Written by Dr David Owens
I have explained previously that all public health interventions involve a cost-benefit analysis. This not only involves consideration of the economic cost-benefit but also a balance of the rights and interests of the individual with those of the population. Sometimes, such as in vaccinations for the elderly and vulnerable, the evidence is so overwhelming that the answer is easy. In this case, the answer is YES we should be vaccinating as many vulnerable and elderly patients as possible. The arguments for and against the vaccination of children and adolescents are much more nuanced. The main issues in the vaccination of children are covered in the following questions.
Is COVID-19 generally a mild disease in Childhood?
A study in the Lancet reviewing data from seven countries showed an estimated 2 in every million deaths in children. The majority occurring in those with other medical conditions and risk factors. Clearly, any death in childhood is a tragedy but when risks of the disease are so low, we would normally need overwhelming evidence of safety before recommending widespread vaccination.
Are COVID-19 vaccinations in children safe?
We have evidence of both the effectiveness and safety of COVID-19 vaccinations in children from multiple populations.
Are there side effects of COVID-19 vaccinations?
The main side effect of the BioNTech vaccine is myocarditis (inflammation of the heart). A recent study, which has not yet been peer-reviewed, suggested that COVID-19 vaccination may cause more hospitalisations than it prevents in adolescent boys. The condition resolves naturally in the vast majority of cases without treatment. The rates of hospitalised cardiac adverse events (mainly myocarditis) in boys following the second BioNTech dose were 162 per million (ages 12 - 15) and 94 per million (ages 16 - 17); among females, rates were 13.0 and 13.4 per million, respectively. Hong Kong has recently advised giving only a single shot to children age 12 to 17 years to reduce this risk.
Sinovac has been given to children and adolescents in China and other countries with no reported increase in side effects. However, Sinovac contains Aluminium Hydroxide as an adjuvant and as yet there has been no large peer-reviewed trials of safety in children.
Is mortality the only measure of disease severity?
Clearly there is more to disease severity than mortality. Indeed, there is an argument that in young people and children the greatest indication for vaccination may be the prevention of Long Covid. We are accumulating evidence that vaccination reduces the risks of Long Covid by up to 90%. We know that Long Covid can affect children and the impact can be significant.
In addition to Long Covid we must also consider the impact on a child’s education and social development. In Hong Kong schools are limited in teaching face to face dependent on vaccination rates. The increasing use of vaccine passes and the application of quarantine regulations also has the potential to adversely impact normal family life.
Will vaccinating children allow us to reach herd immunity?
Answer: Almost certainly not
We have explained in a previous article that the delta variant makes herd immunity impossible by vaccination alone. It will certainly be much harder if we do not vaccinate children, but this raises an ethical question. Is it ethical to vaccinate a child predominantly to protect the elderly and vulnerable rather than the child? I would argue not and especially when the elderly and vulnerable are refusing to be vaccinated. We should only vaccinate children if there is clear evidence of risk-benefit in favour of the child.
If I only have one dose of the vaccine who will benefit the most?
Answer: The elderly, vulnerable and those in high risk occupations
An elderly and vulnerable person is many hundreds of times more likely to die of Covid than a child or adolescent. A small fraction of health care workers in developing nations have been vaccinated. Taking a reductionist and utilitarian perspective we should be vaccinating the most vulnerable rather than vaccinating children and giving booster doses. This is the view of the WHO and many international public health experts.
Do we really have a vaccine shortage?
Answer: Probably not
The counter-argument is that supplies and logistics is not a justification to risk the lives or health of children. There are many vaccines, often in the wrong place. There are also other solutions, such as waiving patent rights and increasing vaccine production within developing nations. In this narrative governments have a duty to act in the best interests of their own population not the rest of the world.
So should we be vaccinating children?
Public health decisions are ultimately a balance and are frequently nuanced. In the UK the Joint Committee on Vaccination and Immunization voted against vaccination for children but the Chief Medical Officers disagree and have advised vaccination. I have discussed this issue in our podcasts with Professor Ben Cowling. It is one of the few areas in which we respectfully differ in our opinions. In general Professor Cowling has been more supportive of vaccinating children and I have been more cautious. The nature of science is to modify opinions on the basis of evolving evidence.In my opinion, the evolving evidence of vaccine protection against Long Covid is tipping the balance in favour of vaccination although the optimal age at which to commence vaccination, which vaccines to give and the optimal schedules of vaccination will need to be determined by ongoing research.
In view of the increasing importance and evidence around Long Covid, including in children, we have compiled ongoing evidence-based research and information regarding the condition into a Long Covid resource centre. If you are aware of helpful research or literature in this field we would be very grateful for your input at firstname.lastname@example.org.
1. R;, B. S. S. B. J. O. B. B. (n.d.). Children and young people remain at low risk of COVID-19 Morality. The Lancet. Child & Adolescent Health. Retrieved September 16, 2021, from https://pubmed.ncbi.nlm.nih.gov/33713603/.
2. Høeg, T. B., Krug, A., Stevenson, J., & Mandrola, J. (2021, January 1). Sars-CoV-2 mRNA vaccination-associated myocarditis in children ages 12-17: A stratified national database analysis. medRxiv. Retrieved September 16, 2021, from https://www.medrxiv.org/content/10.1101/2021.08.30.21262866v1.
3. Scientific Committee on Emerging and Zoonotic Diseases and Scientific Committee on Vaccine Preventable Diseases. Centre for Health Protection. (2021, September 15). Retrieved September 16, 2021, from https://www.chp.gov.hk/files/pdf/consensus_interim_recommendations_on_the_use_of_covid19_vaccines_in_hk_15sept21.pdf.
4. Buonsenso, D., Munblit, D., De Rose, C., Sinatti, D., Ricchiuto, A., Carfi, A. and Valentini, P. (2021). ‘Preliminary evidence on long COVID in children’. Acta Paediatrica, 110: 2208-2211. 09 April 2021. Available at: <https://onlinelibrary.wiley.com/doi/10.1111/apa.15870> [Accessed 10 September 2021].
5. Öcal Demir et al. (2021). ‘SARS-CoV-2 associated multisystem inflammatory syndrome in children (MIS-C). A single center's experience’. Minerva Pediatrics. 23 April 2021. Available at: <https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/pt/covidwho-1200473> [Accessed 10 September 2021].
6. Rubens J H, Akindele N P, Tschudy M M, Sick-Samuels A C. (2021). ‘Acute covid-19 and multisystem inflammatory syndrome in children’. BMJ 2021; 372 :n385. 1 March 2021. Available at: <doi:10.1136/bmj.n385> [Accessed 10 September 2021].