Should we delay covid-19 vaccination in children?
BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1687 (Published 09 July 2021) Cite this as: BMJ 2021;374:n1687Read our latest coverage of the coronavirus pandemic
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor
I would just like to add in regard to my letter of 17 July [1] the phrase “in which the patient died shortly after vaccination” is the language of the MHRA weekly summary [2] whereas the ‘Case Series Drug Analysis Prints’ [3,4,5,6] identify these deaths as “fatal” reactions. Of course, there will be many people who have died since the second week in December and probably most will have had Covid vaccines, but we still ought to be concerned about dismissing cases where it was someone’s perception that a product was implicated. Again, if someone was very frail and expected to die imminently anyway should they have been vaccinated at all?
[1] John Stone, ‘ Should we not take children out of the war on disease? This is a messy story’, 17 July 2021. https://www.bmj.com/content/374/bmj.n1687/rr-6
[2] https://www.gov.uk/government/publications/coronavirus-covid-19-vaccine-...
[3] https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
[4] https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
[5] https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
[6] https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor. I also moderate comments for the on-line journal ‘The Defender’ for which I am paid. I am also a member of the UK Medical Freedom Alliance
Dear Editor
55.6% of all fatal reports on the United States Vaccine Adverse Event Reporting System (VAERS) begun in 1990 are now for Covid products rolled out since just last December (10,991/19,820) [1,2]. The United Kingdom Yellow Card system has by now returned more than 300,000 cards for the products, with more than a million adverse reactions and 1,470 in which the patient was recorded as having died shortly after vaccination [3]. Because VAERS and Yellow Cards are passive recording databases these numbers are likely to be only a fraction of actual cases, even if not confirmed. There are a host of reasons why reports might never be made, not least cultural hostility.
However inadequate these systems are they are the only ones we have, so we had better take this data seriously. We have, moreover, no idea what the long term effects of any of these products will be since none was even on the drawing board 18 months ago and they have not undergone long-term testing. Their real effectiveness is anyhow much in doubt [4]. There is a real danger of magical thinking. This is a messy story.
This project seems more like playing dice with children’s lives than protecting them, and it is dehumanising to talk about children in terms of “rabid dogs” or “reservoirs of disease” [5]. If we are so willing to sacrifice individuals will it really be for the collective good? I doubt it, and it is more than time we stopped thinking like this. The prospect of children becoming the next tier of collateral damage is truly disturbing.
[1] https://tinyurl.com/6n7m8urx
[2] https://tinyurl.com/wes3wkfy
[3] “As of 7 July 2021, for the UK, 87,789 Yellow Cards have been reported for the Pfizer/BioNTech vaccine, 219,374 have been reported for the COVID-19 Vaccine AstraZeneca, 8,953 for the COVID-19 Vaccine Moderna and 927 have been reported where the brand of the vaccine was not specified.
“For the Pfizer/BioNTech, COVID-19 Vaccine AstraZeneca and COVID-19 Vaccine Moderna the overall reporting rate is around 3 to 7 Yellow Cards per 1,000 doses administered…
“Up to and including 7 July 2021, the MHRA received and analysed 87,789 UK Yellow Cards from people who have received the Pfizer/BioNTech vaccine. These reports include a total of 245,395 suspected reactions (i.e. a single report may contain more than one symptom). The first report was received on 9 December 2020.
“Up to and including 7 July 2021, the MHRA received and analysed a total of 219,374 UK reports of suspected ADRs to the COVID-19 Vaccine AstraZeneca. These reports include a total of 785,519 suspected reactions (a single report may contain more than one symptom). The first report was received on 4 January 2021.
“Up to and including 7 July 2021, the MHRA received and analysed a total of 8,935 UK reports of suspected ADRs to the COVID-19 Vaccine Moderna. These include a total 25,627 suspected reactions (a single report may contain more than one symptom). The first report was received on 7 April 2021.
