Vaccinating children against COVID-19 remains ethically controversial. In this webinar on 13 Sept, which attracted over 400 global attendees, a panel of experts considered the ethics and justifications of doing so.
To watch the webinar ‘Children and COVID 19 vaccination: Ethical Issues and Considerations’ click here
- Lisa Forsberg, British Academy Post-Doctoral Fellow, Faculty of Law, Oxford Uehiro Centre for Practical Ethics, University of Oxford, UK
- Beate Kampmann, Professor of Paediatric Infection & Immunity, Director of The Vaccine Centre, London School of Hygiene & Tropical Medicine, London, UK
- Govind Persad, Assistant Professor, Sturm College of Law, University of Denver, Denver, Colorado, USA
- Anthony Skelton, Associate Professor, Department of Philosophy, Rotman Institute of Philosophy, University of Western Ontario, Canada.
- What are the ethical considerations and issues associated with vaccinating children against COVID-19 given known risks and benefits and a context of relative uncertainty?
- Where COVID-19 vaccinations have been authorized for children, should vaccination be made mandatory in schools?
- Where COVID-19 vaccinations have not been authorized for children, should they ever be given off-label to this population?
- Because children tend to be at lower risk than some other populations, should countries refrain from vaccinating children until the most vulnerable are vaccinated globally?
Dr Anthony Skelton began the seminar by considering the indirect and direct health benefits of vaccinating children against COVID-19. These include the prevention of death, severe infection, long-term illness, and the reduction in mental and physical health burdens associated with closing schools. Dr Skelton posited that these benefits outweigh any risks and highlighted that myocarditis, which is considered one of the main risks associated with paediatric COVID-19 vaccination, is more likely to occur as a result of COVID-19 disease. He also notes the UKs Joint Committee for Vaccination and Immunisation (JCVI) concluded on balance, vaccinating children against COVID-19 is beneficial. In relation to the 2nd question about mandatory, paediatric vaccinations, Dr Skelton argued that that the state has an obligation to protect children from parents or guardians who might expose them to avoidable harm. Paediatric COVID-19 vaccination is an extension of this obligation; and would furthermore accord with how the state protects children from other areas of risk, such as car seats, and vaccines for other infectious diseases. Finally Dr Skelton considered that the question of whether we should vaccinate healthy children from high income countries (HICs) before vulnerable adults in low and middle income countries (LMICs) is misleading. It assumes there is a vaccine shortage; however, evidence suggests vaccine hoarding and waste is more a driving force of inequity. While ethical fairness would assume we should redistribute vaccines, this would not completely solve the problem of unequal access. Instead the relaxing intellectual property rights and sharing vaccine recipes is a more radical solution which would result in substantial welfare gains worldwide.
Drawing on her experience as a vaccinologist in the UK and West Africa, Professor Beate Kampmann suggested a more cautious approach might be warranted. While there are several reasons as to why children should be vaccinated against COVID-19, they need to be interpreted in the broader context of equity of access. In terms of paediatric health, Professor Kampmann notes that evidence points to the fact COVID-19 presents as a relatively mild disease in children, with a relatively low risk of death of around two per million (Viner, et al. 2020). While data is still emerging in regard to long COVID, evidence suggest it appears to affect 1-10% of paediatric COVID-19 patients. An ongoing study, suggests only 1.56% of children with long COVID have symptoms beyond day 56, on par with other post-viral non-COVID-19 respiratory illnesses (Molteni, et al. 2021). Professor Kampmann said fundamentally we have to know that COVID-19 vaccines are safe, immunogenic and efficacious in paediatric populations. At present, the only data available is from phase 1 and 2 trials of the Pfizer-BioNtech vaccine which included children. Until we get new data from the 40 international trials currently recruiting, concerns need to be taken seriously. Touching briefly on the argument that children should be vaccinated to protect vulnerable adults, Professor Kampmann highlighted the fact the UK already recommends this for children who live with immunocompromised adults and other vulnerable adults should already be vaccinated. Finally Professor Kampmann argued the UK’s cautious approach in regard to paediatric vaccinations aligns with the World Health Organisation’s approach, and is due to the evidential risk of myocarditis which is not yet fully understood. Returning, to the broader context of vaccine equity, she argued it is important not to jeopardise other childhood immunisation campaigns in LMICs via the implementation of broad COVID-19 vaccination campaigns, which could stress resources further.
