Risks and Benefits Evaluating the Case for Vaccinating Children

German federal and state governments want to vaccinate children and adolescents against COVID-19 as quickly as possible. But does that make sense from a medical perspective? Experience in Israel has shown that infection numbers, even with the B.1.1.7 mutant circulating, can be lowered without vaccinating kids.
A young school pupil is given a vaccine to protect her against COVID-19 in the United States: Germany has yet to decide on whether to immunize children.

A young school pupil is given a vaccine to protect her against COVID-19 in the United States: Germany has yet to decide on whether to immunize children.

Foto: Hannah Beier / REUTERS

The sugar cube was given to all the children at school on a little spoon. All you had to do was stand in line in the auditorium, yet you felt like you were part of something bigger: It was possible to avert an invisible, sinister threat simply by swallowing a sugar cube. There was even a government slogan to go along with it: "Vaccination is sweet. Polio is terrible.”

The anti-polio campaign in West Germany lasted almost two decades. But now, more than a half-century later, a mass vaccination campaign of children and adolescents could make a return. Only this time, it’s against the SARS-CoV-2 pathogen and the pandemic it has caused – a disease whose horrible consequences do not have to be drilled into children through advertising copy. They've already had a year of their lives robbed from them.


The article you are reading originally appeared in German in issue 22/2021 (May 29, 2021) of DER SPIEGEL.

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Vaccinations had been scheduled to begin at the Feodor Lynen Secondary School in Planegg, a suburb of Munich, on May 21. Pupils were to be vaccinated "individually in classrooms” by doctors, says Agnes Schmidt, an administrator at the school. The plan had been to give everyone over the age of 16 a dose of the Pfizer/BioNTech vaccine. The school’s parent-teacher council supported the idea – finally, it seemed, someone was thinking about younger people.

For the time being, though, a historic reintroduction of school vaccinations won’t be happening in Germany. Politicians and doctors attacked the plans as premature and the project was cancelled.

Fresh Hopes for Parents across the Country

The parents of the high school students are disappointed. For more than a year now, young people have been forced to take a back seat. Why, many have wondered, haven't they experienced more solidarity?

Now, though, there are fresh hopes for parents across Germany, including those of children younger than 16. Now that the European Medicines Agency (EMA) has approved the Pfizer/BioNTech vaccine for those age groups, it can then be administered in children aged 12 and over. The United States began vaccinating boys and girls in that age range more than two weeks ago. And last Tuesday, U.S. producer Moderna announced that its vaccine had shown 100-percent efficacy in a study of more than 3,700 children between the ages of 12 and 17. The company plans to file for approval with the Food and Drug Administration in June. Tests have long been underway with the Pfizer/BioNTech vaccine in younger children – reportedly with encouraging results.

Vaccinations would allow children to meet friends again without restrictions and, more importantly, return to school without worries after a year and a half of privation - with many children having fallen hopelessly behind while others experienced depression or the trauma of domestic violence.

Politicians, led by Health Minister Jens Spahn, have fueled these hopes. There were also plans for a separate campaign to vaccinate children, for which several million doses were to be diverted from the vaccine supplies. The state of Thuringia even drew up plans for a "vaccination summer for children, adolescents and families.” In Lower Saxony, Education Minister Hendrik Tonne of the center-left Social Democratic Party (SPD) presented a concrete vaccination schedule for teenagers, saying he wanted to "build a stable bridge toward full attendance in classes after the summer holidays.”

The willingness on the part of parents in Germany to have their children vaccinated is high, as a poll taken as part of Thuringia’s Cosmo Study showed. Close to two-thirds of parents of teenagers say they would be prepared to have their children vaccinated immediately.

“Young people have kept their feet still for 14 months. Felix was quarantined four times!”

Alexandra Ligges-Hufnagel of Dortmund has no understanding for parents who are opposed to vaccination. If it were up to the 48-year-old, her sons Felix, 17, and Maximilian, 20, would have been immunized long ago. To speed things up, she and other parent representatives have written letters to the city mayor and the education minister. "Young people have kept their feet still for 14 months,” she says. "Felix was quarantined four times!” Now, he should at least be able to prepare for his graduation exams without having to worry. And Maximilian would like to finally see the inside of his university.

