Analysis

COVID-19 and children: should there be a vaccine roll out and could school nurses be key?

Vaccinating children could help protect vulnerable people but doubts remain over its priority

Vaccinating children might help curb transmission to vulnerable people but views differ on what priority it should have

  • The WHO wants wealthier nations to delay vaccinating children and instead donate supplies to low-income countries.
  • Although exceptions can already be made for some children aged 12 and over, charities complain of confusion and inconsistency over guidance
  • Given the right support, vaccinating children in schools could be preferable to using the current adult vaccination centres

The government is on track to offer all UK adults a first dose of a COVID-19 vaccine by the end of July. As that milestone nears, there is growing interest in whether children will, and indeed should, be next.

Vaccinating children might help curb transmission to vulnerable people but views differ on what priority it should have

  • The WHO wants wealthier nations to delay vaccinating children and instead donate supplies to low-income countries.
  • Although exceptions can already be made for some children aged 12 and over, charities complain of confusion and inconsistency over guidance
  • Given the right support, vaccinating children in schools could be preferable to using the current adult vaccination centres
Vaccinating children might help curb transmission of COVID-19 to vulnerable people but views differ on what priority it should have
Picture: Guzelian

The government is on track to offer all UK adults a first dose of a COVID-19 vaccine by the end of July. As that milestone nears, there is growing interest in whether children will, and indeed should, be next.

Here, we look at the current situation with COVID-19 vaccines for children and young people, clinical trials and what an eventual rollout could look like.

Are any children currently eligible for a COVID-19 vaccine in the UK?

None of the three COVID-19 vaccines that have been given emergency approval by the UK regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), are approved for children under the age of 16. Two – those made by AstraZeneca and Moderna – are licensed for use in over 18s, while the Pfizer jab has been approved for over 16s.

February 2021

Oxford COVID-19 vaccine study in children got under way

The vaccination programme is focusing on over-18s only. The exception is for children and young people over the age of 16 who are classed as vulnerable: they are entitled to a vaccine as part of priority groups four (extremely clinically vulnerable) and six (those with defined health conditions) on a list drawn up by the Joint Committee on Vaccination and Immunisation (JCVI).

The JCVI also says children aged 12 and over with severe neurodisabilities and recurrent respiratory tract infections who spend time in residential care settings can also be considered. Such vaccinations would be considered on an unlicensed basis and would need the approval of an authorised prescriber.

However, charities representing children with disabilities and clinical vulnerabilities have warned that there has been confusion and inconsistencies in how this guidance had been applied.

Clearer and expanded guidance needed

No decision has been made yet about how a child vaccination programme would be run, but school settings with school nurses have their benefits
Picture: iStock

In March, the charity Contact conducted a survey, obtaining responses from 3,000 families, and found that 10% (300) wanted a vaccine off-licence, but only 1.5% (45) had been successful in getting one, while 70% (2,100) said they would want their children to be vaccinated when licensed.

Contact says it has helped several families in their fight to get vaccinated, with its specialist nurses and doctors often backing their cause, only to be blocked by GPs and vaccination centres. The charity has also written to ministers asking for clarity and for vulnerable children to be prioritised if vaccines are licensed for under 16s.

Contact chief executive Amanda Batten says: ‘We need clearer and expanded guidance about which children can get unlicensed jabs. As more lockdown easing is being enjoyed by many, some families we support are still stuck at home desperately waiting for news of a vaccine.

6-17 years

Age range of children involved in the AstraZeneca vaccine trial

‘Many don’t have the confidence to emerge from shielding without being vaccinated so, at the very least, they should be offered a jab so they can get their lives back.’

What clinical trials are currently underway involving children?

In March, Pfizer reported successful results from a COVID-19 vaccine trial in adolescents. It reported 100% efficacy in stopping infections and a strong immune response from trials involving 2,260 children aged 12-15 in the US. The trials also suggested the vaccine is safe, with no unusual side effects.

In the trial, 18 cases of COVID-19 were seen in a group given a placebo and none in the group given the vaccine. There were no tests for asymptomatic infection – children displaying no symptoms.

Following those results, the US Food and Drug Administration and Health Canada, the Canadian public health department, granted authorisation for the vaccine’s use for children in that age group. The MHRA is currently assessing the application for approval in the UK.

Pfizer is also carrying out trials in younger children, while Moderna and AstraZeneca are carrying out their own trials in children.

Moderna reported faovurable results in phase 2/3 trials involving 12-17 year-olds. It found its vaccine was 93% effective against COVID-19 in children after the first dose and 100% two weeks after the second dose, with no cases of COVID-19 reported among vaccinated participants.

The AstraZeneca trial, run by the Oxford Vaccine Group in the UK, began in February and involves children aged 6-17.

The trial was paused briefly in April pending the outcome of an MHRA review of rare blood clots in adults. While the review did not recommend any age restriction on the use of the vaccine, the JCVI suggested those under 30 should be offered an alternative on a precautionary basis. The trial for children is continuing, but no more children are being recruited.

The AstraZeneca trial, run by the Oxford Vaccine Group in the UK, began in February and involves children aged 6-17.
Picture: Guzelian

What could a COVID-19 vaccination programme for UK children look like?

The adult vaccination programme has been run from local vaccination centres at GP surgeries, community centres, pharmacies and larger venues as well as hospital hubs. Mobile vaccination clinics have also been deployed and home visits made to those who are housebound.