“Additionally, up to and including 7 July 2021, the MHRA received 927 Yellow Card reports where the brand of vaccine was not specified by the reporter…
“The MHRA has received 456 UK reports of suspected ADRs to the Pfizer/BioNTech vaccine in which the patient died shortly after vaccination, 983 reports for the COVID-19 Vaccine AstraZeneca, 7 for the COVID-19 Vaccine Moderna and 24 where the brand of vaccine was unspecified…”
https://www.gov.uk/government/publications/coronavirus-covid-19-vaccine-...
[4] John Stone, ‘Iatocracy’, 7 July 2021, https://www.bmj.com/content/373/bmj.n1605/rr-3
[5] Sheldon S Ball, ‘Re: Should we delay covid-19 vaccination in children?, 15 July 2021, https://www.bmj.com/content/374/bmj.n1687/rr-0
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor. I also moderate comments for the on-line journal ‘The Defender’ for which I am paid. I am also a member of the UK Medical Freedom Alliance
Dear Editor,
Let's not forget that there is no long-term follow-up with these new vaccines and soon there will be no control group left because almost everyone will have had one of the mRNA vaccines.
Vaccinating a vulnerable patient in his or her 80s is one thing. If their high risk from Covid can be reduced, then any possible long-term adverse reactions that may develop years later are almost academic. This is completely reversed for children. Should we give a still fairly experimental vaccine technology with no long-term safety profile to children who are at almost no risk from the disease? And if so, how do we justify that?
Competing interests: No competing interests
Dear Editor
In the interesting "head to head" on the reasons for and against Covid-19 vaccination for children and adolescents (1), it is surprising that the consequences on this population of what was called "secondary pandemic” were not taken into account. Indeed, there are several other good reasons for vaccination in the adolescent population, whose life has been affected in all its domains by the Covid-19 pandemic's containment measures.
Of special concern are the consequences on the mental health and well-being of children and adolescents: anxiety, depression, disturbances in sleep and appetite, isolation and self-harm have been increasing, and the negative impact on childrens' and adolescents' mental health will continue for years (2,3). Prolonged school closures have produced a dramatic learning loss, particularly among the most disadvantaged students, which will translate into an epidemic of school failures, drop-outs and increase in drop-outs and in gloomy life perspectives for many (4).
The multidimensional adverse consequences for children and adolescents of the Covid-19 pandemia have been highlighted at global level by international agencies, but they do not seem to be taken in adequate consideration at country level when discussing vaccination strategies and remedial measures.
The risk to benefit ratio of vaccination for pre-adolescents and adolescents is definitely in favor of the benefits, for adolescents themselves and for the whole society, as only vaccination can allow them to restore their normal social and educational process and have their rights, widely neglected during the pandemic, respected. The way children and adolescents have been forced to live for over a year has been the most dangerous "variant" for their life.
References
1. Wilkinson D, Finlay I, Pollard AJ, Forsberg, Skelton A. Should we delay covid-19 vaccination in children? BMJ 2021;374:n1687 doi: https://doi.org/10.1136/bmj.n1687
2. de Figueiredo CS, Sandre PC, Portugal LCL, et al COVID-19 pandemic impact on children and adolescents' mental health: Biological, environmental, and social factors. Prog Neuropsychopharmacol Biol Psychiatry. 2021 Mar 2;106:110171. doi: 10.1016/j.pnpbp.2020.110171.
3. Meherali S, Punjani N, Louie-Poon S, et al. Mental Health of Children and Adolescents Amidst COVID-19 and Past Pandemics: A Rapid Systematic Review. Int J Environ Res Public Health. 2021;18(7):3432. Published 2021 Mar 26. doi:10.3390/ijerph18073432
4. Rajmil L, Hjern A, Boran P, Gunnlaugsson G, Kraus de Camargo O, Raman S; International Society for Social Pediatrics & Child Health (ISSOP) and International Network for Research on Inequalities in Child Health (INRICH) COVID-19 Working Group. Impact of lockdown and school closure on children's health and well-being during the first wave of COVID-19: a narrative review. BMJ Paediatr Open. 2021 May 25;5(1):e001043. doi: 10.1136/bmjpo-2021-001043.
