Considering Mandatory COVID-19 Vaccination Policies for Students
Public health and school officials need to consider strategies now.
Amid the emergence of SARS-CoV-2 variants such as Omicron and its more transmissible sibling, BA.2, it is the strong recommendation of both the American Academy of Pediatrics1 and the CDC2 that all eligible school-aged children 5 years and older be vaccinated against COVID-19, with boosters also recommended for those 12 years and older. Starting July 1, 2022, California will be the first state in the US to mandate the COVID-19 vaccine in all schools, for all students (after FDA approval) in kindergarten through 12th grade, and for all school employees.3
Although COVID-19 vaccine4 availability for children and adolescents4,5 was celebrated by many parents, others have been hesitant, especially those with younger children. As of March 30, 2022, the CDC estimates that only 34% of children aged 5 to 11 years in the US have had at least 1 dose of the COVID-19 vaccine compared with 67% of 12 to 15 year olds.6
There is discourse among some parenting circles over whether kids should be vaccinated for COVID-19 at all. Some rural, conservative counties in California are reporting that they will not enforce7 the school mandates because many parents in their districts do not plan to vaccinate their children. However, the controversy surrounding pediatric COVID-19 vaccination is fueled by misconceptions: (1) the “appeal to nature fallacy,” (2) the belief that children are not affected by COVID-19, and (3) that COVID-19 vaccines are a less safe way for children to acquire immunity vs the virus itself. There are fundamental misunderstandings around the risks and benefits for both the vaccine and the virus.
MISCONCEPTION NO. 1: THE APPEAL TO NATURE FALLACY AMONG VACCINE-HESITANT PARENTS
Humans are generally not very good at assessing risk. People tend to hold beliefs based on an appeal to nature bias,8 whereby things that occur naturally are perceived as good or better,9 and things that are man-made are seen as bad or harmful. This false dichotomy also extends to COVID-19 vaccines, especially for children. Some parents believe that allowing their children to acquire “natural immunity” from COVID-19 is safer or “better” than the immunity derived from “synthetic” or “unnatural” vaccines. But the growing body of evidence does not support this viewpoint.
MISCONCEPTION NO. 2: COVID-19 DOES NOT AFFECT YOUNG CHILDREN
This misconception is driven by a woeful minimization of pediatric COVID-19 data. Recent prevalence estimates show that children and adolescents account for 1 in 5 US COVID-19 cases.10 Estimates of postacute sequelae SARS-CoV-2 infection11—which refers to new, returning, or ongoing health problems experienced by people 4 or more weeks after initial coronavirus infection (colloquially referred to as “long-COVID”)—in children vary, but the lower end of the prevalence range in a recent large population-based study was 4%.12 This percentage seems low but equates to more than 500,000 children in the US with long-COVID, given the high cumulative incidence rates of pediatric COVID-19.
Thankfully, severe COVID-19 is not as prevalent in children as adults, but it is not always predictable when severe COVID-19 will occur. Children with certain medical conditions such as obesity, diabetes, asthma, chronic lung disease, sickle cell disease, or immunosuppression are at increased risk for severe illness,13 but children without underlying medical conditions also experience severe illness and hospitalization.14 During the Omicron surge in January 2022, COVID-19 hospitalizations among children and adolescents were the highest they had ever been,15 with most admissions among unvaccinated children.16 To date, there have been nearly 8000 diagnosed cases of multisystem inflammatory syndrome in children (MIS-C),17 a life-threatening condition associated with COVID-19, and COVID-19 also ranked in the top 10 causes of death in children for 12 of 13 months during the period January 2021 through January 2022.18
MISCONCEPTION NO. 3: COVID-19 VACCINES ARE A LESS SAFE WAY FOR CHILDREN TO ACQUIRE IMMUNITY THAN THE VIRUS ITSELF
The misconception that children acquiring natural immunity from COVID-19 is safer than immunity from the vaccine is due to parents misunderstanding (1) actual risks from COVID-19 vs the vaccine, (2) variability of individual immune responses after SARS-CoV-2 infection, and (3) waning long-term immunity due to viral variants and time.