No decision has been made yet about how a child vaccination programme would be run. However, School and Public Health Nurses Association chief executive Sharon White says: ‘Schools are exactly the right settings. The UK has one of the highest uptakes for child vaccination and that is because it is delivered by fabulous school nurses.

‘They know the pupils and the staff – that is a big advantage, whether it is chasing up admin and consent or calming kids and answering their questions. If you did it in the local vaccination centres you risk having lower uptake, particularly among more deprived communities.’

School and Public Health Nurses Association chief executive Sharon White
Sharon White

But she says while school nurses and the dedicated school immunisation teams should lead the programme, extra support would be needed. ‘We also need to be able to do our day-to-day work – if that stops children will suffer. We could recruit some of the vaccinators from the current centres to support us. There would need to be a bit of extra training, but I think it could work well.’

End of July 2021

UK government target to offer all adults a first vaccine dose

Another option would be to have school nurses involved in delivering the vaccine outside of education settings. During the past year, routine childhood vaccinations such as the human papillomavirus (HPV) jab have been given at drive-through centres and in sports stadia while schools have been closed.

‘Logistically it takes more organising but we have shown it can work. It would also mean we do not have to wait until September when schools return – unless it was approved before the end of term, but time is running out. I still think a school-based programme will be the most effective,’ says Ms White.

Do children really need a COVID-19 vaccine?

As with other vaccination programmes, the reasons to vaccinate children are two-fold – to protect them from the virus and to help curb transmission to more vulnerable members of the community.

At University College London’s Institute of Child Health, professor of adolescent health Russell Viner agrees, saying it is finely balanced. ‘There is undoubtedly a very small group of teenagers who are extremely clinically vulnerable and would benefit from vaccination,’ he says. ‘However, for healthy children and teenagers it’s difficult to argue for, given our current knowledge.’

JCVI member Adam Finn, who heads the Children’s Vaccine Centre at the University of Bristol, says there is still debate on whether healthy children should be offered the vaccine.

‘Most children who get COVID-19 do not get seriously ill, indeed most don’t get sick at all. And, although the importance of children in transmission of the virus is not entirely clear, the evidence we have suggests that it is not great, especially where younger children of pre-school and primary school age are concerned.’

Professor Finn also says the experience of Israel shows that vaccinating adults may be enough to reach the herd immunity threshold, so vaccinating children should be a low priority.

University College London’s Institute of Child Health, professor of adolescent health Russell Viner
Russell Viner

The risk of serious disease and paediatric multisystem inflammatory syndrome is low, while the true extent of the risk of long-COVID in children remains unknown, says Professor Viner, a former president of the Royal College of Paediatrics and Child Health.

He says the emerging evidence on vaccines slowing transmission provides weight to the argument in favour of vaccination. But doing that would be about benefiting adults and would require careful ethical consideration. ‘We do vaccinate children to protect others, however we do this with the full knowledge about the risks.’

He says this is yet to be determined for COVID-19 vaccines, although the results of the Pfizer trial were promising. ‘Children’s immune systems differ – they respond differently. There will undoubtedly be very rare side effects.’

What about the ethical implications?

While the debate about whether children need to be vaccinated may be finely balanced, the moral argument is much clearer, experts say.

Flu: 5 reasons to get your child vaccinated flu poster
Flu: 5 reasons to get your child vaccinated flu poster

In May, World Health Organization (WHO) director general Tedros Adhanom Ghebreyesus called on wealthier nations to postpone plans to vaccinate children and young people, and instead donate supplies to low-income countries.

Dr Adhanom Ghebreyesus said the international distribution of COVID-19 vaccines remained uneven: ‘In low- and lower-middle-income countries vaccine supply has not been enough to even immunise healthcare workers, and hospitals are being inundated with people that need life-saving care urgently.’

While nearly all of Europe and the Americas have begun vaccination campaigns, the roll-out across Africa is concerning, with most countries administering less than four doses per 100 people. In comparison, as of 20 May, the UK had a vaccination rate of 86 doses per 100 people, and the US 83.

The Covax scheme for equitable vaccine access was developed with the aim of first vaccinating 20% of the population in the 92 poorer countries that signed up, starting with healthcare workers. But given how far behind that target they are, many of those working on vaccine programmes agree with the WHO.

Andrew Pollard, director of the Oxford Vaccine Group, which worked with AstraZeneca to develop its vaccine, says: ‘When you look at the overall aim of a global vaccination programme in a pandemic, it’s to stop people dying.’

Professor Pollard says that, given the awful circumstances in some countries, it would feel completely wrong morally to roll out vaccines to a younger population who are at very low risk.

View from RCN professional lead for public health Helen Donovan

RCN professional lead for public health Helen Donovan
Picture: Barney Newman

‘While older people are more at risk from severe disease, younger people are still likely to catch the infection and then pass this on even if they are not ill themselves. As such it does make sense to vaccinate the population and particularly secondary school age children, who are more likely to mix with others and be exposed to infection and therefore pass it on.

‘But the ethics are hard when there are so many countries that have not vaccinated many of those at risk of severe illness – global and equitable access to vaccines across the world is vital.

‘If we are to do it, a school-based programme would make sense as it’s always best to offer vaccines where people are and make it as easy as possible for people. The capacity of the school immunisation services will be a challenge, though, and there will still need to be options for some to have the vaccines in their GP surgery, where either the children or parents feel this would be best.’



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