At the time of writing (24.09.2021), the majority of the UK have received not one, but both available coronavirus vaccines – numbers as high as 66.9% or over 44.6 million people. By the 23rd August this year, the government committed to offering all 16–18-year-olds a vaccination, before the return to schools, colleges and universities. Of course, this cohort has been of interests to ministers and epidemiologists alike as infections in this age range are typically the ‘gateway’ to infections travelling through the age groups to parents and older adults, with sociable young adults effectively vectors for transmission. On the progress in that cohort, health secretary Sajid Javid said, “It is brilliant to see tens of thousands of young people have already received their vaccine - thank you for helping to further build our wall of defence against COVID-19 across the country”. In the last few weeks however, the government announced that 12–15-year-old children will now also be offered a jab (from 13th September 2021), sparking content, relief, anger and concern in equal measure. The move comes after controversy and speculation of the efficacy of the vaccines in this age range, as well as issues of consent, risks, benefits, and trade-offs.
Back in July of 2021, the BMJ produced an open letter/blog on the topic of vaccinating younger children. Much of the narrative around this topic was based on the claim that by immunising younger children, the chain of transmission could be broken, particularly in dense settings like schools, nurseries and playgroups. The Center for Disease Control (CDC) in the USA estimate child mortality from coronavirus (in 0-17 years old) at 20 per 1,000,000. There are still debates about the rates of long-covid in children and UK statistics estimate this could be as high as 1 in 7, according to a paper published in the BMJ. There has been subtle dismissal of claims that children can get severely ill or have post-infection syndromes including chronic fatigue, all of which fall into the long-covid category. In the July paper, as many as 3 out of 4 children experienced significant side effects from vaccination in a Pfizer trial of 13-year-olds, namely flu type symptoms and pain.
Data coming out of Israel suggests that myocarditis (heart inflammation) from Pfizer’s coronavirus vaccine may be as high as 1 in 3000 to 6000 males (aged 16-24). It is these types of trade-offs that are assessed in clinical trials and by medicine agencies when pursuing therapeutic routes. In early September, the JCVI (Joint Committee of Vaccination and Immunisation) found negligible benefit when examining clinical evidence on efficacy of vaccines in the younger age group (12-15 years). It was not so much that the risks outweighed the costs (as in Israel and other countries), with the JCVI acknowledging the risks from covid to children and vaccines both being low. Their decision was based on a lack of evidence for significant benefit, a lack of data on long term effects, and a risk perceived as ‘not needing to be taken’.
In the context of the pandemic and the domination of the Delta variant (which emerged in March this year from India and the east), it has become apparent that vaccines are much more effective in preventing severe disease and death than they are at preventing transmission. Early observational data a year ago suggested Pfizer, the Oxford vaccine or Moderna vaccine could be upwards of 85% effective after two doses at preventing transmission. With Delta, it appears this may have dropped as low as 40-50%, which has lead governments around the world to commence booster campaigns to protect the most at risk. Thus, if the vaccine does not provide good onward protection of transmission, particularly in children, the JCVI may be justified in their decision making and perhaps expect a better outcome from other safe, non-invasive measures such as distancing, masks, and school isolation policies.
The four chief medical officers, however, have recommended vaccination programmes for children in 12-15 age group, when accounting for societal impacts, child mental health, school closures and the effect of isolation on the economy. This raises issues of consent, as the 17–18-year-old cohort are legally believed to have autonomy in decision making. In the 12-15 age group, however, there remains a desire from the government and the NHS to aim for full agreement and consent from the child and their parents. However, the clinicians are expected to use the Gillick competence in circumstances where children may want a vaccine, but their parents do not agree. This competence specified in such a way as, “As a matter of Law, the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.”. This is assessed by clinicians by the child’s understanding of the treatment, it’s implications, risks, benefits, and impact. Similar tension has risen in the past with the HPV vaccine (for cervical cancer) and raises a grey area over who gets to make such a decision, with occasional overruling by healthcare professionals themselves if they believe a treatment is in the child’s best interests.
Given the low incidence of death and serious outcomes from the vaccines, it does seem wise to advise vaccination for children. However, given the adverse event rate, this may deter some children and parents who are particularly sceptical. Some scepticism is to be expected, of course, and will have been bolstered by the poor handling of the pandemic by the government. The author postulates that it would be best to spread our health ‘investment’ so to speak, instead of putting it in one ‘basket’. If (and more importantly, when) a new variant emerges, any viral passage in those individuals who are partially vaccinated could provoke a future variant which may be even more vaccine resistant and thus the proportion of protection against infection could be expected to drop in line.
It would be more prudent to utilise tried and tested public health measure such as masks, distancing, and isolation, all measures we have seen the impact of in keeping community transmission low. It appears the government are towing the line on the vaccine giving immunity from infection, and yet this is not consistent with the amount of breakthrough infection and poor outcomes in the vulnerable, double vaccinated cohorts. A proactive and early approach is best to prevent severe surges is demanded by the evidence, yet the government is relying on old data which suggested an incredible efficacy in transmission. The author again postulates that, the impact on infection rate in schools may be greater with masks and ventilation than in vaccines. There is poor public health messaging around the purpose of vaccines, which were solely designed to prevent mortality and poor outcomes, and infection efficacy seen as a pleasant side effect. We still do not have any data on the capacity for long-covid to develop in children despite being vaccinated, and the way to prevent further transmission and community infection is to employ those public health measures we have tried and tested again and again. Letting the virus go through the age groups and school cohorts is immoral and could serve to create an even more virulent strain which could put us back months or years in our progress.