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Europe is grappling with one of the most ethically fraught decisions of the pandemic — expand vaccination to children or donate jabs to those who need them most in the rest of the world.
As yet, no EU country has pledged to delay jabs for kids and send these vaccines elsewhere, despite the fact that the pandemic is still raging in many other parts of the world, including South Asia and South America.
Instead, following approval from the European Medicines Agency of the BioNTech/Pfizer vaccine for children aged 12-16, countries across the bloc are preparing to begin vaccinating their adolescents, with several EU countries eyeing a start date this month. That move seems to contradict guidance from the European Centre for Disease Prevention and Control (ECDC), which stated Tuesday that “equity issues concerning vaccine availability and access need to be carefully considered when deciding on expansion of COVID-19 vaccination to groups with lower individual risk of severe disease.”
Germany plans to open appointments to children aged 12 and over on June 7, with France doing the same from June 15. Lithuania hopes to begin this month for over 16s, and Italy’s pediatricians are also getting ready to use the jabs.
On Friday, the U.K.’s regulator authorized the vaccine for children aged 12 and over, but the committee that advises the government on how vaccinations should be rolled out has yet to issue recommendations.
Elsewhere in the world, such plans seem like a far-off dream. Scores of low- and middle-income countries have yet to vaccinate even just 1 percent of their populations. Kenya, with a population of over 50 million, hadn’t administered 1 million vaccines by June 2. Nigeria — with a population of over 200 million — has only just passed the 2 million-dose mark.
To Keymanthri Moodley, director of the Centre for Medical Ethics and Law at Stellenbosch University in South Africa, it’s simple math.
She takes the example of the U.S., where children 12 and over can walk into their local pharmacy and get the BioNTech/Pfizer vaccine. There are roughly 25 million kids in this group, which means about 50 million doses would be needed for full coverage — not taking into account that the vaccine may be authorized for younger kids later this year. Those 50 million doses can be compared against the total number of doses administered on the entire African continent: 33 million.
“It robs the global pot of vaccines,” said Moodley.
But others point out it’s not a simple matter of rerouting a jab meant to go into the arm of an American teen to the arm of a health care worker in Ghana. Logistics, the complexity of rolling out vaccination campaigns, expiry dates and the science all make things more complicated.
The science of vaccinating children
While scientists (and governments) are broadly in agreement about the importance of vaccinating adults, it’s not as clear cut when it comes to vaccinating children. Commission President Ursula von der Leyen touched on this dilemma when she recently stated that vaccinating children is “not a political decision, it’s clearly [an] evidence-based, scientific decision.”
But in the U.K., it seems the government’s scientific advisers are saying the opposite and passing the buck over to the politicians. And some public health experts are pushing back.
Imposing immunization on children if it’s not really needed would be “the wrong thing to do,” said Adam Finn, a member of the U.K. committee that makes recommendations on vaccination and a professor of pediatrics at the University of Bristol. He told Times Radio on Monday that the committee “really needs a little bit more evidence on this before it can give clear advice.”
The research is clear that children are much less likely to become severely sick with COVID-19, and that death is rare. But there are cases of children becoming very ill, including developing so-called pediatric multisystem inflammatory syndrome, which is a “critical, severe condition,” explained Verina Wild, a professor of medical ethics at the University of Augsburg.
In addition, just as there are adults with comorbidities that need to be prioritized for vaccines, there are also children that may need earlier protection, according to Moodley. “It’s about not only looking at age, but looking at risk stratification for the different age groups,” she said.
Despite these exceptional cases, the “argument for vaccinating [children] is not 100 percent clear if you only look at the individual case,” Wild said. That statement mirrors the ECDC guidance that the individual direct benefits of vaccination of children are expected to be limited in comparison to those for older people.
But what if children could help a country reach herd immunity? Do they have a bigger role to play?
Most scientists agree that this is where vaccinating children may be vital. It’s ultimately going to depend on what percentage of the population needs to be vaccinated to reach herd immunity, said Anita Shet, director of child health at the International Vaccine Access Center and a senior scientist at Johns Hopkins Bloomberg School of Public Health.
