We Should Vaccinate Children in High-income Countries Against COVID-19, Too

Written by Lisa Forsberg, Anthony Skelton, Isra Black

In early September, children in England, Wales and Northern Ireland are set to return to school. (Scottish schoolchildren have already returned.) Most will not be vaccinated, and there will be few, if any, measures in place protecting them from COVID-19 infection. The Joint Committee on Vaccination and Immunisation (JCVI) have belatedly changed their minds about vaccinating 16- and 17-year olds against COVID-19, but they still oppose recommending vaccination for 12-15 year olds. This is despite considerable criticism from public health experts (here, here, and here), and despite the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) declaring COVID-19 vaccines safe and effective for children aged 12 and up—Pfizer/BioNTech in the beginning of June, and Moderna the other week.

In Sweden, children returned to school in the middle of August. As in the UK, children under 16 will be unvaccinated, and there will be few or no protective measures, such as improved ventilation, systematic testing, isolation of confirmed cases, and masking. Like the JCVI in the UK, Sweden’s Folkhälsomyndigheten opposes vaccination against COVID-19 for the under-16s, despite Sweden’s medical regulatory authority, Läkemedelsverket, having approved the Pfizer and Moderna vaccines for children from the age of 12. The European Medicines Agency approved Pfizer and Moderna in May and July respectively, declaring that any risks of vaccine side-effects are outweighed by the benefits for this age group.

In both countries, the refusal to recommend vaccination for eligible children has attracted criticism. Teacher unions have emphasised that it is not possible to ‘keep distance’ in school environments and that disease outbreaks will severely interfere with children’s education. Independent public health experts point out that we now have considerable evidence regarding the vaccines’ safety in children, and others have warned of the costs associated with adopting an approach that seems to make it overwhelmingly likely that many, or most, children will be infected with COVID-19.

The UK’s and Sweden’s decision conflicts with the approach taken in most other countries where vaccine supply is good. Their respective reasons for their recommendations not to vaccinate children under 16 have not been publicly articulated—Sweden’s FHM has in particular been notoriously non-transparent and unwilling to share any grounds on which they have made decisions during the pandemic, and JCVI have so far not shared the basis for their decision.

In this blog post, we examine two arguments commonly provided for the position that we ought not at present to provide vaccinations to children.

The argument from insufficient evidence

Proponents of the insufficient evidence argument hold that COVID-19 vaccination may not offer a favourable cost benefit ratio to children. The benefits of vaccination for COVID-19 may not outweigh the risks, because a smaller proportion of children get seriously ill or die in the acute phase of COVID-19 infection compared to adults, and vaccination can carry risks of which we know too little.

This argument was originally premised on the number of individuals who had been enrolled in the clinical studies on COVID-19 vaccination in children. With only this evidence, the argument perhaps had some plausibility. Now, however, we need no longer need rely on these studies for evidence. Many countries have been vaccinating children for months. Millions of children have been vaccinated. Serious side-effects discovered in large-scale vaccination programmes have been extremely rare.

Moreover, the risks of COVID-19 infection have increased with the Delta variant, which is more transmissible, including among children (see here, here, here, and here). Even if only a small proportion of young people get seriously ill or die in the acute phase of the infection, high numbers of infected individuals will mean that a sizeable number of children will get seriously ill. A small proportion of a high number is a large number.

In addition, while opponents of vaccination tend to focus on risks of serious illness or—especially—death in the acute phase only, it is now very well established that children and young adults are at risk of other adverse outcomes when they get infected with Covid. These outcomes—which are a lot more common than death and hospitalisation in the acute phase—include long covid, MIS-C, various kinds of organ damage, and—particularly worrying—cognitive and neurological problems (see also here and here).

Those offering the argument from insufficient evidence often fail to compare risk profile of vaccines to the risk profile of largely uncontrolled COVID-19 infection spread. We know that vaccination offers protection against severe illness and death. We know less about whether it offers protection against long-term health effects, such as long covid. But vaccinating children means fewer infections, and therefore fewer individuals affected by long-term health complications. Conversely, not vaccinating and letting infection spread means a larger number of individuals infected, and a larger number of them developing long-term health complications. Again, a small proportion of a very large number will be a large number. So the idea that ‘only a small proportion’ get severely affected is a lot less compelling when children are infected at a large scale.