That is, if the two can get access to the vaccine. The national "vaccination summit” held last Thursday between German Chancellor Angela Merkel and state governors didn’t really do much to make it easier for them to get vaccinated. Following EMA’s approval  of the Pfizer/BioNTech vaccine for children 12 and older and the lifting of prioritization of vaccination for risk groups on June 7, the federal and state governments have decided that adolescents will join representatives of all other age groups in the competition for the vaccine, supplies of which are still limited in Germany. The plan is for all people willing to be vaccinated in Germany to be able to do so by the end of the summer.

But is it fair to give perfectly healthy children their jabs at the same time as over-40-year-olds? And does it even make sense from a medical perspective?

Many of the controversial questions surrounding vaccination for children can’t be answered conclusively. In approaching sensible decisions, it is helpful to look abroad – to the U.S., Britain and Israel. Those countries offer examples of how things could be done in Germany. How to vaccinate children – not blindly and hastily, but based on scientific facts. And more importantly, not for the wrong reasons: as an election campaign promise to people who have grown weary of the pandemic.

Even in Germany, not all experts are enthusiastic about just moving ahead uncritically and vaccinating children. One of the critical voices should be taken especially seriously – that of the Standing Committee on Vaccination (STIKO), an independent expert commission that provides scientific analysis of the risks and benefits of vaccination. It is part of the Robert Koch Institute, Germany’s center for disease control.

The committee's preliminary findings ought to put a damper on all the euphoria surrounding vaccinations. "The decision-making process is still ongoing at the moment,” says STIKO member Rüdiger von Kries, a professor of social pediatrics and adolescent medicine at Munich’s Ludwig Maximilian University. He says there might not be a general recommendation in favor of vaccinating 12- to 17-year-olds.

Initially, vaccinations will probably only be recommended for children with underlying conditions like diabetes, cancer or immunodeficiencies. All others would be allowed to get vaccinated, but it would not be done routinely, and certainly not in mass numbers at schools as once was the case with polio. Instead, it would be handled on the basis of individual decisions made by parents in consultation with doctors.

For STIKO, the decisive factor in making the decision on whether a vaccination is recommended or not is the risk-benefit analysis. The danger posed by the disease is balanced against the potential risks associated with vaccination. With measles, for example, the trade-off is perfectly clear: Around one in 10,000 to one in a 1,000 dies of the disease and there is a risk of long-term damage and deadly late effects that can first appear years later. Severe side effects from the vaccine, by contrast, are exceedingly rare.

But what does the situation look like with COVID-19?

STIKO feels the question regarding side effects hasn’t been sufficiently clarified. Pfizer/BioNTech's pivotal Phase 3 trial only included just over 2,000 children as test subjects. That isn’t a large enough sample to detect rare or late-onset side effects. And even though the immune system is usually mature by the age of 12, those children are still growing. They're not the same as adults. It’s quite conceivable that certain side effects could occur more frequently in children.

One of the main questions that is still unanswered is how seriously to take suspicions in the U.S. and Israel that vaccination with an mRNA vaccine could lead to myocarditis in rare cases. This is a known side effect of other vaccinations, as well. The inflammation, which can lead to cardiac arrhythmia or even heart failure, is also triggered by viral infections, including COVID-19. It is difficult to determine in individual cases whether vaccination or infection is the cause.

Data which could confirm or dispel such suspicions is expected in the coming weeks from the U.S., where the COVID-19 vaccination of over-12-year-olds is already in full swing. A study is also underway in Israel in which vaccinated individuals are being examined to determine if they have suffered from heart inflammation.

There are also still many unknowns about how dangerous SARS-CoV-2 infections really are for children. It is clear that cases tend to be far less severe than in adults, and deaths are extremely rare. Experts, though, estimate that Pediatric Inflammatory Multisystem Syndrome (PIMS) occurs  in about one in 1,000 infected children. PIMS, the consequence of a flawed immune reaction, can lead to inflammatory processes in various organs and in the blood vessels. The condition often requires hospital treatment, sometimes even in intensive care. At the same time, it is unclear how often the dreaded long-COVID syndrome, which includes symptoms such as shortness of breath and exhaustion, occurs in children.

Jörg Dötsch, director of the Department of Pediatrics and Adolescent Medicine at the University Hospital in Cologne, is in favor of vaccinating children and adolescents if the risk-benefit ratio is positive. But he also believes that parents need to get vaccinated first. "For adults, we have a win-win situation,” he says.