Competing interests: No competing interests
Dear Editor,
I am grateful for the chance to reply.
The argument that children are needed to help arrive at population herd immunity is a false one. If children are needed from a ‘numbers’ point of view for driving population level ‘herd’ immunity, then they must be allowed to do so 'naturally, to get infected naturally and harmlessly as part of day-to-day living and we do it by mingling, by opening schools and allowing them to live reasonably normal lives with sensible precautions e.g. enhanced sanitation, hygiene, and disinfectant. Children can and do get infected as they do for usual pathogens they encounter in their daily lives, ‘naturally.’ These pathogens include the common influenza virus and other influenza-like illnesses.
Allow child-to-child daily interaction. Not only will that drive the adaptive immunity but it will give the children a more robust defense against any mutant variants of the virus itself. This will also allow our children’s immune systems to be taxed and tuned up daily, as opposed to the weakening we are subjecting it to with the year-long lockdowns and school closures. We do it while at the same time strongly protecting the elderly who are frail, the elderly in general, and those with comorbid conditions and obese individuals. We must use stringent protections of our nursing homes and other similar congregated settings (including the staff). It is better science to use a more ‘focused‘ protection and targeting that is based on age and known risk factors especially, regarding the children.
History teaches us to pause and reflect upon our previous miscues and unforced blunders that had significant consequences. It behooves us to remember the increased incidence of narcolepsy in children in Scandinavian countries following the H1N1 influenza ASO3-adjuvanted vaccine used for the 2009 pandemic (Pandemrix influenza vaccination program). Additionally, the harms caused by the dengue vaccine in children in the Philippines also come to mind that bore a burden on our society of humans. Sanofi Pasteur halted the vaccines in 2017 due to the very dangerous risk of plasma leakage akin to ebola. The tainted polio vaccine that sickened and fatally paralyzed children in 1955 in the United States is also worthy of review in this context. The harm that can accrue from a rapid deployment of mass vaccination to the children has not proven to be safe in all the cases.
Competing interests: No competing interests
Dear Editor
Many factors have to be considered in deciding whether or not to vaccinate children for Covid 19 to include assessment of all the risks and benefits. Public health definitely matters but so too do our children. Pursuing an individual-centred perspective in undertaking a very careful assessment of whether or not to vaccinate children is a must particularly in view of what happened in a previous pandemic when the swine flu vaccination schedule was extended and Pandemrix was administered to children and young people.
A significant number of children and young people suffered narcolepsy and cataplexy following administration of the Pandemrix vaccine, something which was not noted in the older age groups. On that occasion many children and their families paid a huge price for contributing to overall public health and they will be living with the consequences forever.
We need to be absolutely sure that something similar is not waiting in the wings this time around before we start vaccinating children with Covid 19 vaccine.
If anything has been learned from the Pandemrix fiasco it is that an individually centred perspective is precisely what is required when considering whether or not to vaccinate children with Covid 19 vaccine.
Furthermore, although it may seem an obvious step to take for the furtherance of public health overall, vaccinating children hasn’t always resulted in a positive impact on the rest of society. In this regard we need to be vigilant also.
Vaccinating children for mumps resulted in a shift in susceptibility to older age groups with a rise in serious complications and although not relevant to Covid 19 vaccine, should remind us all of the need to be meticulous and insightful when considering the possible impact on everyone in vaccinating children for Covid 19.
Competing interests: No competing interests
Dear Editor,
A purpose in vaccinating children is to prevent them from transmitting SARS-CoV2 to others. Vaccine discussion seems to be all about an individual-centered persepctive. What about a public health perspective? Why do we vaccinate dogs for rabies? .. to prevent them from transmitting rabies to humans. How are we going to control this pandemic? We will do so by eliminating reservoirs of the disease. We also need to distribute vaccines to under-served populations in the world, including but not limited to Africa.