As we noted previously, parents and states have obligations to protect children from various risks of death and injury, and we adopt many other measures to avoid preventable paediatric deaths. Notably, we normally do a lot to prevent paediatric deaths also from causes affecting only a small proportion of children (e.g., chicken pox). Failing to protect children from being exposed to COVID-19 with the knowledge of the risks infection carries seems to represent a serious moral failing on the part of states, societies, and individuals who let it happen, or who defend approaches allowing it.

One might wonder what level of uncertainty about risk would satisfy proponents of the argument from insufficient evidence. What kind of evidence would proponents of the wait and see approach like to see, before they conclude that vaccinating children is ethically defensible, or obligatory? And how many young people dead or injured from COVID-19 infection are they willing to tolerate, before they conclude that vaccination is ethically defensible, or obligatory? It would be interesting to see a risk-benefit analysis by proponents in which these questions were addressed. Neither UK’s JCVI nor Sweden’s FHM has so far produced a risk-benefit analysis supporting their decision not to recommend that adolescents get vaccinated. Other public health experts have produced such risk-benefit analyses showing the benefits of vaccines far outweigh any risks.

(An aside. It is important to emphasise the benefits of COVID-19 vaccination for children, as some have argued that uncertainties about its safety and efficacy undermine vaccine mandates for COVID-19. If public health experts are correct in this risk-benefit analysis, mandates are not undermined for this reason (and, in any case, uncertainty about vaccine safety and efficacy cannot undermine an in-principal argument for mandating vaccination).)

In reply to the now considerable data regarding vaccine safety and the negative effects of COVID-19 infection, opponents of vaccination have sometimes recast the insufficient evidence argument to focus on the long term. They may accept that we have sufficient data to conclude that the vaccine is safe and effective in the short term. But, they may insist, uncertainties persist about its long term effects. This argument might buttress the conclusion of this argument if the alternative to vaccination was risk free. But the alternative to vaccination against COVID-19 is not risk free – on the contrary. It involves significant risk of covid infection. We have at present no reason to believe vaccination will have long-term negative effects, while we do have good reason to believe that covid infection will carry long-term negative effects. Given what we know about COVID-19 at this point, then, the insufficient evidence argument against children’s vaccination looks increasingly disingenuous.

The argument from global equity

Proponents of the argument from global equity argue that it is inequitable to provide vaccines to children in high-income countries over more vulnerable individuals living in low- and middle-income countries. It is unfair to provide vaccines to individuals at low risk of severe illness over those at much higher risk of severe illness who lack access to vaccines through no fault of their own (including older individuals and health care workers living in countries with low vaccination rates due to vaccine scarcity).

There are three main problems with the argument from global equity against vaccinating children against COVID-19.

First, the argument from global equity could easily have been but was not appealed to earlier in the vaccine rollout process. Many healthy adults living in wealthy countries like the UK and Sweden have been vaccinated for months. But most healthy adults in wealthy countries were much less vulnerable than many individuals living in low- and middle-income countries. So by the argument from global equity, healthy adults should not have been given priority for vaccination over the (often much) more vulnerable. The former could much more easily shield and wait for vaccines which would have produced greater benefit had they been given to the latter, vulnerable populations in low- and middle-income countries. It is therefore curious to raise claims of global equity only when considering whether to vaccinate children. Indeed, appeal to the argument only at this juncture looks rather disingenuous.

Second, it seems somewhat unfair to impose the burden of the demands of global equity on children, who have already shouldered great burdens for the purposes of controlling infection spread, including lost educational and social goods, many of which such goods may not easily be replaceable by other, future goods. Of course, one reason it might not be unfair to impose the burden of the demands of equity on children is that children are at much less risk from COVID-19 infection than adults. But, as we have argued above, it does not seem obvious that children are at much less risk from COVID-19 infection overall. We cannot, in any case, be certain this is the case given the potential long-term health consequences of infection from COVID-19.