“We don’t vaccinate to help people go to school."

When recommending vaccination for children and adolescents, should the fact that vaccination can help cushion the negative psychosocial consequences of the pandemic for children play a role? Thomas Fischbach, president of the Professional Association of Pediatricians and Adolescent Doctors in Germany, is firmly of that opinion. "The consequential psychosocial damage of the pandemic is significant," he says, adding that the harm caused by this can be just as great as the physical consequences. "After all, the question of getting vaccinated isn’t just about dying. It’s as much about children and young people’s participation in social life.”

Does it matter to STIKO that vaccination can give children a path back to school? Would that not be a worthy goal on the benefits side of the scale? "We don’t vaccinate to help people go to school,” says pediatrician von Kries. "Especially not if school attendance can be made possible in other ways – if the parents are vaccinated, for example.” Particularly, he adds, given that school attendance, the right to participate, is a fundamental right.

The Pandemrix trauma still lingers deep in the memory of many physicians. Starting in 2009, when the swine flu was rampant, a new vaccine was hastily concocted. Too hastily, as it turns out. A rare late effect remained undetected for a long time: More than 1,300 cases of narcolepsy have since been reported. "We're lucky we didn't vaccinate all the kids and teens at the time," Kries says.

There are other voices, as well. Deepti Gurdasani, an epidemiologist and doctor at Queen Mary University of London, is calling for children to be given a priority in vaccinations. Even though children rarely have severe progressions of the disease, she says it is still "entirely unethical" to keep them from getting immunized. Writing in the digital weekly PoliticsMeansPolitics , she said "it is not acceptable to expose any group to transmission with a virus we still don’t know much about, that causes not just acute but chronic debilitating disease we barely understand.” Gurdasani also sees an epidemiological effect because vaccination eliminates children as carriers of the virus.

“Our daily new infections are now at close to zero. And we managed to do that without vaccinating the under-16s.”

In Israel, however, the most active virus spreaders might have been identified, and it hasn’t been the children. "In our case, it could have been the young adults," says Ron Dagan, professor of pediatrics and infectious diseases at Ben Gurion University in Beer Sheva. The finding was something of a byproduct of the country’s unprecedented vaccination campaign.

Shortly after the vaccine campaign began in January, there were still sometimes more than 8,000 new infections reported each day, even though some 60 percent of the population had received at least one vaccine dose within a few months. Dagan says that although all age groups over 16 years of age likely contributed to the infection rate, young individuals are much more mobile than the old. And to the extent that most adults got the vaccine, the infection rate went down – even in unvaccinated children.

"Our daily new infections are now at close to zero,” Dagan reports. "And we managed to do that without vaccinating the under-16s.”

Dagan, who has chaired several global expert panels on childhood infectious diseases during his career, says he was amazed by it himself. "Just a few months ago, I would have predicted something very different,” he says.

The Pfizer/BioNTech vaccine is also now awaiting approval in Israel for 12- to 15-year-olds. After that, an Israeli Health Ministry commission that Dagan is a member of must decide whether to recommend the vaccination. "Israel is not in a hurry with that right now, though,” he says. There might be some very small theoretical risk for adverse events that are relatively serious, and given the very low rates of COVID-19 in children, the risk-benefit analysis is different than in a country with still ongoing frequent transmission. The risk of contracting COVID-19 in the first place also needs to be considered, he says. "And that’s close to zero in Israel right now, for children as well.”

So, is it possible we can get our old lives back without having to vaccinate the kids? Probably not quite, as the Israeli example also shows. Eighty percent of 40- to 49-year-olds in Israel have received their second vaccine shot, but there are still significant restrictions. No Israeli is allowed to enter the country without a negative PCR coronavirus test, only citizens and residents of Israel are allowed in, and masks are obligatory in indoor spaces. It’s quite possible that things like stays abroad, travel to far-off places or exciting internships might not be available to children and young people who aren’t vaccinated for some time to come.

That’s why parents, and even their children, are likely to push for vaccination – simply so they can get their old lives back. "I already have a list of people wanting to be vaccinated that's six pages long," says pediatrician Fischbach. But he’s still missing one thing: the vaccine. "The vaccination of children and adolescents isn’t going to happen quickly," he fears, "especially given that the country is opening access to the vaccine up to all people outside the priority groups as of June 7.”

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