When several European countries paused use of the Oxford/AstraZeneca Covid vaccine in March 2021, the criticism from many commentators was swift, extreme…
I think we are drifting perilously close to exceptionalism in the debate about the Covid-19 vaccine for children and adolescents. The narrowed, individualistic framing of anti-vax movement arguments against mandatory childhood immunization is too often applied in critics’ discussion about Covid vaccination for the under-18s at all. Then, people making the case for vaccination too often respond on the same limited discussion ground. I think it’s tilting this debate in damaging ways right now. We shouldn’t let this become normal.
While it’s clear that most healthy children and adolescents – like most healthy young and middle-aged adults – aren’t a global priority, the rich world’s decisions and priorities around vaccine R&D for the very young have repercussions for other countries, too. And it’s only a matter of time till this isn’t just a pressing debate for rich countries. For perspective: there are just under 200 countries. In high income ones, the average proportion of the population that’s aged under 15 is only 16%. In low income countries, it’s 42%. There are around 60 countries where the proportion of the population under 15 is between 30 and 50%, and many others aren’t far off – Israel, for example, is at 28%. That’s a profoundly different context for discussions about how you get a high enough rate of immunity in a community, and stemming the evolution of the coronavirus and the pandemic.
To explain my concern about some current debate, let’s start with what I mean about anti-vax movement framing of vaccines for children, and why that propels its reach so far and wide. Many people’s perception of anti-vaccine argument could be skewed because wild conspiracy theories and disinformation campaigns get a lot of attention. In fact, rhetorical argument about children is deeply at the heart of this phenomenon – even in Covid-19 debates, where “Think of the children!” is the most common rhetorical strategy. And it’s spread by social media globally. Anoop Nair and colleagues conclude social media is a key factor driving vaccine hesitancy in Kerala, India, for example, and that getting better at tackling that communication medium could be a constructive strategy. The conversation matters.
David Broniatowski & co published a critical content analysis of English-language Facebook pages opposing vaccination from 2009 to 2019. They chart a critical shift from after the “Disneyland” measles outbreak in January 2015, which they describe as kicking off a phase of vaccine opposition going mainstream. It coalesced around the issue of mandatory vaccination, and led to anti-vaccine rhetoric getting increasingly civil liberty-focused. That got another kick of steam with Wakefield’s Vaxxed movie, and by 2019, the civil liberties frame had become dominant:
Given the shifting rationales for vaccine refusal, a “civil liberties” framing fundamentally recontextualizes vaccination, making it into a value-laden political issue, rather than a debate over scientific or medical facts.David Broniatowski & co (2020)
Proponents of vaccination and communicators need to understand this context, Broniatowski and his colleagues argue, and I agree. This individualistic framing, they point out, has enabled enormously successful local activism and influence in the US. It paired up easily with old staples – like, you don’t need to vaccinate, because the diseases are disappearing already.
The individualism that is the beating heart of so much current anti-vax campaigning drags the emphasis away from the public health ethos of vaccination, to focusing purely on what’s in it for the person getting vaccinated – coupled with exaggeration of vaccine risks and downplaying those of the disease. I think that needs to be countered: now is the time to reinforce community-spirited values, not let them be sidelined or misrepresented.
In the public health ethos, direct risk and benefits to individuals are utterly critical, of course – but the benefits column is much wider than that. There are the widespread indirect benefits that come from reducing a pathogen’s ability to circulate freely and widely, as well as the protection of those who are both vulnerable to the disease and less-protected by vaccines. There’s still personal interest at play even with the societal benefits: a pathogen’s success blows back consequences on everyone – just think of the impact of increased healthcare costs alone – and there’s a benefit of being spared the distress of having endangered someone vulnerable around us. And that’s a very big group of people.
In the US, for example, over 5% of the population is estimated to be immune-suppressed, and for them, vaccine protection from Covid-19 is often inadequate. Those for whom vaccination protection may be weaker is a very wide swathe – people with transplants, people trying to recover from cancer, people on some arthritis medications, and so much more. They’re frontline workers in hospitals and everywhere else, they have children, grandchildren, friends – and of course, there are immunocompromised children and adolescents, too. The circles of concern around those millions of people ripple out widely across the community. We should all care, and not let “but they had co-morbidities” become the new “but they were very old”.
That we only protect the most vulnerable among us if we vaccinate en masse is one of the basic tenets of vaccination, of course. And while you might get a different impression from some of the current debate, that doesn’t apply only to adults. Wider values for infectious diseases are part of why the under-18s get vaccinated, too, and we shouldn’t make an exception out of Covid-19 vaccination. In the case of the rubella vaccine in the routine childhood immunization program, it’s explicitly the point. That’s the “R” in the MMR vaccine. It’s not there to protect children from a very mild disease that was eliminated in many communities years ago. It’s to protect against the risks to fetal development should pregnant women become infected if the virus were to circulate again. Protection against getting sick if rubella does circulate is a bonus, but it’s not the reason infants were vaccinated. Another example: in the US, most adolescent boys might be getting vaccinated against HPV, though the main direct benefit is for women.
