NB Throughout this piece “children” refers to the ages from birth up to and including 17 years.
As the UK COVID-19 vaccination programme opens up to all those aged 18 and over, many are asking if and when children should be vaccinated.
The UK’s JCVI (The Joint Committee on Vaccination and Immunisation which advises UK health departments on immunisation) has made the decision, thus far at least, not to vaccinate children with the exception of children who are at much higher risk medically from COVID-19 such as those with severe neuro-disabilities that require residential care. (1)
There are always at least two sides to every argument.
Given that COVID-19 is a very mild illness for the vast majority of children, some argue as to why we should vaccinate them against something that is unlikely to harm them?
The counter-argument is that we should we be vaccinating children to stop them from spreading COVID-19 and thereby protect those who are more vulnerable in society.
Do young people have a duty, for want of a better word, to accept a medical intervention to protect society? Or does society have a duty not to impose certain measures on the younger generation?
The USA and Israel are already vaccinating their children but whether the UK will remains unclear.
Fours Arguments in Favour of Vaccinating Children
1) Perhaps the most compelling argument for vaccinating all children is because they will continue to supply COVID-19 with infection targets. Whilst the virus continues to spread amongst children it is being allowed time to mutate into other, possibly vaccine resistant, variants.
As Dr Julian Tang, Professor of Respiratory Sciences at the University of Leicester, says: “Under-18s could be ‘reservoirs’ for virus when all adults are jabbed. As a consequence of the ongoing COVID-19 vaccination programme into the younger age groups [over 18s], this will drive the virus into the under-18 child age-range, so in the absence of current COVID-19 vaccination in this age group, the virus will eventually concentrate in this school-age population which will eventually become a reservoir and driver of any ensuing delta variant epidemic, as well as being a hotspot in which new mutations may arise.” (2)
2) Pre-pandemic, the importance of school attendance was well documented. Local councils and individual schools frequently ran campaigns explaining how missing school for just three weeks could equate to losing out on as much as 10% of the child’s education. (3)
Since March 2020, the UK’s 11.7 million school age children have had their educations shattered by two nationwide lockdowns. The school experience has been disrupted by the need for social distancing measures across all schools with the addition of mask wearing and regular lateral flow testing in secondary schools. (4)
At any one time large cohorts of healthy children are having to self-isolate at home for 10 days when a classmate or member of staff they have been in contact with tests positive for COVID-19. A quarter of a million children missed school last week (14-18 June 2021) because of COVID-19 infections, self-isolation or school closures because staff were self-isolating. (5)
If children are not vaccinated, these repeated disruptions are going to keep happening again and again into the next school year and possibly beyond.
3) COVID-19 may be a mild illness for children but it's not necessarily a mild illness for the adults they can pass it on to. Whilst the onus is now on all adults to get themselves vaccinated, and thus protected from COVID-19, there are many who will be double vaccinated but may not mount a full immune response, for example people on treatments for cancer or people with immune disorders. These people could be the child’s teacher or parent or grandparent. (6)
4) There is already a precedent for vaccinating children to safeguard others. With Rubella, we vaccinate all children in order to safe guard people not yet born – Rubella is a mild infection for children but can be fatal for the foetus in pregnant women. We vaccinate children to protect the babies of the future. (7)
Four Arguments Against Vaccinating Children
1) If COVID-19 is a mild illness for the vast majority of children then one can argue that if vaccination has no personal benefit to the child we should not be doing things to children to protect adults.
Dominic Wilkinson, Jonathan Pugh and Julian Savulescu are ethics experts at Oxford University and they have argued children should not be vaccinated for moral reasons. (8)
For any vaccine whether it is beneficial for an individual is based on three questions: how effective is the vaccine at preventing the disease, how likely is that person to become ill from the disease it prevents and what are the risks of vaccination?
Multiple studies have shown that the first benchmark is reached, all of the COVID-19 vaccines are showing high levels of efficacy against COVID-19.
However, a study across seven countries found that for a million COVID-19 deaths, less than two occurred in children. It appears from this that the COVID-19 vaccine, if used in children, protects against a tiny risk of dying from COVID-19. (9)
2) We also have to consider the benefits of a vaccine against its potential side-effects. Trials carried out to date appear to be reassuring but have only been in small numbers of children age 12 to 17.
