number of people who are immune to a disease reaches a certain level, the disease no longer has as many chances to spread. This is best achieved through vaccination. In the case of SARS-CoV2, most researchers still agree that at least 70% of the population needs some level of immunity to slow the spread of COVID. One researcher has even started to use “herd immunity” interchangeably with “normality”. On the other hand, several other scientist are questioning if herd immunity is even an achievable goal. Another way to think of herd immunity is to consider it to be the level of immunity others in the community around a person have that will provide a buffer to keep the virus from rapidly spreading.

Calculating Herd Immunity

Calculating the percentage that provides herd immunity is tricky and requires that researchers have first calculated R0, or the rate of the disease’s transmission in a population with no natural immunity to a particular virus. In order to calculate R0, we need data on the rate of case transmission before anyone in the population was infected or vaccinated. The estimates for R0 range from 0.8 – 10, which means herd immunity ranges from 50-90%. There are certain populations where diseases spread more rapidly, such as congregate living situations or those who spend long periods in places social settings where food is served.

[Table 1: Range of Possible Herd Immunity Levels for SARS-CoV2 Based on Observed R0]

Measuring Herd Immunity

Cases are decreasing in Alabama, which is certainly wonderful news! However, this does not mean that we have achieved herd immunity; we still need Alabamians to keep getting vaccinated. Research data suggests that the human body may not have lasting immunity from SARS-CoV2 infection. This means that some people who had immunity from a previous infection (symptomatic or asymptomatic) may not have the same level of immunity today. In order to maintain the level of immunity we currently have in Alabama – which is working to reduce the spread of SARS-CoV2 – we need to continue vaccinating about 100,000 people each week.

Estimating Current Level of Immunity in Alabama

Immunity to SARS-CoV2 could be achieved in three main ways:

  1. Immunity without infection – People have antibodies even without a positive test due to asymptomatic infection or lack of test availability early in the pandemic. These people may have had symptoms or may not have had any symptoms. We have no idea how long the immunity lasts in people who did not have symptoms. Early data suggests that immunity in this group may fade as soon as 90 days after antibodies were detected in their blood.
  2. Infection – People become sick, test positive, and then recover, having gained antibodies. This is the least desirable way to achieve immunity because some of the people who become sick will never recover. This approach leads to death, hospitalization and long term illness for some of the population.
  3. Vaccination – This is the most desirable approach. This leads to the greatest benefit in terms of keeping people from getting sick and potentially dying. The complication rate from the vaccine is not zero but it is extremely low.

[Figure 1: Model Estimating When Alabama Might Experience Herd Immunity]

Model Assumptions

  1. At least 70% of the people in the State of Alabama will receive a COVID vaccine in 2021 (number will be easier to achieve if FDA clears the vaccine for 12-15 year-olds)
  2. Vaccination is relatively similar across age, race, sex, and geographical location of residence
  3. For every 1 positive test, there are 4 individuals who were not tested but have immunity (from undiagnosed, likely asymptomatic, cases)
  4. Case rate will continue at current level
  5. Vaccine provides some level of protection against variants
  6. Immunity begins to fade after 6 months and by 12 months those with previous SARS-CoV2 infection are susceptible to reinfection
  7. 30% of those vaccinated already had some level of immunity (this is the primary reason the green curve decreases when vaccinations ramp up)

Which of these assumptions could cause the most problem if they are not met?

  1. Vaccination rate: If at least 70% of Alabamans, do not receive the vaccine, community immunity levels will decline. By November of 2021, the total level of immunity in Alabama is estimated to be very similar to where it was in November of 2020 meaning the holiday season might look similar to last year.
  2. Vaccination is similar by group: In Alabama, the group that is least likely to pursue the vaccine currently are those aged 16-30. This is also the group with risk behaviors that make them most likely to be in situations where SARS-CoV2 could rapidly spread. SARS-CoV2 does has a lower rate of mortality for young people compared with older individuals but there is now way to know if future variants will behave in the same way. Previous coronavirus pandemics (SARS and MERS) demonstrated a higher mortality rate in young people (1 in 50 aged 25-34 died). Failing to vaccinate 70% of the population could place unvaccinated groups such as children in a very dangerous place if the virus mutates and becomes more lethal.
  3. Number of people with immunity but no positive test (asymptomatic individuals): Right now the bulk of the immunity in Alabama is from people who have immunity but have not had a positive COVID test and have not received a vaccine. If there are actually fewer of those individuals in the population, we are only at about 50% of the totally population with some level of immunity which is no where near high enough to stop the spread.

Conclusions and Next Steps

Overall we are in a good place in Alabama at the moment because:

However, if we do not continue to vaccinate at least 100,000 people per week through November 2021, we could be tossed right back into an outbreak. This would force us to make hard decisions about whether or not we can remain open, allow children to go to school in person, and hold major events, which is a place no one wants to return to.