So coming from a public health perspective, let’s unpack some of the recurring themes in arguments downplaying the value of Covid vaccine for the very young. The first quote below is from Cody Meissner, one of the authors/signatories of the Great Barrington Declaration, an alternative take on dealing with Covid-19 that sprang from what the Wikipedia designates as “a free-market think tank”. The second comes from medico Vinay Prasad, from whom I first heard of Meissner’s argument.
We are asking children to accept the vaccine, to get immunized, to protect the adults. That isn’t necessary. (Meissner)
There’s no question that Covid-19 is an emergency for adults, a catastrophic disease that becomes more deadly with advancing age. But it isn’t that for children. For them it is a respiratory pathogen with a rate of harm that is comparable to other, annual respiratory pathogens like influenza. (Prasad)
Let’s put the emergency argument to one side. Covid-19 is an emergency, with emergency use authorizations for vaccines, because it’s a pandemic. The emergency isn’t age-stratified: it affects the whole community. Children and adolescents have borne a huge burden – and they will again wherever it breaks out, especially if they’re unvaccinated.
Within these arguments there’s a strong bias formed by beliefs from early in the pandemic – that unlike other respiratory diseases, the young don’t spread this virus much. And the idea that it doesn’t pose them personally much of a danger – the whole “it’s just the flu”, thing. This is packed with false premises. Firstly, it’s based on the coronavirus pre-Alpha: the virus itself has changed.
Secondly, as Terry Jones and colleagues have pointed out, we didn’t have a good take on how much of a disease vector children and teens were. To know how often they were carrying and transmitting the virus we would have needed better data. But they got less symptoms, and testing was symptom-based, so the asymptomatic weren’t seen so well. On top of that, to get a really good assessment of viral load, you needed to get a decent swab up very high in the nose. People tended to spare the young that discomfort – and the very young made it awfully hard to do anyway. What do we know now? Jones & co conclude that “viral load differences between children and adults are too small to alone produce large differences in infectiousness”. In Canada, for example, serum surveys are showing more of the very young may have been infected than seniors.
Thirdly, even if it were true that it was “just the flu”, more than half of adolescents in the US get vaccinated against influenza. That’s because we take it very seriously. It only takes a few hundred deaths a year to make it into the major 20 causes of child deaths there. It’s not the same as the flu, though. On average, just over 100 children and young people under 18 die of influenza in the US each year: over 300 died of Covid-19 in just over a year there. In Sub-Saharan Africa, 2.4% of Covid deaths have been in people under the age of 18. Just what that could translate to in a runaway pandemic is hinted at by Brazil: by April, more than 67,000 children under 10 had been hospitalized for Covid.
Fourthly, we know a lot about influenza. However, Covid-19 is a brand new illness, and its long-term consequences just aren’t known yet. We don’t know how long the morbidity of Long Covid will last, whether there’s organ damage with lifelong consequences, and how many of the very young will be affected by it.
There are other biases in the way people make these arguments, too. For example, they contrast the risks of Covid for young children with the risks of Covid for the oldest of the old. But that’s absurd. By that measure, vaccination for people in their 20s, 30s, and 40s looks pretty different, too. If we’re talking about vaccinating 18-year-olds but not 17-year-olds, or 15-year-olds but not 11-year-olds, the frame of reference shouldn’t be 95-year-olds.
I agree, of course, that the ideal would have been for adults to solve this problem. But the chances of vaccinated adults alone squashing the pandemic in most of the world are looking slim – partly because of how young many populations are, and partly as vaccine hesitancy looms large in many parts of the world. In the US, only 50-60% of adults in some parts of the country have gotten vaccinated and the rate is slowing: and nearly 22% of the nation is under 18. (The vaccine hasn’t been available for them for long, but nearly 5% of all people with at least one dose is under 18.) In Israel, with a younger population, they had to begin promoting vaccination in 12-15-year-olds because of surging infections, even though a very high proportion of adults are vaccinated.
Not taking vaccination for the very young as seriously as it deserves means we’re letting children and adolescents down in our vaccine R&D and authorization priorities, too. This time last year it was clear that mRNA and viral vector vaccines for Covid-19 were coming with a hefty load of adverse reactions. Vaccine tolerability and safety, especially for children and adolescents, should have been a massive priority then – and it should be now. That would mean exploring more lower dosing options for the very young, for example, and having bigger follow-up trials for the vaccines we do have. And making additional vaccines that might be better for young people a very high priority.
Yet, countries like the US aren’t acting as though vaccines with lower rates of adverse reactions and from platforms with longer safety track records are important: because there are vaccines that are great for adults, the pressure is off. Thinking a problem is solved when there is a solution suitable for adults is, unfortunately, typical. That’s one way that I wish Covid-19 vaccines had been an exception.
Disclosures: My interest in Covid-19 vaccine trials is as a person worried about the virus, as one of my sons is immunocompromised: I have no financial or professional interest in the vaccines. I have worked for an institute of the NIH in the past, but not the one working on vaccines (NIAID). More about me.