A core feature of our common-sense moral thinking is that we are permitted to give more weight to the interests and needs of those with whom we have close social relations and bonds (e.g., co-nationals) over those living in other (even developing) nations. It is possible that behind the decision to give priority to adults in high-income countries is commitment to this permission of partiality. This permission might justify giving vaccines to adults in the high-income countries over those in low- and middle-income countries. An appeal to this aspect of common-sense morality will not, however, help defend the claim that we ought to delay providing vaccines to eligible children. After all, the permission to give priority to adult co-nationals would also, it seems, justify giving vaccines to children co-nationals in high-income countries over more vulnerable individuals in low- and middle-income countries. We might be permitted to give priority to our children even in the case where the threat to them of COVID-19 infection is less severe than it is to adults.

Now, of course, it is possible defenders of the claim that we ought to delay vaccinating children think we got it wrong when we gave priority to adults in high-income countries. We ought to have been more impartial in how we distributed vaccines. We should not continue to do what is wrong, the argument might continue, by giving priority to eligible children in high-income countries; instead, we should make them wait until (a sufficient number) of the more vulnerable in low- and middle-income countries are vaccinated.

This line of argument presupposes that we have to choose between vaccinating children in high-income countries and the more vulnerable in low- and middle-income countries But it is false that we have to choose whom to vaccinate in this case. And this is our third point. We ought not accept the austerity narrative upon which the argument from global equity is based: the false claim that vaccine scarcity means choosing between vaccinating children in high income countries and vulnerable individuals in low- and middle-income countries. Vaccine scarcity is not a result of a forces outside our control; it is the result of political and policy choices made by rich countries.

Recently, we have seen Pfizer and Moderna price gouge their covid-19 vaccines. This gouging is occurring in the middle of a pandemic which has killed many millions of people, and which kills and injures more people each day it is permitted to continue. Leaders in rich countries let them do so.

People in poorer countries deserve access to vaccines now; they should not be forced to wait until rich countries decide whether to donate a small number of doses they would otherwise have used to vaccinate children. The most efficient way of securing access would be to temporarily waive intellectual property (IP) protections for coronavirus vaccines to allow the scaling up of vaccine production. As a recent Nature editorial notes: ‘Every country should have the right to make its own vaccines during a pandemic’. The campaign for temporary waivers initiated by India and South Africa has been backed by more than 100 countries, and international organisations such as the World Health Organization and UNAIDS. The UK and Sweden are among the countries blocking the initiative. Countries like India have excellent facilities for manufacturing pharmaceutical supplies. Low- and middle-income countries are not unable to produce vaccines; rather, they are denied the opportunity to do so by rich countries (see also here).

But not only are the UK and Sweden opposing IP waivers that would allow middle- and low-income countries to manufacture vaccines to protect their populations. They are also not donating vaccines to any meaningful extent. The UK diverted 10 million doses from India at the height of their Delta variant crisis. They have been cutting foreign aid; they are donating almost nothing to the COVAX vaccine access initiative, or by other mechanisms. Sweden has so far donated small amounts.

The vaccination of children in the UK and Sweden has been delayed, but there is nothing to suggest that it is being done as a necessary condition of discharging their obligation (of fairness) to provide vaccines to those living in low- and middle-income countries. Instead, rich countries are wasting excess supply, hoarding it to potentially use as booster doses for their own population in the future, or saving on buying in the first place (aiming for ‘hybrid immunity’). Children in rich countries are not being asked to wait, or being sacrificed, for some noble cause, that is, to benefit people in poorer countries.

None of us will be truly safe until the pandemic ends. Ensuring that the world is vaccinated is both an imperative of fairness and in each of our self-interest. We should be calling for effective measures, including IP waivers, to make this happen. We should not support narratives that let leaders in rich countries pretend that their refusal to vaccinate children is motivated by concern for the wellbeing or fair treatment of people in countries they are actively denying access to vaccines.