Randomized clinical trials in pediatric19 and adolescent populations20 demonstrated that the Pfizer-BioNTech COVID-19 vaccine is safe, immunogenic, and effective. The safety profile21 is associated mostly with vaccine immunogenicity reactions, such as pain at the injection site, fatigue, headache, injection-site redness, injection-site swelling, muscle pain, chills, fever, joint pain, lymphadenopathy, nausea, malaise, decreased appetite, and rash.
Recent pediatric real-world data from the Omicron time frame shows that the Pfizer-BioNTech COVID-19 vaccine is effective in preventing both infection and hospitalization. A recent prospective cohort study found that the vaccine reduced the risk of Omicron infection by 31% among children aged 5 to 11 years and by 59% among children aged 12 to 15 years.22 Another CDC study found that the Pfizer-BioNTech COVID-19 vaccine reduced the risk of Omicron-associated hospitalization by two-thirds among children aged 5 to 11 years and prevented critical illness in those aged 12 to 18 years.23
Rare postmarketing reports of myocarditis24 are a major reason that some parents balk at giving their children the COVID-19 vaccine. Myocarditis is an inflammation of the heart muscle that most commonly results from viral infections, including COVID-19.25 Although extremely uncommon, the incidence of myocarditis after vaccination in male adolescents and young adults has been higher than expected26 compared with the normal rate in the population and occurs most frequently within a week of the second dose.
What’s often missing from the dizzying headlines about myocarditis is the fact that cases of myocarditis that develop after COVID-19 are far more severe and take longer to resolve. A study of 48 large US health care organizations found that young male patients infected with the virus are up to 6 times more likely to develop myocarditis than those who have received the vaccine.27 Another retrospective study pooled electronic chart data from 40 health care systems in the US and found that across all age groups the incidence of cardiac complications were higher after COVID-19 than after vaccination. Specifically in young males the risk of myocarditis, pericarditis or multisystem inflammatory disease ranged between 2 to 6x higher in young males aged 12 to 17 after COVID-19 compared with the vaccine. Patients with COVID-19 vaccine–related myocarditis are also more likely to experience a mild case28 and prompt resolution of symptoms and improvement of cardiac function vs those with classic viral myocarditis or myocarditis resulting from MIS-C.29
Another concern that parents have voiced is about the COVID-19 vaccine and potential infertility issues, which were never based on evidence and have been disproven with recent published studies.30,31 However, COVID-19 has been shown in these studies to be associated with male infertility.32
Recently, concerning data regarding detrimental neurological effects of COVID-19 have been published. A study of the medical records of nearly 1500 children with acute severe COVID-19 infection or MIS-C showed that 40% developed headaches and other lingering neurological symptoms.33 Additionally, a case-control study comparing MRI brain images before and after COVID-19 in more than 400 patients vs the same time points in non–COVID-19-positive controls found that patients with even mild COVID-19 had greater loss of gray-matter volume and more brain tissue damage than controls an average of 4.5 months after infection.34 It is unknown at this time whether this issue will resolve with long-term follow-up.
Lastly, Omicron and its subvariants have presented a challenge to neutralizing antibodies derived from both the vaccine35 and the virus,36 so any risk of severe COVID-19 in children is not balanced by the benefit of lasting immunity. A preprint of a retrospective cohort study of New York children found that the vaccine waned rapidly against mild Omicron infection but that it continued to show sustained protection against severe disease.37 Antibodies from COVID-19 infection also wane, and in fact, immunity acquired through previous infection is less effective against Omicron36 than against other previous variants.
CONCLUSION
In children, the COVID-19 vaccine predictably prevents severe SARS-CoV-2 outcomes, with minimal short-term immunogenicity reactions and very rare complications. The COVID-19 virus, on the other hand, can unpredictably cause severe infection, hospitalization, MIS-C, long-term chronic health problems, and death. Although immunity from infection and vaccines will wane over time, it is not really worth taking a chance on severe outcomes for transient immunity from infection. Thus, the vaccine is a safer way to shift pediatric COVID-19 illness to the milder end of the spectrum.
Vaccine hesitancy fueled by the appeal to nature fallacy that natural immunity is safer than the vaccine is not new. Throughout the pandemic, the proliferation of misinformation has led to public confusion surrounding the necessity and the safety of COVID-19 vaccines for children. Social media posts presenting misleading data have caused some parents to hesitate or completely decide against getting their children vaccinated while not understanding that they are putting their children at higher risk of severe illness. Children experience a significant burden of disease for COVID-19, and any preventable severe illness or death in a child is unacceptable.