Both the US and Israel have reported cases of a rare heart condition called myocarditis, possibly associated with the mRNA vaccines (Pfizer and Moderna are the two mRNA vaccines.) Myocarditis is an inflammation (or swelling) of the heart muscle and can be caused by infections, especially viral infections. COVID-19 itself can cause myocarditis. Other causes include potent drugs such as cancer treatments and autoimmune diseases where the body attacks itself. It causes chest pain, a rapid heartbeat, shortness of breath and flu-like symptoms. (10)
Most "natural" cases of myocarditis are in young adults with males affected more often than females. The vast majority of cases resolve without complications but a minority lead to serious heart problems and can be fatal. Over 3 million people worldwide will develop myocarditis naturally each year. (11)
There have been reports of myocarditis in adolescents and young people following mRNA vaccination. Males were more affected than females and cases were more common after the second dose, usually occurring within four days of receiving the second dose. Most of the cases were mild. (12)
The rate of myocarditis in Israel was consistent with the normal background number of cases that occur leaving it unclear if the vaccine was a potential cause or the cases of myocarditis would have occurred anyway. If there is a link with the vaccine, the risk based on these Israeli figures would be 0.001%.
In the USA, the CDC (Centers for Disease Control and Prevention) has noted that some teenagers and young adults, again nearly all men, have presented with myocarditis post vaccination with the Pfizer or Moderna vaccine. The CDC has recommended further investigation but, like Israel, has noted that the number of cases thus far identified is consistent with the normal background case rate. (13) (14)
Regulators in Europe have noted that some cases of myocarditis have also been reported in Europe after receiving the Pfizer vaccine but they do not think the vaccine is the cause. (15)
Whilst there is uncertainty about the safety profile of the vaccine in children it is reasonable to say vaccination may not be the child’s best interests.
3) There is also a humanitarian reason why some argue we should not be vaccinating children at the present time. Many low income and middle income countries have barely started immunising their populations. For example, Nepal ran out of vaccine when only 2.5% of its population had been fully vaccinated.
4) There is a moral argument to send spare vaccines overseas rather than using them to vaccinate children. There is also a scientific reason, new variants will continue to emerge until transmission of the virus is brought under control worldwide. There is always the risk that a vaccine resistant variant will emerge with even fully vaccinated countries then finding themselves dealing with further waves of infection. (16)
However this same scientific argument - that we need to decrease the risk of a vaccine resistant variant emerging - can also be used to support vaccinating children. Ideally we need to stamp out reservoirs of infection everywhere.
Is there a third argument - To only vaccinate some children?
Scientists have established that there is a link between ethnic minorities and the risk of becoming seriously ill with COVID-19 and this includes children.
Children from ethnic minority backgrounds are more likely to have COVID-19 than white children and Asian children are more likely to be admitted into hospital than non-Asian children.
Scientists from the Universities of Leicester, Nottingham, Cambridge and Southampton analysed the health care records of 2,576,353 children to establish if there was a link between ethnicity and COVID-19 in children.
6.4% of the children had tested positive for COVID-19 and 0.01% were admitted to hospital with it. Compared to white children, Asian children were 1.8 times more likely to have COVID-19 and black children were 1.12 times more likely.
Asian children were 1.62 times more likely to be admitted to hospital with COVID-19 compared with white children. All non-white children were more likely to remain in hospital for 36 hours or longer compared with white children.
Co-author of the study Professor Julia Hippisley-Cox, said “While children are at a substantially lower risk from COVID-19 compared with adults, this study suggests that race and ethnicity play an important role in outcomes for COVID-19 across all age groups. Our findings reinforce the need for ethnicity-tailored approaches to diagnosing and managing COVID-19 in community settings, so those families at most risk of severe illness are better informed and have greater access to tests.” (17)
In Conclusion
There are sound arguments to be made both for vaccinating and not vaccinating children in the UK. Some of the arguments even support both viewpoints.
As time passes we will know more about the safety profile of the vaccines in children, not least because other countries are already administering them to children. Hopefully there will also be more vaccine doses reaching poorer nations as the G7 countries and others pledge to send billions of doses overseas and there will no longer need to be a trade-off between who is vaccinated and who isn’t. In the interim, the middle ground may be to initially offer vaccination to those children at a higher risk of COVID-19.
(6) https://www.health.com/condition/infectious-diseases/coronavirus/immunocompromised-covid-vaccine
(15) WaPo 25 May CDC probes rare cases of heart inflammation in vaccinated teens, young adults May 25, 2021 at 12:18 a.m. GMT+1
(17) Saatci D, Ranger TA, Garriga C et al. Association between race/ethnicity and COVID-19 outcomes in 2.6 million children in England. JAMA Paediatrics 2021 21 June 2021. https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780966
