If under-18s are vulnerable, let’s jab straight away. Then we need a wider plan that doesn’t leave teenagers as the unvaccinated ‘class apart’
The UK vaccination programme has been an extraordinary success. However, as most adults become “double jabbed”, it is the unvaccinated who are left to catch and spread this virus. This throws the spotlight on to children, teenagers and schools. We can see this already, with infection rates rising in teenagers and young adults (who are only starting to be vaccinated) but staying low among the doubly-vaccinated middle-aged and elderly.
What to do? Should we vaccinate teenagers (and, later, younger children)? I asked my own in-house expert, my teenage son. He felt he didn’t need a vaccine but would have one “if it made things go back to normal”. Just one view, but it made me think that one answer to our dilemma is to seek the views of teenagers; it strikes me as both puzzling and remiss that their voices have been largely absent. We would never consider vaccinating other minority groups without seeking their opinion, and yet almost all surveys report the views of parents rather than young people.
About 40% of teenagers have Covid antibodies, meaning they’ve already been infected… which tells us many are already protected
There’s no doubt children and teenagers can catch and spread coronavirus. Primary school children appear less likely to catch it, but we know that about 40% of teenagers have Covid antibodies, meaning they’ve been infected over the last year. This is important as it tells us many are already protected, but it is nowhere near enough.
The majority of children and teenagers have silent Covid infection – or almost no symptoms. The risks of them becoming severely ill are very low and of dying from Covid extremely remote. There have been about 30 deaths of under-18s over the first pandemic year, giving an overall risk close to two in a million. The majority of deaths in under-18s have been in children with severe medical conditions or disabilities, who are vulnerable every winter regardless of Covid.
The risk of dying of Covid for otherwise healthy children is closer to one in 2 to 3 million. Any death of a child is one too many. Yet it is important to put this in context. Before Covid, we lost nearly 2,000 under-18s (excluding premature babies) each year from a range of illnesses and accidents, averaging 15 a year from influenza. The benefits of vaccination for teenagers are threefold. First, the reduction in risk of them becoming ill. Second, the reduction in transmission to vulnerable adults. Third, the benefits of less disruption to their lives and schooling. The benefit from reducing the risk of illness is very small for healthy teenagers. There’s undoubtedly much more benefit for teenagers with underlying medical conditions or disabilities. But the risks of post-Covid syndromes (also called “long Covid”) in children are unknown and need to be factored in. I say unknown because we only have data on numbers of infected children who have persisting symptoms.
There are worrying reports of up to 25% of infected children having continuing problems. However, this ignores the very high levels of fatigue and headache that even healthy teenagers have reported. We need to know what Covid brings on top of the common symptoms of daily life. This data should be with us soon.
Reducing transmission to vulnerable adults is the largest benefit of vaccination of teenagers. But there are ethical questions about vaccination of individuals to primarily benefit others. We have precedent in doing this, in that we vaccinate children against rubella to protect pregnant women and their unborn babies. We also vaccinate teenage boys against HPV largely to protect teenage girls and the women they become. But in doing this, the safety “bar” needs to be very high.
The risks of vaccinating teenagers are twofold: any side-effects of vaccination, and using scarce vaccine supplies that might be better deployed elsewhere. We currently only have vaccine safety data in teenagers from the Pfizer and Moderna trials for about 3,000 teenagers, although only the Pfizer data has been fully published. The trials reported that the vaccines were highly effective and very safe, and Pfizer is licensed for use in teenagers in the UK. The US and some European countries are now rolling out vaccines for those over 12.
There have been reports of very rare side-effects of these vaccines in young men in the US and Israel, although almost all cases have been mild and the particular condition (myocarditis) appears much more common with Covid than after vaccination. This reminds us that, while the trials in teenagers were extremely positive, all vaccines will have very rare side effects and we need data from much larger numbers to fully understand the risks.
Other benefits and risks are much more difficult to quantify. How do we value the reduction in disruption to education?
The Joint Committee on Vaccination and Immunisation (JCVI) will be looking carefully at balancing the risks of severe illness and death against risks from the vaccine. These are relatively easy to put numbers on. However, the other benefits and risks are more difficult to quantify. How do we value the reduction in disruption to education?
My conversation with my son reminded me that reducing the disruption of education and the freedom to see friends without anxiety and controls must not be underestimated – particularly as the pandemic has taken a high toll on children’s mental and physical health and learning opportunities.
So, where have I landed? Without trying to second guess the JCVI, I believe it is reasonable to now offer to vaccinate teenagers with chronic diseases and medical conditions that make them more vulnerable. As for healthy teenagers, let’s first use our vaccine supplies to raise adult vaccination levels as high as possible, provide boosters for the elderly and fulfil our promises to provide vaccines for poorer countries. Then, we should vaccinate healthy teenagers once we have adequate safety data – but for this we must wait.
Vaccination will be one of the most important things we can do to normalise children’s lives and reduce the harms the pandemic has already brought them. It will also counter what I sense as a coming danger, evident in how some countries are now allowing in vaccinated UK adults and children under 12. Let’s not end up in a place where unvaccinated teenagers are treated as a class apart.
Russell Viner is a paediatrician and professor at the UCL Great Ormond Street Institute of Child Health
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