To minimize the impact of COVID-19 on this population ignores the reality that children exist in larger communities. By vaccinating the youngest among us, we can help break cycles of transmission in schools as well as in multigenerational households and other shared communities. Mandating vaccines for school has been found to be associated with increased adherence with vaccination,38 which will protect a greater number of children from severe complications of COVID-19.
References
1. American Academy of Pediatrics Applauds CDC Advisory Committee's Approval of Safe, Effective COVID-19 Vaccine for Children Ages 5-11. Aap.org. https://www.aap.org/en/news-room/news-releases/aap/2021/american-academy-of-pediatrics-applauds-cdc-approval-of-safe-effective-covid-19-vaccine-for-children-ages-5-11/. Published 2022. Accessed April 15, 2022.
2. COVID-19 Vaccines for Children and Teens. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html?s_cid=11370:cdc%20covid%20vaccine%20children:sem.ga:p:RG:GM:gen:PTN:FY21. Published 2022. Accessed April 15, 2022.
3. California to require Covid vaccine for all students, Newsom says. EdSource. https://edsource.org/2021/california-to-require-covid-vaccine-for-all-students-newsom-says/661843. Published 2022. Accessed April 15, 2022.
4. Coronavirus (COVID-19) Update: FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Adolescents in Another Important Action in Fight Against Pandemic. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use. Published 2022. Accessed April 15, 2022.
5. FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Children 5 through 11 Years of Age. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use-children-5-through-11-years-age. Published 2022. Accessed April 15, 2022.
6. CDC Data Tracker. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends. Published 2022. Accessed April 15, 2022.
7. Failing to enforce California’s Covid-19 vaccine mandate may put school districts in financial peril. EdSource. https://edsource.org/2022/failing-to-enforce-california-vaccine-mandate-may-put-school-districts-in-financial-peril/667143#:~:text=The%20vaccine%20mandate%2C%20meant%20to,go%20into%20effect%20July%201. Published 2022. Accessed April 15, 2022.
8. Curtis G. Logical Fallacy: Appeal to Nature. Fallacyfiles.org. https://www.fallacyfiles.org/adnature.html. Published 2022. Accessed April 15, 2022.
9. How the phrase ‘natural immunity’ misleads us about real risks and dangers. https://www.washingtonpost.com/outlook/2021/09/29/natural-immunity-public-health/. Published 2022. Accessed April 15, 2022.
10. Children and COVID-19: State Data Report. https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%203.31.22%20FINAL.pdf. Published 2022. Accessed April 15, 2022.
11. Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-background.html. Published 2022. Accessed April 15, 2022.
12. Illness duration and symptom profile in symptomatic UK school-aged children tested for SARS-CoV-2. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(21)00198-X/fulltext. Published 2022. Accessed April 15, 2022.
13. COVID-19: People with Certain Medical Conditions. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Published 2022. Accessed April 15, 2022.
14. Underlying Medical Conditions Associated With Severe COVID-19 Illness Among Children. JAMA Network. 14.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780706. Published 2022. Accessed April 15, 2022.
15. Laboratory-Confirmed COVID-19-Associated Hospitalizations. CDC. https://gis.cdc.gov/grasp/covidnet/covid19_5.html. Published 2022. Accessed April 15, 2022.
16. CDC: Record Number of Kids With Coronavirus Are Hospitalized. US News. https://www.usnews.com/news/health-news/articles/2022-01-07/cdc-record-number-of-kids-with-coronavirus-are-hospitalized. Published 2022. Accessed April 15, 2022.
17. Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. CDC. https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance. Published 2022. Accessed April 15, 2022.
18. COVID-19 leading cause of death ranking - Peterson-KFF Health System Tracker. Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/brief/covid-19-leading-cause-of-death-ranking/. Published 2022. Accessed April 15, 2022.
19. Evaluation of the BNT162b2 Covid-19 Vaccine in Children 5 to 11 Years of Age | NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/nejmoa2116298. Published 2022. Accessed April 15, 2022.
20. Safety, Immunogenicity, and Efficacy of the BNT162b2 Covid-19 Vaccine in Adolescents | NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/nejmoa2107456. Published 2022. Accessed April 15, 2022.
