Moderna and Pfizer have released data suggesting that their vaccines are well tolerated in adolescents and highly effective in preventing COVID-19. Canada, the US and the EU have already authorised the Pfizer vaccine in children as young as 12. And the UK has just approved the use of the Pfizer vaccine in children aged 12 to 15. But there may a case for holding out on an immediate rollout, for several reasons.
Whether a vaccine is beneficial for someone depends on three things: how likely they are to become seriously ill from the infection, how effective the vaccine is, and the risks of vaccination.
Children have less severe COVID-19 than adults. A recent study across seven countries suggests that there were less than two in a million COVID deaths in children. Even if the vaccine is highly effective in children, it can only eliminate an already tiny risk. Of course, there are other problems, such as long COVID, but we don’t know yet how common this is in children.
We also have to weigh the benefits against vaccine side-effects. So far, trials are reassuring, but those studies only gave the vaccine to about 3,000 young people (aged 12 to 17). They are not large enough to identify rare events. For example, the blood clots associated with the AstraZeneca vaccine were not seen in the much larger initial adult trials.
The US Centers for Disease Control and Prevention (CDC) is looking into reports of heart inflammation in teenagers and young people who have received COVID vaccines. We don’t know whether these are indeed related to the vaccines, what a true rate might be or if this relates to children.
Because of residual uncertainty about the safety profile and the relatively small benefit in a low-risk population, we cannot be sure that COVID vaccines will overall be in children’s best interests.
The moral questions
As well as direct benefit, vaccines have an important indirect benefit: they reduce the spread of the virus and stop other people from being infected. If you can help others in a significant way, at little personal cost, risk or burden, you have an ethical duty to do so – a so-called duty of easy rescue.
Vaccinating children could help to achieve herd immunity and protect older adults. For this reason, some ethicists advocate targeting flu vaccination programmes at children.
There is data to suggest that adults living with children may be at increased risk of infection and hospital admission. There is also some concern that a large number of cases of new variants may be occurring in younger people.
Meanwhile, evidence is emerging that the COVID vaccines do prevent transmission of the virus. However, vaccine-induced herd immunity may not be possible if virus variants are able to evade antibody protection.
Next, a duty of easy rescue only applies if an intervention is low risk. It applies to tried-and-tested vaccines, such as flu, but we don’t know that for sure about COVID vaccination in children.
Also, despite their low risk from COVID itself, the pandemic has had a huge toll on children’s mental health and educational development. It may not be fair to impose further duties on them, given the sacrifices they have already made for older people.
If herd immunity is indeed possible, it can potentially be achieved by vaccinating 60% to 70% of the population. In the UK and many other countries, that would be possible without vaccinating children.
But there is a final, even more important reason why, at the present time, vaccinating children would be wrong. There are massive inequalities in global vaccine distribution and access. For example, last month Nepal suspended its vaccination programme because of lack of vaccine supply, despite a massive surge in cases. Only 2.5% of its population have been fully vaccinated so far.
Peru, which recently recorded the highest number of COVID deaths per capita in the world, has only fully vaccinated 4% of its population. Given current data, 13 million vaccine doses (enough to vaccinate all of the UK’s children) could prevent many thousands of deaths in a country like Peru.
This argument is partly altruistic. The UK, for one, should be giving vaccines to adults at high risk of serious illness in countries in urgent need of vaccine, rather than to low-risk populations, such as children within its own borders. But it is also in the UK’s interests.
As others have highlighted, the emergence of more transmissible coronavirus variants in countries with low vaccination rates means that the UK may be facing a particularly dangerous phase of the pandemic. In the short term, we urgently need to achieve widespread vaccination of the vulnerable in countries at greatest need. If the virus is allowed to rage in countries unchecked, there will be a risk of further waves of coronavirus even in countries with high rates of vaccination.
These concerns are likely to change. Greater evidence will lead to greater confidence that vaccinations are safe in children and young people. Greater international distribution of the vaccine would mean that doses for young people in developed countries will not come at the cost of those in poorer countries at a much higher risk of dying.
But for the coming months, and possibly longer, COVID vaccination campaigns in high-income countries should not include children.
Dominic Wilkinson receives funding from the Wellcome Trust (203132/Z/16/Z) and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation Pandemic Ethics accelerator https://ukpandemicethics.org (AH/V013947/1).
Jonathan Pugh works for The University of Oxford. This work was supported by the UKRI/ AHRC funded UK Ethics Accelerator project, grant number AH/V013947/1.’ The UK Ethics Accelerator project can be found at https://ukpandemicethics.org/
Julian Savulescu receives funding from eceives funding from the Wellcome Trust (203132/Z/16/Z) and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation Pandemic Ethics accelerator https://ukpandemicethics.org (AH/V013947/1). He is a Partner Investigator on an Australian Research Council Linkage award (LP190100841) which involves industry partnership from Illumina. He does not personally receive any funds from Illumina.