In the third presentation Dr Govind Persad considered the ethical dimensions of discussions about vaccinating children via the lens of prioritisation. While age can be considered one factor in prioritisation decisions, age-only prioritisation is not necessarily appropriate. A World Bank Working Paper by Gabriel Demombynes (2020) shows age-based mortality curves are flatter in LMICs. A US study by Bassett and colleagues (2020) also highlighted racial and ethnic disparities in COVID-19 age-based mortality rates. Both studies show age-based risk is not necessarily uniform. Dr Persad also noted that paediatric vaccinations are unlikely to be a driver of global injustice and that scarcity and inefficient usage are a more likely culprit. Dr Persad then turned his attention to off-label prescribing, arguing while it would preferable if everyone who wanted to access a COVID-19 vaccinations could do so through trials; this is not happening. As a result off-label prescribing, needs to be considered as an ethical approach to reduce harm. In regard to schooling, Dr Persad also argued that the benefits of paediatric vaccination outweighs risks. However, if the goal is to prevent COVID-19 in unvaccinated adults, it could be more appropriate to mandate adult vaccination. If education is a fundamental interest then excluding people based on vaccination status works to the disadvantage of children who have vaccine hesitant parents. In his concluding remarks Dr Persad spoke of ethical factors that go beyond a basic risk-benefit analysis. For example, vaccinating children could be considered favourable because of the ‘fair innings’ arguments which suggest resource prioritisation should favour those who have not yet had the opportunity to live a ‘normal’ lifespan. Furthermore, children don’t have the same capacity as adults to control their exposure to COVID-19 and are thus entitled to protection. However as COVID-19 risks do in general increase with age, when viewed in the context of scarcity, concerns could arise that vaccinating children could increase global vaccine inequity.
Questions and Answers
There were several questions put to the panel regarding vaccinating children in the context of uncertainty. On the one hand it could be argued that, we should wait until we obtain more research data before committing to paediatric vaccinations. In contrast, given the current real world data, questions arise about whether the idea of waiting longer while children remained at risk was an appropriate position. The panel also discussed the case for mandating vaccines for children. Although the case for adult vaccination mandates was considered stronger, questions arose about whether mandates could potentially be justified in children, on the grounds children can’t control their exposure to COVID-19. A contrasting view is that rather than focusing on mandates, attention should be focused on global vaccine hesitancy which poses more a problem. In relation to vaccine prioritisation, one position is that each country must work within their own settings and prioritise accordingly. Given inequities in vaccine access it could also be argued that HICs have an obligation address resource limitations, for example by waiving IP rights and sharing more freely. The panel agreed that HICs could do more in terms of addressing global vaccine inequity by tackling inefficiency and waste.
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- Bassett MT, Chen JT, Krieger N (2020), Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study, PLoS Medicine; 10.1371/journal.pmed.1003402.
- Causey, K, et al (2021), Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study, the Lancet; 10.1016/S0140-6736(21)01337-4.
- Demombynes, G, (2020) COVID-19 Age-Mortality Curves Are Flatter in Developing Countries, Policy Research Working Paper, 9313, World Bank; 10986/34028.
- Lewis, D, (2021) Long COVID and kids: scientists race to find answers, Nature; 10.1038/d41586-021-01935-7.
- Molteni, E*, Sudre, CH *, et al (2021) Illness duration and symptom profile in symptomatic UK school-aged children tested for SARS-CoV-2, The Lancet Child & Adolescent Health; 10.1016/S2352-4642(21)00198-X.
- Shrotri, M, Swinnen, T, Kampmann, B, Parker, EPK (2021), An interactive website tracking COVID-19 vaccine development, Lancet Glob Health; 9(5):e590-e592.
- Viner RM, Ward JL, Hudson LD, et al (2021), Systematic review of reviews of symptoms and signs of COVID-19 in children and adolescents, Archives of Disease in Childhood; 106:802-807.