21. The Pfizer-BioNTech COVID-19 Vaccine. Cvdvaccine-us.com. https://www.cvdvaccine-us.com/#. Published 2022. Accessed April 15, 2022.
22. Effectiveness of 2-Dose BNT162b2 (Pfizer BioNTech) mRNA Vaccine in Preventing SARS-CoV-2 Infection Among Children Aged 5–11 Years and Adolescents Aged 12–15 Years — PROTECT Cohort, July 2021–February 2022. https://www.cdc.gov/mmwr/volumes/71/wr/mm7111e1.htm. Published 2022. Accessed April 15, 2022.
23. BNT162b2 Protection against the Omicron Variant in Children and Adolescents | NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2202826. Published 2022. Accessed April 15, 2022.
24. Myocarditis and Pericarditis After mRNA COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html. Published 2022. Accessed April 15, 2022.
25. Understanding Myocarditis – Myocarditis Foundation. Myocarditis Foundation. https://www.myocarditisfoundation.org/about-myocarditis/?gclid=EAIaIQobChMIhu__k6DE9AIV4o1bCh0c7QIHEAAYASAAEgJYDvD_BwE. Published 2022. Accessed April 15, 2022.
26. Myopericarditis following COVID-19 vaccination: Updates from the Vaccine Adverse Event Reporting System (VAERS). https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-10-20-21/07-COVID-Su-508.pdf. Published 2022. Accessed April 15, 2022.
27. Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination — PCORnet, United States, January 2021–January 2022. https://www.cdc.gov/mmwr/volumes/71/wr/mm7114e1.htm. Published 2022. Accessed April 15, 2022.
28. Risk of Myocarditis from COVID-19 Infection in People Under Age 20: A Population-Based Analysis. https://www.medrxiv.org/content/10.1101/2021.07.23.21260998v1. Published 2022. Accessed April 15, 2022.
29. A Prospective Cohort Study of COVID-19 Vaccination, SARS-CoV-2 Infection, and Fertility. https://academic.oup.com/aje/advance-article/doi/10.1093/aje/kwac011/6511811. Published 2022. Accessed April 15, 2022.
30. Comparison of MIS-C Related Myocarditis, Classic Viral Myocarditis, and COVID-19 Vaccine related Myocarditis in Children. https://www.medrxiv.org/content/10.1101/2021.10.05.21264581v1. Published 2022. Accessed April 15, 2022.
31. In Vitro Fertilization and Early Pregnancy Outcomes After Coronavirus Disease 2019 (COVID-19) Vaccination. Obstetrics and Gynecology. https://journals.lww.com/greenjournal/Fulltext/9900/In_Vitro_Fertilization_and_Early_Pregnancy.378.aspx. Published 2022. Accessed April 15, 2022.
32. Implications of testicular ACE2 and the renin–angiotensin system for SARS-CoV-2 on testis function. Nature. https://www.nature.com/articles/s41585-021-00542-5. Published 2022. Accessed April 15, 2022.
33. Prevalence and Risk Factors of Neurologic Manifestations in Hospitalized Children Diagnosed with Acute SARS-CoV-2 or MIS-C. https://www.pedneur.com/article/S0887-8994(21)00276-9/fulltext. Published 2022. Accessed April 15, 2022.
34. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. https://www.nature.com/articles/s41586-022-04569-5. Published 2022. Accessed April 15, 2022.
35. Omicron extensively but incompletely escapes Pfizer BNT162b2 neutralization. https://www.nature.com/articles/s41586-021-04387-1. Published 2022. Accessed April 15, 2022.
36. Dresden) T, (OMRF) O, (TUM) T, Munich H. COVID reinfections surge during Omicron onslaught. Nature.com. https://www.nature.com/articles/d41586-022-00438-3. Published 2022. Accessed April 15, 2022.
37. Effectiveness of the BNT162b2 vaccine among children 5-11 and 12-17 years in New York after the Emergence of the Omicron Variant. MedRXiv. https://www.medrxiv.org/content/10.1101/2022.02.25.22271454v1.full.pdf. Published 2022. Accessed April 15, 2022.
38. Impact of school vaccination mandates on pediatric vaccination coverage: a systematic review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703989/. Published 2022. Accessed April 15, 2022.