COVID and Prisons

This piece was originally written in August 2020 by Jake Lindahl, 2020-21 Health Policy Ambassador


Schools across the country are struggling to reopen amid the COVID-19 pandemic. With small, poorly ventilated classrooms, high student/faculty ratios, and already overstretched budgets, the pressure is on localities to make these facilities safe. Many of the same problems have meanwhile been present in US prisons since the virus hit in March. “The number of US prison residents who tested positive for Covid-19 was 5.5 times higher than the general US population,” according to researchers at John Hopkins Bloomberg School of Public Health. After decades of overcrowding and underfunding, and without many advocates to pressure from the outside, US prisons are likely the worst place to be during a deadly pandemic like COVID-19.

The United States has the highest prison population in the world with 2.12 million people incarcerated. This is down from last year, mostly due to early release for immunocompromised prisoners in some states. Prisons remain overcrowded and violent with little to no resources for mental health and widespread inadequate health and dental care. With these conditions, it is clear why COVID-19 has hit prisons so hard. There is no way to social distance in a prison. Every meal is communal. Guards and staff interact with the outside world, sometimes reintroducing the virus many times over months. US prisons are a massive petri dish for COVID-19.

Conditions are especially harsh in Alabama, where the state correctional system was exposed for breaking federal law by not providing adequate healthcare back in 2014. USA Today reported on March 9, 2020 that, “chaos, confusion and corruption” plagued the prison system despite the ongoing federal investigation. The 17th Alabama prisoner died on August 11th, and six new inmates have tested positive. This puts the total cases at 296, but the Alabama DOC admitted in July that it neglected to adequately test the prison population.

A New Surge (Outbreak) in COVID-19 in Alabama

August 4, 2021 by Suzanne Judd, LHC Director


I think I speak for all of us when I say that we had all hoped to be on the path to freedom from COVID-19 by now. Surely, Americans everywhere would like to move on in whatever ways they can – family gatherings, community events, concerts, travel, and so many other things that we’ve been missing for well over a year now seemed within reach just a few weeks ago. Unfortunately, it seems that what progress we had made in overcoming the pandemic is at risk, and we may have to wait a bit longer before we can truly be free from the virus.

Beginning in early June, there were indications in Missouri that we hadn’t quite made it out yet. The delta variant of SARS-CoV-2, the virus that causes COVID-19, began to circulate and cases spiked quite rapidly. As a localized outbreak, the outlook for the rest of the country wasn’t too bleak. However, it wasn’t long until the variant spread down to Florida and the Gulf Coast. Here in Alabama, we are now seeing exactly what it means to have a surge in cases from the delta variant. The figure below uses statistical modeling to predict how many cases we may observe from this new surge.

What do these data mean for hospitalizations?

One piece of data that has become clear is that the vaccine helps to keep people out of the hospital, even if they develop mild symptoms from exposure to a person who has COVID. UAB Hospital has recent recently reported that over 95% of the people hospitalized with COVID-19 had not yet received the COVID-19 vaccine. Since Alabama only has about a 40% vaccination rate right now, this leaves many people at risk of being hospitalized.

What about missing work, school or other activities?

The Southern Alabama curve allows us to estimate the number of people who would be infected, quarantined, or in the hospital at the peak of the surge. If the entire state begins to surge at the rate Southern Alabama is currently surging, there would be about 20% of the population out due to either illness or quarantine for 3 weeks centered around August 26. This assumes that each sick person would come into contact with about 5 other people who would have to quarantine. It also assumes isolation and quarantine to be 14 days. It is really challenging to estimate the number of contacts a person may have or the potential impact of a whole sports team, classroom, or congregation in quarantine. It is possible that 30-50% could be out at one time depending on how people were exposed to an infected individual.

Table 1Table 1. Outcomes of Various Transmission Rates
Updated August 12

What can be done?

Absenteeism could be reduced by 37% if masking were required in schools while COVID is circulating at high levels.  Masking would reduce absenteeism to between 6% and 14% in the setting where 5 close contacts have to quarantine. In the case where large groups (classrooms, teams, choirs) have to quarantine, masking could reduce absenteeism from 50% to 37%.

Higher levels of vaccination will have lower levels of absenteeism, since vaccinated people with no symptoms do not have to quarantine and the biggest driver of absenteeism will be quarantine (accounts for 80% of the absenteeism). This has a direct impact on the faculty and students over age 12. It could keep faculty from having to quarantine due to an exposure in their classroom, which will reduce faculty absenteeism.

A school with 90% of the faculty vaccinated would have an absenteeism rate among the faculty of 1% at the peak of this surge compared to 19% in a school with only 10% vaccination rate. The same is true for classrooms where children are 12 and older.

How will we know which of the 3 curves Alabama is on?

The curves above are only predictions. There is uncertainty in the models so it is important to regularly check the data to see how the models are performing. Actual case data can be used to examine how well the model is predicting hospitalizations in Alabama. The figure below shows how well the models are tracking with the number of hospitalizations reported each day. Currently we are much closer to the Southern Alabama path than the India or UK paths but masking, reducing social activities, and increasing vaccinations will all help to bend the curve down so that we do not stay on this path.