Competing interests: No competing interests
Should COVID-19 be a vaccine disease or a childhood disease?
Dear Editor
In the discussion regarding COVID-19 vaccination of children, several aspects seem to be missing.
First, vaccination of children is based on a small Pfizer-sponsored phase 3 trial of 2260 adolescents randomized to BNT162b2 COVID-19 vaccine or saline. The resulting paper concludes that the vaccine ”had a favorable safety profile”(1). However, based on data presented in supplementary table 2, in the age group 12-15 years, 7/1131 vaccinated vs. 2/1129 unvaccinated had a severe adverse event (1), i.e. a 3-fold increased risk. In the 16-25 years age group presented in the same paper, 9/536 vaccinated vs. 3/561 unvaccinated had a severe adverse event (1), i.e. likewise a 3-fold increased risk. The combined results indicate a 3.28 (95% confidence interval 1.21 to 8.94)-fold increased risk in severe adverse events in the vaccinated adolescents/young adults (2). In absolute numbers, 1 of 100 vaccinated experienced a severe event, vs. 3 of 1000 unvaccinated. Data was not presented by sex.
A protective vaccine can have negative non-specific and sex-differential effects on overall health (3). For instance, a protective measles vaccine had to be withdrawn after being associated with 2-fold higher all-cause mortality for females (4). A partially protective malaria vaccine was recently likewise associated with 2-fold higher female mortality (5). These epidemiological observations indicate that while the vaccines protected against the target disease, they increased the susceptibility to other diseases. In other words, the specific protection came at the price of increased susceptibility to other diseases. This epidemiological phenomenon of negative non-specific effects has been linked to innate immune tolerance (3, 6). Though the number of participants was small, the only study so far of BNT162b2 COVID-19 vaccine indicates that this vaccine induces innate immune tolerance towards bacterial and viral ligands (7). Thus, protection against COVID-19 could come at the price of increased risk of other infections.
Other pandemic vaccines have later been found out to have caused rare but severe side effects, like Guillain-Barré syndrome in recipients of flu vaccines in 1976, and narcolepsy linked to one brand of swine flu influenza vaccine in 2009(8). None of the phase 3 trials of COVID-19 vaccines were designed to study either non-specific sex-differential effects, or rare but severe long-term side effects (8).
Given the low risk of severe COVID-19 in previously healthy children - none in the Pfizer-sponsored phase 3 trial (1) - it is not clear that vaccine benefits outweigh harm in healthy children.
Second, arguments for vaccinating children include that infection in children could lead to more dangerous variants. Variants of concern have typically been the result of persistent infections in immunocompromised people that can cause the virus to mutate more frequently because the person's immune system cannot clear the virus as quickly as the immune system of a healthy person (9). Presumably healthy children, who typically have very mild/short-lasting infections, are unlikely to give rise to variants of concern. Noteworthy, individuals, who have had COVID-19 infection, will likely have broad resistance towards SARS-CoV2 variants(10), and thus contribute importantly to herd immunity.
This leads us to the third point: Should COVID-19 be a vaccine disease or a childhood disease? There has been surprisingly little discussion about the future of COVID-19. Many people seem to assume that COVID-19 will become a disease for which we vaccinate the whole population perhaps annually or biannually. This will be expensive - and potentially harmful, if the (repeated) vaccinations have negative effects. We do not think vaccination of the whole population is necessary either; in fact, it may be counter-productive for society.
The known endemic human Corona-viruses (HCoV) infect most people before age 15; thereafter people may become re-infected again, but as evidenced by the lack of IgM responses, the response is a recall response (11). These HCoV rarely cause severe disease until the age of immunosenescence and we would never contemplate vaccinating against HCoVs at the population level, even if vaccines existed.
