COVID Vaccines for Teenagers: Conversations and Consent

On Sept. 13 the UK chief medical officers recommended that all 12-15 year olds be offered a single dose of Pfizer-BioNTech COVID-19 vaccine. This followed a previous recommendation by the Joint Committee on Vaccination and Immunisation not to offer COVID-19 vaccines to healthy 12-15 year olds.

The UK now joins a growing list of countries offering vaccination to those aged 12 and over, but it is providing only one dose rather than the two given in other countries because of concerns about rare side effects such as heart inflammation.

The health benefits of COVID-19 vaccination are small in this age group since COVID-19 infection is not a serious threat to their health. However, the chief medical officers’ decision was influenced by the wider benefit of reducing further disruption to education.

Parents are understandably concerned about vaccine safety. It’s not yet clear how schools and healthcare professionals will cope with delivering up to 2.6 million COVID-19 vaccines, answering parents’ questions and supporting teenagers to make informed decisions.

The case for offering COVID-19 vaccines to healthy teenagers is less compelling than the case for routine childhood vaccinations, which have direct benefits for individuals and many years of safety data.

Healthy teenagers are at extremely low risk of hospital admission and death from COVID-19 infection, although vaccines do protect against symptoms such as headache and fatigue that can last beyond 12-16 weeks in a very small proportion of teenagers. Additional benefits may be limited, as 30-50% of teenagers may already have acquired natural immunity to COVID-19.

Most adolescents aged 12-15 who received the Pfizer-BioNTech vaccine in clinical trials or during mass vaccination in North America reported only minor transient side effects such as fainting and pain from the injection site (79-86%). Other reactions include fever, fatigue and muscle pains (64%) and headache (49%) lasting up to a week.

However, a few cases of heart inflammation (pericarditis and myocarditis) have been reported, affecting boys more than girls. The risk of myocarditis after this vaccine rises from 3-17 cases per million after one dose to 12-34 cases per million after a second dose, and this informed the UK decision to offer only one dose to under 16s.

To date, no deaths are known to have occurred as a result of myocarditis following vaccination, but long term effects are unknown. The risk of myocarditis associated with COVID-19 infection may be higher than that after vaccination, but more research is needed to weigh risk against benefit. Importantly, past COVID-19 infection does not seem to increase risk of myocarditis after vaccination.

Potential disagreements

Conversations about vaccinating adolescents aged 12-15 against COVID-19 may be more challenging for health professionals because the scientific case is weaker than for adults. Over half of parents in UK secondary schools report they definitely want their child to be vaccinated, but a further 40% are unsure.

By contrast, 89% of young people aged 16 and 17 report no hesitation about COVID-19 vaccine — apart from incidental concerns such as anxiety about needles — and over half had their first dose within a month of becoming eligible.

The Royal College of Paediatrics and Child Health is now seeking the views of 12-15 year olds. Clearly, potential exists for teenagers and parents to disagree, or for teenagers and families to perceive pressure or stigma if their decisions differ from those of their peers and the wider school community.

Consent procedures for COVID-19 vaccines in schools will be managed by school age immunization service teams experienced in obtaining informed consent for human papillomavirus vaccination and other programs.

Parents will be asked for consent, but children under 16 with capacity to understand the risks and benefits can provide their own consent, which will have primacy over parental views. Experts have questioned the validity of informed consent when safety data are still emerging, and some families may delay or refuse consent if queries or conflicts cannot be resolved before immunization teams are on site.

Public Health England has published information for children and parents, but families may still opt to seek advice from trusted NHS professionals such as general practitioners and practice nurses, who have always been key facilitators of decision making about vaccines.

Communicating with families and consenting and vaccinating up to 2.6 million young people will add substantially to existing workload pressures of general practitioners, nurses and school immunization teams, which are already overstretched catching up with routine vaccinations disrupted by the pandemic.

Tailored communication and community engagement will be needed for some communities to help overcome barriers to access such as language or digital literacy.

The UK could look to other countries for accessible, relatable resources in friendly formats on social media to enable teenagers and families to make informed decisions about COVID-19 vaccination.

The U.S. introduced peer-to-peer vaccine advocate programs such as the COVID-19 Student Corps, and a high school student set up the VaxTeen site providing resources for young people on subjects such as how to talk to your parents about vaccines. Over 12 million adolescents in the U.S. aged 12-17 have now received one dose.

NHS professionals in the school immunization service and primary care must have protected time and resources to facilitate informed conversations with young people and their parents without pressure or judgment. Whatever teenagers and families decide, their views must be heard and respected.

Acknowledgments:

We thank the parents and young people aged 12-21 who commented on this article, including Amanda Young, Lauren Branston, Ben Bryant, Nina Pollok and Habiba Haque, community empowerment officer of Mosaic community trust.

Footnotes:

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies.

Originally published by The BMJ, Sept. 22, 2021, written by Sonia Saxena, professor of primary care; Helen Skirrow, clinical National Institute for Health Research doctoral research fellow; Helen Bedford, professor of children’s health; and Kate Wighton, parent representative, reproduced here under the terms of the CC BY NC license.

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