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AstraZeneca or Moderna? Sinopharm or Sputnik?

For the more than 500 American colleges that plan to require COVID-19 vaccines for students coming to campus this fall, a major challenge will be implementing this requirement for international students who might not have access to one of the three vaccines currently authorized by the U.S. Food and Drug Administration for use in the U.S.

Some of those students may have access to a different vaccine authorized by a different national regulator in their home country, or they might not have access to a COVID-19 vaccine at all.

“It runs the gamut,” said Edythe-Anne Cook, associate director for administrative services at the Student Health Center at American University in Washington, D.C. “As you can imagine, every country has their own access to vaccines, and they have their own policies and plans for how they’re distributing them.”

For the purposes of its COVID-19 vaccine requirement, American is accepting any COVID-19 vaccine authorized for emergency use by either the FDA -- the Moderna, Pfizer and Johnson & Johnson vaccines -- or any vaccine listed for emergency use by the World Health Organization, a list that includes the AstraZeneca vaccine and the Sinopharm and Sinovac vaccines, both of which are made in China, among others.

A review of dozens of colleges’ mandatory vaccine policies suggests that many are going the route American has taken of accepting either FDA- or WHO-authorized vaccines. This aligns with interim guidance from the Centers for Disease Control and Prevention for individuals vaccinated outside the U.S., which says that people who have received all recommended doses of a COVID-19 vaccine listed for emergency use by the World Health Organization do not need additional doses of an FDA-authorized vaccine. By contrast, those who have been vaccinated with a vaccine that is not authorized by the FDA or WHO “may be offered a complete FDA-authorized COVID-19 vaccine series” assuming a minimum of 28 days has passed since their last dose of a different vaccine.

According to the CDC, only people who have received all recommended doses of an FDA- or WHO-listed vaccine should be considered fully vaccinated for purposes of public health guidance.

Gerri Taylor, co-chair of the American College Health Association’s COVID-19 task force, said colleges already have a track record of accepting international versions of vaccines for more long-standing vaccine requirements, such as those for preventing meningitis, measles, mumps and rubella.

“Each college has to make their own decision, and the WHO is a good standard, as is the CDC,” said Taylor. “If we follow what they’re recommending, I think schools will be in good shape.”

Not all vaccines available internationally are currently recommended for emergency use by the WHO: among the notable vaccines not listed by the WHO currently are Covaxin, which is available in India, and Sputnik V, which is available in Russia. Many colleges have plans in place to help students who are unable to be vaccinated with WHO- or FDA-approved vaccines prior to coming to campus get vaccinated after arrival.

But that raises the question of what special precautions students might need to take in the weeks until they are fully vaccinated: according to the CDC, a person is considered fully vaccinated two weeks after a single-dose Johnson & Jonson vaccine or two weeks after a second dose of the Moderna or Pfizer vaccine. Taylor, of the American College Health Association, said colleges with COVID vaccination requirements are struggling with how to house students who arrive on campus without being fully vaccinated for whatever reason.

“This is not just an international issue; it’s all students,” Taylor said. “Do you house somebody who’s vaccinated with somebody who’s not vaccinated? ACHA is in discussions right now trying to make a decision” about what to recommend in this regard.

Colleges are taking different approaches.

Whitman College, in Washington, posted guidance last week saying that students “who are unable to obtain a COVID vaccination in their community before coming to campus will be given quarantine housing, assuming that they agree to work with the college to be vaccinated as soon as possible.”

A Whitman spokesman said decisions about whether these students could attend in-person classes would be made on an individual basis. "We are working to bring students in this situation to campus early enough for them to be fully vaccinated by the start of the semester," he said. "For those who are not able to be on campus that early, we will work closely with them and their professors to find individual solutions that do not put our students, faculty and staff at additional risk."

Cook, the student health center administrator at American, said the university will let international students who have not yet been vaccinated with an approved vaccine move into residence halls and attend in-person classes, but they will have to wear face masks and participate in surveillance testing. They will also be subject to any city health department requirements related to COVID testing and restriction of activities upon arrival. She said these students will be able to attend in-person classes while they get vaccinated.

“We know that there will be some members of our campus community who aren’t vaccinated right away, but we’re confident that they’ll agree to continue to follow the health and safety guidelines to keep everyone safe,” Cook said.

Boston University plans to accept any COVID-19 vaccine, including those without WHO or FDA authorization or approval. But the university notes on its website “that while BU will accept all vaccines, current Centers for Disease Control (CDC) guidance exempts only fully-vaccinated individuals who have received a WHO/FDA-authorized or approved vaccine from having to quarantine after travel or close contact with someone diagnosed with COVID-19. If this remains the case in the fall, students who arrive on campus with a vaccine from another country may still be subject to close contact quarantine, travel quarantine, or other requirements set by the Commonwealth [of Massachusetts].”

David Hamer, professor of global health and medicine at the BU School of Public Health and BU School of Medicine, cited a few reasons why BU decided to accept all COVID-19 vaccines for the purposes of its institutional vaccination requirement.

“One is we’re worried about what students will have access to,” he said. “If we do not accept certain vaccines, then when they arrive, they would have to be basically in quarantine and not able to attend class until they’ve been fully vaccinated, and that could take three or four weeks. That means those students might be at risk for not being able to start their semester on time unless they came early, and then there could be added costs if that would be the case.”

“The other reason is we just don’t know enough yet about mixing different vaccines,” Hamer said. “We don’t want to force people to have a second vaccine when we don’t know how a series would be in terms of reactions.”

Some smaller colleges are considering each international student’s situation individually. This is the case for Albion College in Michigan, which expects to enroll about 30 international students this fall, according to Matt Arend, the college's COVID-19 coordinator and associate dean for wellness and director of athletics.

“We are truly evaluating on a case-by-case basis,” he said. “We’re working with our local health department in trying to assess the different vaccines that are out there.”

Sudhanshu Kaushik, executive director of the North American Association of Indian Students, urged colleges to have “a little bit more empathy and a lot more context in terms of understanding” what their vaccine requirements mean for international students.

“Just putting it on them and saying you have to get this vaccine or you won’t be allowed to enter on campus or attend in-person classes” is inappropriate, he argued, noting that this comes after nearly a year and a half of many international students paying tuition to take their classes remotely.

Cheryl Matherly, vice president and vice provost for international affairs at Lehigh University in Pennsylvania, said questions about Lehigh’s vaccination requirement are “hands down the biggest set of questions we’re getting” from international students.

She said Lehigh officials are fielding questions from students in India, for example, who can get one dose of a COVID vaccine before they travel to the U.S. but not a second, and are questioning whether they should get that first dose. University officials are also getting many questions from students about quarantine and what that means: students who are not vaccinated with a FDA- or WHO-approved vaccine will need to arrive on campus seven days prior to the Aug. 15 orientation to quarantine.

Added to that, Matherly said students from many countries are finding it difficult to find flights to the U.S. at affordable prices.

“We have people trying to balance time to quarantine with availability of flights,” she said.

“Each individual piece has to line up to make it possible for the student to get here, and it’s requiring that we be extraordinarily flexible with students on everything from arrival dates to housing to how we’re going to handle orientation to even the start of classes,” Matherly said. “At the end of the day, it’s requiring that as an institution we be consummately flexible.”

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