Unintended Consequences: COVID-19 Policy

May 8, 2020 | Sean McMahon and Sara Harper, LHC Staff


The COVID-19 pandemic seems to have launched us into the great unknown. It’s hard to predict what will change in the world outside the safety of our homes. While news outlets are operating a constant stream of pandemic-related updates, there are other changes going on that don’t make as many headlines. Even in normal times, every policy change leads to unintended consequences, side-effects of the change that are not in line with the goal of the policy. Stay-home orders have certainly slowed the spread of SARS-CoV-2 (the novel coronavirus which causes COVID-19), but what else have those orders done? We’ve rounded up some of the news of the last two months that may be side-effects of staying at home.

Excess Deaths

WeeklyExcessDeaths condensedExcess death data from the CDCUsing data from previous years, the CDC uses statistical modeling to calculate “expected deaths” across the country on a weekly basis. “Excess deaths” is the difference between observed deaths and the expected number. Of course, with over 75,000 COVID-19 deaths in the United States, we would expect roughly that same number in excess deaths. However, in several cities and states the number of excess deaths is larger than their COVID-19 deaths. Death certificates are often submitted without a cause of death with the intention of later completion, so the particular causes can’t be teased out just yet. These deaths stem from a number of possible factors: people may be avoiding healthcare facilities, foregoing medical treatment; people are struggling financially, possibly unable to afford necessities; food insecurity is on the rise. We won’t know exactly what is causing the excess deaths until we have more complete data from death certificates.


Primary Health

On the other end of the healthcare spectrum, a survey of 2,000 primary care physicians reported that approximately 20% predict they will be forced to close within the coming weeks. Privately owned primary care clinics typically operate as small businesses, which have taken a massive blow during the COVID-19 pandemic. Patients aren’t engaging with primary care as we quarantine within our homes, and in consequence, we may see a surge in preventable illnesses in the coming months. Of course, with fewer patients, fewer primary care offices have the resources to remain open. When we emerge from this crisis some families will be left without a primary care physician. Primary care losses can impact treatment access for other deadly diseases like routinely screened cancers, as most treatment referrals come through primary care physicians. Already, lockdowns have resulted in an 86-94% drop in routine cancer screenings and a 60% decrease in chemotherapy attendance.


WHO Mental HealthWHO mental health materialsMental Health

“Are we required to wear masks or not? Are we still seeing 3,000+ deaths a day? All my hometown Facebook friends are posting conspiracy theories. Working from home is not as great as I thought it would be.”

Uncertainty can be hard to deal with. Things are changing so quickly that it’s difficult to keep track of what’s going on. Overall, it seems that mental health and our support systems are taking a hit around the world. Isolation can be a trigger for suicidal ideation, panic attacks, depression, and several other concerns. US alcohol sales spiked at the beginning of the crisis, and “problem drinking” is on the rise in the United Kingdom. Our support systems are also on the rocks. Drug users across Europe cannot access their opioid substitutes and other treatment services. With support groups held online with virtual platforms, participation and accountability may be lower as well. A lack of readily available support services coupled with an economic downturn has led to an increase in deaths from drugs, alcohol and suicide; or what researchers call “deaths of despair”.



LucysImage of Lucy’s Coffee & Tea. Image from the shop’s Facebook pageOf course, ordering businesses to close has dealt a major blow to the economy. To mitigate this, Congress passed the CARES Act in late March. This $2 trillion stimulus has proven too little, too late in some cases. As of the writing of this blog post, 33.5 million people have filed for unemployment as a result of the pandemic. Over 7 million small businesses are at risk of permanently closing their doors. Several small businesses across the country have already been forced into this. Much to our dismay, Lucy’s Coffee & Tea has shut its doors for good. While some community favorites are forced out of business, other companies find themselves in a position to turn a profit by raising prices on everyday items. Texas Attorney General Ken Paxton, along with a group of individuals in California, has filed a lawsuit against the country’s largest egg producer for price gouging in the midst of a pandemic.



Not every unintended consequence of stay-home orders has been detrimental. Air quality in the world’s major cities has improved since the lockdowns started. Some cities have seen particulate matter 2.5 (PM 2.5) levels decrease by 60%. This drastic change has increased breathability and visibility in normally crowded cities; quite noticeably in New Delhi. These PM 2.5 declines are beneficial to the environment and human health in general. Lower levels of air pollution also could help fight the novel coronavirus, according to a study from Harvard that found increased susceptibility to COVID-19 in those who have been chronically exposed to high levels of PM 2.5. Air quality will continue to change as countries reopen their economies, hopefully with an increased awareness of sustainability. The National Oceanic and Atmospheric Administration is set to conduct its own studies on the environmental effects of stay-home orders. Delhi ComparisonNew Delihi’s India Gate war memorial on 17 October 2019 and on 8 April 2020. Photograph: Anushree Fadnavis/Adnan Abidi/Reuters

More Speculations:

Re-opening strategies put communities of color at greater risk

Some domestic violence aid organizations are worried about a drop in reports, a sentiment echoed by the UN Secretary-General.

Some people may be grappling with a “Quarantine 15,” as physical activity decreases and calorie intake increases.

Experts predict a rise in tuberculosis cases as a result of lockdowns’ impact on treatment and mitigation efforts.