Caution about COVID vaccines for kids

Five separable but interrelated issues should inform policies about COVID vaccines for kids. First, what is the goal? Vaccine doesn’t prevent infection but it decreases the likelihood of severe disease. So any measure of efficacy must look at severe disease. Second, vaccines have side effects. Whether the risks are worth the benefits depends upon the frequency of adverse events and the likelihood of severe disease with or without vaccine. Third, how reliable are the studies of safety and efficacy? Studies use somewhat arbitrary age categories. Do we know enough about vaccine safety and efficacy in very young children? The virus mutates. We have to extrapolate from studies on last year’s variants to estimate this year’s efficacy. Finally, once we determine that a vaccine is safe and effective, we must decide how to get people to use it. Mandates have their own risks.

Given these five factors, it is not surprising that different people and different countries will come to different conclusions about the appropriate vaccine policy for children. In this issue of the journal, Abecasis argues against vaccination of otherwise healthy children for COVID‐19. The CDC disagrees. The UK national vaccination committee advised a ‘non‐urgent offer’ of vaccination to otherwise healthy children aged 5–11. Finland and Norway have taken a similar approach. Sweden decided in early 2022 against recommending these vaccines for children under 12. The FDA has very recently decided to approve the COVID for children under 5, so policies will have to consider that population as well.

There are points of agreement. COVID‐19 causes less serious disease in children than in adults. However, it is not risk free. Over 1200 children in the United States have died of COVID‐19. Estimates of the prevalence of long COVID in children vary widely. It would be best to prevent COVID-19 infection in kids if it could be done safely.

Parental attitudes mirror the differences in national policies. As of 7 December, only 11% of US children under age 5 and 32% of children 5-11 had gotten even one dose of vaccine.

Parents are weighing the benefits themselves. If their child has previously had COVID and recovered, they seem more concerned to avoid possible risks associated with vaccination. Differing parental attitudes could represent an opportunity to do an open‐label, non‐randomised prospective trial to refine estimates of vaccine efficacy.

Science can guide us in deciding whether COVID vaccine for children is safe enough and effective enough, even with the limitations stated in this article. But it cannot answer the question of how to decide what those ‘enoughs’ mean.

Pediatricians are in an uncomfortable position. Our professional organization recommends vaccine for all children. But we need to provie parents with balanced information to make decisions for their child depending on their family structure and the child's age and health.

At this point, the most urgent issue is to make the COVID vaccine available for every adult and older child in the world and to educate parents, patients and clinicians so that they can make informed decisions. Finally, it is imperative that any remaining uncertainty that parents or professionals have about COVID vaccination does not affect the uptake of other proven effective, safe, and vital childhood vaccines.