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7 Responses to We Should Vaccinate Children in High-income Countries Against COVID-19, Too

  • Alberto Giubilini says:

    Thanks for this interesting post. I disagree, as you can imagine.
    In particular, you claim that there is a risk of “long covid” in children, but to support your claim you link a Twitter thread by some doctor, which talks about the effects of other viruses, not covid, and then a study that does not seem to say anything about the risk of long covid in children. If I understand the study well (but I might be missing something), the study is based on an observation of 7 (seven) children with possible “long covid”, and it compares them with 21 healthy children. This says nothing about the risk of long covid in children. Indeed, the study merely concludes that “these results provide arguments in favour of possible long COVID in children”, but it is not meant to be an assessment of the risk.
    Using this study to claim that children are at risk of long covid – assuming I understand the study correctly – does not seem to be different from what the anti-vaxxers often do, i.e. pick a few cases of adverse effects of the vaccine and then claim that therefore vaccines are risky.
    The other study you link about neurological disorders is not specifically about children.
    Vaccinating children would further protect older people, who are already vaccinated with vaccines that are very effective against serious symptoms. If we want an extra layer of protection that makes us feel even safer, vaccinating children would give us that. But whether that is justifiable remains to be proved, as it is not clear that children would benefit much or at all from that and it is not clear that we are entitled to feel safer.

  • SarahP says:

    Many children have already had COVID, and the evidence suggests natural immunity is much better than vaccine immunity. You would not CHOOSE it instead of vaccine immunity because it probably has higher risk to get it, but once they have natural immunity, adding vaccines is adding a risk for a likely zero or negligible benefit. They should take an antibody test first at least. That’s important because as you say, a small proportion of a large number is a large number: vaccinating all children whether they need it or not will see children being avoidably harmed.

    There has already been tons of over confidence in the vaccine- it would stop transmission, it would prevent long COVID, it would be long-lasting, which all now look shaky, overstated, or plain wrong. We shouldn’t be over-confident about the long term effects and ignore those who have already taken on the risk of COVID and have nothing to gain from vaccination to make us feel better about our vaccination rate.

    We should not just carry on making policy in the hope that enough vaccines will end this thing. It’s surely time to apply some of the information we have about the value of natural immunity.

    • Lisa Forsberg says:

      Thanks for your reply, Sarah. It is far from clear that natural immunity is all things considered better than vaccination. You concede that it would be wrong to opt for natural immunity when we have a safe, effective and readily available vaccine for COVID-19. Moreover, some evidence suggests that it is beneficial to be vaccinated once one has been infected with COVID-19. Recent studies show that vaccination after infection supplies more robust immunity than both vaccination or recovery alone.

      You are right that we should be careful not to be more sanguine about vaccines than the evidence favouring them allows. At the same time, we have good reason to be confident in the effectiveness of vaccines, including with respect to long covid. A recent study found evidence that COVID-19 vaccination significantly decreases one’s risk of long covid in the event of an infection. In addition, vaccination provides a layer of protection against COVID-19 infection. It is one tool in the fight against COVID-19 alongside physical distancing, masking, proper ventilation, among other non-pharmaceutical interventions.

      Anthony, Isra, and Lisa

  • Alberto Giubilini says:

    Indeed, the advice of the JCVI just published does not recommend vaccinating children, on the basis of consideration of children’s interests. The main reason is precisely that , if we focus on the health interests of children, we really don’t know enough about the risks of the vaccine to say that it’s in their best interest, given the extremely low risk posed by covid on them (including long covid: the risk for children is almost non-existent).

    As the JCVI document says, “When deciding on childhood immunisations, the JCVI has consistently maintained that the main focus should be the benefits to children themselves, balanced against any potential harms to them from vaccination”. And also “There is evidence of an association between mRNA COVID-19 vaccines and myocarditis. This is an extremely rare adverse event. The medium- to long-term effects are unknown and long-term follow-up is being conducted. Given the very low risk of serious COVID-19 disease in otherwise healthy 12 to 15 year olds, considerations on the potential harms and benefits of vaccination are very finely balanced and a precautionary approach was agreed.”