Given that we are so lucky that SARS-CoV2 very rarely cause severe disease in children, the safest and cheapest way forward seems to be to tame SARS-CoV2 to a common childhood disease like other HCoV. This would happen by allowing SARS-CoV2 to infect children, who thereby likely become protected against severe disease well into late adulthood. Importantly, this transition of SARS-CoV2 into a childhood disease would be delayed if there is too little SARS-CoV2 circulating. As noted by others: “Once most adults are vaccinated, circulation of SARS-CoV-2 may in fact be desirable, as it is likely to lead to primary infection early in life when disease is mild, followed by booster re-exposures throughout adulthood … This would keep reinfections mild and immunity up to date”(12).
In conclusion, there are good arguments why not vaccinating children may in fact serve several purposes at the individual as well as at the societal level:
• Not vaccinating children protects children against the potential unknown harms of COVID-19 vaccinations.
• Not vaccinating children gives them the opportunity to develop a broad natural immunity, contributing to herd immunity, and speeding up the transition of SARS-CoV2 into a childhood disease.
The avoided costs of making COVID-19 a vaccine disease, for which we vaccinate the whole population maybe annually or biannually, could be well spend on other health related issues such as smoking, cancer, obesity, and mental health.
References
1. Frenck RW, Jr., Klein NP, Kitchin N, Gurtman A, Absalon J, Lockhart S, et al. Safety, Immunogenicity, and Efficacy of the BNT162b2 Covid-19 Vaccine in Adolescents. N Engl J Med. 2021.
2. Benn CS. https://www.linkedin.com/posts/christine-stabell-benn_safety-immunogenic.... LinkedIn post 2021.
3. Benn CS, Fisker AB, Rieckmann A, Sørup S, Aaby P. Vaccinology: time to change the paradigm? Lancet Infect Dis. 2020.
4. Aaby P, Jensen H, Samb B, Cisse B, Sodemann M, Jakobsen M, et al. Differences in female-male mortality after high-titre measles vaccine and association with subsequent vaccination with diphtheria-tetanus-pertussis and inactivated poliovirus: reanalysis of West African studies. Lancet. 2003;361(9376):2183-8.
5. Klein SL, Shann F, Moss WJ, Benn CS, Aaby P. RTS,S Malaria Vaccine and Increased Mortality in Girls. MBio. 2016;7(2):e00514-16.
6. Blok BA, de Bree LCJ, Diavatopoulos DA, Langereis JD, Joosten LAB, Aaby P, et al. Interacting, Nonspecific, Immunological Effects of Bacille Calmette-Guerin and Tetanus-diphtheria-pertussis Inactivated Polio Vaccinations: An Explorative, Randomized Trial. Clin Infect Dis. 2020;70(3):455-63.
7. Föhse FK, Geckin B, Overheul GJ, van de Maat J, Kilic G, Bulut O, et al. The BNT162b2 mRNA vaccine against SARS-CoV-2 reprograms both adaptive and innate immune responses. medRxiv. 2021:2021.05.03.21256520.
8. Doshi P. Will covid-19 vaccines save lives? Current trials aren't designed to tell us. Bmj. 2020;371:m4037.
9. Peacock TP, Penrice-Randal R, Hiscox JA, Barclay WS. SARS-CoV-2 one year on: evidence for ongoing viral adaptation. J Gen Virol. 2021;102(4).
10. Ferretti AP, Kula T, Wang Y, Nguyen DMV, Weinheimer A, Dunlap GS, et al. Unbiased Screens Show CD8(+) T Cells of COVID-19 Patients Recognize Shared Epitopes in SARS-CoV-2 that Largely Reside outside the Spike Protein. Immunity. 2020;53(5):1095-107.e3.
11. Zhou W, Wang W, Wang H, Lu R, Tan W. First infection by all four non-severe acute respiratory syndrome human coronaviruses takes place during childhood. BMC Infect Dis. 2013;13:433.
12. Lavine JS, Bjornstad O, Antia R. Vaccinating children against SARS-CoV-2. BMJ. 2021;373:n1197.
Competing interests: No competing interests