Estimates of the vaccination coverage needed vary from 60 to 90 percent, she notes — and if it’s closer to 90 percent, kids being jabbed will be vital.
There’s another area where vaccinating children may be important — stamping out new variants.
When the virus is left to spread largely undeterred, new variants emerge. One countermeasure, then, is to “get as many people within a population vaccinated and protected so the virus has less space to grow, less space to spread,” said Shet. “It means that we need to get vaccines into most of the population regardless of age.”
If new variants can be stamped out in countries with high vaccination rates, Shet added, “it benefits the entire world.”
Coincidentally, it’s the same argument that experts make for donating those doses meant for children to other countries.
“Every country wants to immunize everyone to keep the entire country safe,” said Moodley. “But this is not an infection that is limited to specific countries, it’s a worldwide pandemic — so keeping one country 100 percent immunized is not the solution.”
WHO Director General Tedros Adhanom Ghebreyesus has similarly warned that if the virus is spreading anywhere, “it has more opportunities to mutate and potentially undermine the efficacy of vaccines everywhere.”
“We could end up back at square one,” he has warned.
Tedros has been one of the most vocal in this camp. “Countries that vaccinate children and other low-risk groups now do so at the expense of health workers and high-risk groups in other countries,” he said on May 24.
In India, which has been devastated by the latest surge of cases, donations of vaccines meant for teenagers in the U.S. could provide vital protection to the population and “help save lives quickly,” argued several researchers in the Atlantic recently.
Shet, by contrast, takes a somewhat different stance, arguing it’s not a “fair question” to ask whether wealthy countries should rather donate doses than vaccinate their children. Vaccines may be limited, but that’s “not the whole picture.”
For one, there are the difficulties in distributing the BioNTech/Pfizer — the only vaccine that can currently be given to children — due to its ultra-cold storage requirements. That means that it’s not suitable for all places of the globe.
The difficulties countries face in rolling out vaccines was also made clear recently when several countries had to destroy vaccines or return them after being unable to use them before their expiry dates. The reasons for their inability to distribute the vaccines on time are complex, but some include lack of funds, vaccinators, and training to support the rollout.
Shet also points out that some rich countries are now in the position to vaccinate domestically and globally. While the U.S. is vaccinating its kids, it’s also planning on donating doses and has set out its plan for where the first 25 million will go.
The EU, meanwhile, has pledged to donate 100 million vaccines: France and Germany have each offered 30 million, Spain is donating 22.5 million, Italy has pledged 15 million, Belgium is donating 4 million, Denmark and Sweden have each earmarked 3 million, and Romania is giving 2 million.
A year late
There’s also another uncomfortable truth for Europe: The moral dilemma it’s faced with now could have been avoided.
A truly global campaign was the aim of COVAX: Have a giant pool of vaccines and distribute them equitably, according to risk group, around the world.
The plan was that when the world was facing limited vaccine supply, countries would each receive enough jabs for 20 percent of their population — covering the priority groups of the elderly, front-line health care workers and people with comorbidities. The second phase was meant to target countries with vulnerable health care systems and especially high case numbers.
While wealthy countries, including EU nations, pledged cash to COVAX, they didn’t rely on it to cut agreements on vaccines, preferring instead to conclude their own agreements with vaccine developers. That meant that COVAX was just one of many in the queue to negotiate with drugmakers for the limited pot of vaccines.
The WHO’s Tedros has said that the resulting bilateral deals drove up prices and were an attempt to “jump to the front of the queue.”
“We should have had a global distribution plan from the beginning,” said Wild, the medical ethics professor. “It would have made so much sense to vaccinate the elderly and their health care workers first worldwide, and then to move downwards.”
Wild emphasizes she strongly supports the argument for vaccinating health care workers before children in Europe. But she also points out it’s notable that the debate has come to a head only now, as children are being offered a vaccine, and not when low-risk 25 year olds were.
“We could have started that discussion much, much earlier,” she said.
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