    Once we accept this, we can then have all the arguments we want about the societal interests, the interests of teachers, the interests of the most vulnerable, to justify vaccinating children. But we need to be clear that those are the kinds of justification provided. At this stage, there is no solid enough ground to claim that it is in the children’s best medical interest, given current state of knowledge, to get vaccinated. This might change, of course, but in the meantime, it would just be another way of using children, once again, to pursue the interest of older people.

    • Lisa Forsberg says:

      Thank you for your replies, Alberto.

      This is a blog and we aim to provide publicly accessible resources for readers as much as possible, as opposed to those that are paywalled. Also, unlike academic articles, we cannot and do not claim to provide an exhaustive literature review.

      To perhaps put some daylight between ourselves and members of the anti-vaccination community–and indeed members of the Great Barrington Club–and reassure you of our bona fides, below is some evidence on the prevalence of long covid among children:

      There is more evidence than we provide in our post to support our claim about long covid in children. Two sources seem especially pertinent. The Office of National Statistics (ONS) recently released its latest estimates of the prevalence of self-reported long covid. According to the ONS, 1 in 1000 children aged 12-16 have long covid lasting more than one year (table 6). A recent study – the world’s largest on long covid and children – suggests 1 in 7 children who received a positive PCR test result for COVID-19 had three or more long covid symptoms after 15 weeks (see also here). This supports our claim about the benefits to individual children of vaccinating them against COVID-19.

      The studies on the long-term cognitive and neurological effects of COVID-19 infection have been conducted on people 18 years of age and up. But, as Arian Owen states in the TVO segment we linked (here), there is no reason to hold that the cognitive effects of COVID-19 infection will be different for children. The cognitive effects of COVID-19 infection of children are unknown but if Owen is right, then, again, this supports our claim about the benefits for individual children of vaccinating them against COVID-19.

      You refer to the recent decision by the Joint Committee on Vaccination and Immunisation (JCVI) not to offer COVID-19 vaccination to all children aged 12-15. The JCVI claim the benefits of COVID-19 vaccination for children aged 12-15 are only “marginally greater than the potential known harms”. They think a marginal benefit is not sufficient to warrant offering vaccinations to all children aged 12-15. The JCVI claim to be reasoning to their conclusion primarily from a “health perspective”. We think even based on this perspective JCVI’s decision is wrong.

      First, the JCVI argue, e.g., that 92.76 hospitalizations and 2.54 PICU will be prevented per million courses of COVID-19 vaccination provided to healthy children aged 12-15. One might not agree that this counts as a “marginal” benefit. It might be well worth the risk of 15-51 cases of myocarditis which are “typically self-limiting” and resolved in a “short time”.

      Second, it is unclear exactly what falls within the health perspective. The JCVI ignore long covid and potential negative cognitive effects of COVID-19 infections. If vaccination decreases the risks of COVID-19 infection, and so decreases the risk of these threats to health, it is likely that the benefit of COVID-19 vaccination is more than marginal from the health perspective (especially given the Delta variant and the threats posed by few, if any, measures in place in schools to protect children from COVID-19 infection).

      Third, the JCVI consider (it seems) only direct health effects rather than both direct and indirect health effects. We must consider both for the purpose conducting a cost benefit analysis of COVID-19 vaccination for children aged 12-15. It is highly likely that cases amongst children will rise once children go back to school (as they have in America). Even if a child is fortunate enough not to contract COVID-19 their education may be disrupted by rising infections which in turn might have negative effects on mental and physical health, especially in children living in areas and belonging to social groups already disadvantaged. These costs to health may be significantly reduced by vaccinations against COVID-19.

      Fourth, the JCVI maintain that one of the risks of COVID-19 vaccination is myocarditis. It is not a very significant risk, however, since, as they note, it is very rare and “typically” cases are “self-limiting” and resolved in a “short time”. And this cost has to be weighed against the cost in terms of myocarditis due to a COVID-19 infection itself. Recent studies (here and here) conclude that one is 6 times more likely to get myocarditis from a COVID-19 infection than from vaccination. The risk of myocarditis from vaccination is significantly outweighed by the benefits of vaccination in terms of myocarditis.

      For the avoidance of doubt, our claim is that a small proportion of a large number may itself be a large number.

      Anthony, Isra, and Lisa

      • Alberto Giubilini says:

        Thanks.

        Once again, leaving aside the new Twitter thread (I don’t comment on those), the new study about covid complications (myocarditis) that you now link is not about children, so I am not sure how it supports the claim that covid vaccines’ are in children’s best interest. We need evidence specifically about children. I am happy to change my mind on child vaccination if presented with evidence of serious risk of ‘long covid’ including severity of symptoms outweighing the absolute risks posed by covid. You don’t provide that, simply because we don’t have it yet, as far as I know.

        In my new blogpost I provide some reference to studies showing the low prevalence of long covid in children and young people (e.g. Sudre, C.H., Murray, B., Varsavsky, T. et al. Attributes and predictors of long COVID. Nat Med 27, 626–631 (2021),), as well as the fact that long covid is associated with age, as is death and severe symptoms. More generally, it explains how data on covid and vaccine complications varies by age, which is why it is important to understand the risks of each by age group and not to assume a one-size-fits-all approach to vaccination.

        Here you now link a study that says that the risk of myocardatis following covid diagnosis in children is 0.04%. Even assuming that that it is high (is it?), here you focus on a single factor. As this other study shows Høeg et al 20021 ://www.medrxiv.org/content/10.1101/2021.08.30.21262866v1, while that risk of myocarditis following covid is slightly higher than the risk of myocarditis after the vaccine (0.01%), it remains true that “the rate of cardiac adverse events after the second dose exceeded the expected rate of 120 day covid-19 hospital admission at both a moderate (August 2021) and a high (January 2021) incidence of SARS-CoV-2 infection (BMJ 2021;374:n2251)” This is the type of consideration that grounds the JCVI’s decision. We need to consider the whole picture, not cherry pick the factors that support one’s side.

        Then you reference another new study that says that 14% of children 12-15 who had a positive PCR report at least 3 symptoms 15 weeks after the test. Three things here: first, 14% of the children who had a positive test is not 14% of children that caught the virus, as these are mostly asymptomatic cases, so many of them went undetected. That percentage is therefore much smaller if we talk about children that got infected. Indeed, not surprisingly, the ONS data you mention says that “self-reported” symptoms of long covid in children is 1 in 1,000. That is a huge difference between the two figures. Such differences might also be due to the fact that ‘long covid’ is measured by “self-reported” symptoms, including things like feeling tired, and does not include information about severity of symptoms. (if you look at studies on ‘long covid’, you will see how much results differ, because the concept is not very well defined and it is mostly based on self reporting)

        Second, this is one study among several, some of which get to different conclusions, including the one I have referenced above and in my blogpost.

        Third, we really need to put ‘long covid’ into perspective and distinguish among cases of serious and less serious long covid. One of the symptoms in that study is “unusual tiredness”. Feeling tired is bad, of course. But if we don’t know well what the actual long term risks of vaccines for children are, it is not clear to me that “unusual tiredness” tips the risk/benefit balance in favour of vaccines, especially since there’s no information on severity (the ONS does not provide that). But this is exactly what the JCVI says: basically we know so little about the risks of these vaccines that the marginal benefit compared to the “known’ harms does not suffice to say that the marginal benefit is enough. Quite simply, the “unknown’ weighs more.

        Finally, I think it is important that policy makers and parents understand the evidence, including why risks – whether of covid or vaccination – are different for different age groups, and that we can help this analysis by discussing these issues. By contrast, grouping everyone who differs as part of a ‘community’ or part of a ‘club’ tends to limit analysis. I am more interested in arguments and evidence than some kind of group identity. It makes it easier to change one’s mind.

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