What is the status of COVID vaccines for children and adolescents?

Vaccines from BioNTech-Pfizerand Moderna are currently approved in the EU for children and adolescents aged 12 to 17 years. The vaccine has shown 100% efficacy in a clinical trial with participants in that age group and was well tolerated, Moderna said.

Germany's Standing Committee on Vaccination (STIKO) has now recommended vaccination for all 12- to 17-year olds. The body is basing its new assessment on fresh data from the United States, where nearly 10 million children and adolescents have already been vaccinated. In a statement, the committee said the benefits would outweigh the very rare side effects. On August 2, the health ministers of the German states had already decided, contrary to generally allow everyone 12 and older to be vaccinated. On August 13 Health Minister Jens Spahn tweeted that one in four from this age group have already been vaccinated at least once.

How are other countries doing? 

The United Kingdom has also taken a cautious approach so far. Children 12 and older are allowed to be vaccinated if they themselves are at risk of severe COVID-19, or live with someone whose immune system is severely weakened. 

In the United States and Canada, however, BioNTech-Pfizer's vaccine has been used in adolescents and older children since May. In the US alone, more than 4.4 million 12- to 15-year-olds have already been fully vaccinated, and nearly 3.8 million have received a first dose. 

Other countries have also already approved the vaccines for this age group, including Japan and Israel. 

Why is there still a debate about vaccinations for children?

But in many countries, discussions continue about how useful it is to vaccinate children and adolescents against COVID-19, precisely because not all experts agree.

DW takes a look at what role children and teenagers between the ages of 12 and 15 play in contracting and spreading the coronavirus, how likely they are to develop COVID-19, and how safe the vaccines are for that age group.

Please note: DW has concentrated on examining the facts, leaving aside ethical questions regarding the cost and benefit of vaccinations, and the basic rights of children and teens.

Can't we just achieve herd immunity among adults to protect children?

The assumption that vaccinating adults against COVID-19 will also protect children is false. Statistically speaking, children and teenagers make up such a large proportion of the global population that they need to be included in efforts to build herd immunity.

One year ago, the World Health Organization said vaccinating 60% to 70% of the global population would suffice to reach this target. Now, however, many public health experts — including US immunologist Anthony Fauci — say we should be aiming for a 85% vaccination rate. 

The UN Department of Economic and Social Affairs has estimated that children and teenagers up until the age of 17 make up 30.2% of the world's population — the equivalent of 2.35 billion people.

According to Germany's Federal Statistical Office, the proportion of people under 18 in Germany is much lower, at around 16.4% of the population. One could therefore assume that in the case of Germany, vaccination of all adults would be sufficient to achieve herd immunity. After all, just over 62% of the population has already been vaccinated at least once. 

However, the German Professional Association of Pediatricians and Adolescents (BVKJ) has spoken out in favor of vaccinating 12- to 16-year-olds — not least to achieve the desired herd immunity.

"If we were to vaccinate all adults in Germany, then of course it would be a vanishingly small amount," Axel Gerschlauer, a specialist in pediatrics and adolescent medicine and press spokesman for the BVKJ, told DW in May. "But since we have a lot of adults that we won't reach, even these 3 million or so [children and adolescents — Editor's note] are totally important, because we all don't know exactly how many millions we really need to vaccinate to achieve herd immunity."

Professor Karina Top, who studies vaccines and epidemiology at Canada's Dalhousie University, said reaching herd immunity will depend "on getting enough adults vaccinated, and I know there's concern in many countries that many adults are not willing to get vaccinated."

That is why, she said, vaccinating children and teens is more important than ever.

Do children and teenagers face a smaller COVID risk, given that they are less likely to develop serious or lethal cases?

It's misleading to say that children and teenagers are less likely to develop serious cases of COIVD-19. Nevertheless, the Robert Koch Institute (RKI), Germany's disease control and prevention agency, has said that the majority of infected children either have no or only mild symptoms.

An Italian study from 2020 found that teenagers under the age of 18 have a lower risk of developing a serious case of COVID-19. It found that of 3,836 infected children and teenagers, only 4.3% fell seriously ill, with four dying. Cardiologists across the world say that between 0.6% to 2% of children with COVID-19 require treatment in intensive care units. In very rare instances, children and teenagers suffered heart failure.

The American Academy of Pediatrics reports that since the coronavirus outbreak began, at least 4.2 million US children have tested positive for COVID-19 (as of July 29). Of these, 0.1% to 1.9% were hospitalized. In total, depending on the state, up to 0.03% of children died in connection with the virus, though only two-thirds of US states have provided data.

Germany's Federal Ministry of Education and Research (BMBF) notes that children are just as likely to contract the virus as adults, but are less likely to fall ill. The BMBF website states that "this age-dependent difference has been observed with regard to other infectious diseases and is linked to children's and teenagers' immune systems reacting differently to those of adults." Immune systems become less effective as individuals age. Whether this applies to coronavirus infections as well has not yet been scientifically established.

According to the German Society for Pediatric Infectious Diseases, 1,680 hospitalized children and adolescents with a SARS-CoV-2 direct detection have been reported in Germany or Austria since the outbreak of the pandemic (as of July 29). Of these, 84 (5%) were treated in intensive care.

In about 29% of the cases, the children were between the ages of 6 and 15. However, the largest proportion of reported cases — 46% — is among babies and toddlers 1 year old and younger, as their chart shows.

At the same time, Germany's BVKJ has drawn attention to a study by the RKI which found that 11% of girls and 16% of boys under the age of 17 suffer from chronic illnesses. "Just think about the children with serious heart conditions or Down syndrome, who despite their young age are at risk of developing severe [COVID-19] infections," said Gerschlauer of the BVKJ. "These children urgently need an opportunity to get vaccinated. This is about protecting individuals, rather than building herd immunity."

Since June, children and adolescents aged 12 and older who have preexisting health conditions have been able to get their vaccine shots in Germany.

Can children receive the same vaccine as adults?

Very little research has been done on the effects of COVID-19 vaccines on children and teenagers. Vaccines are usually first tested only on adults. The approval of the BioNTech-Pfizer vaccine for children between the ages of 12 and 15 years by the European Medicines Agency was based on a study involving some 2,000 children of this age group. Of the approximately 1,000 who received the vaccine, none developed COVID-19, it was reported; in the comparison group, which was injected with a placebo, 16 developed the disease.

Canada and the US approved the BioNTech-Pfizer vaccine for children between 12 and 15 after a study on 2,260 individuals from this age bracket was completed, in which 1,131 study participants were given the vaccine. BioNTech-Pfizer says the vaccine proved 100% effective in this age group, making it more effective than in any other group.

Canadian vaccine researcher Karina Top said the relatively small number of study participants is appropriate. "I think that is appropriate because we have so much more data and experiences in people 16 and over who were in the larger studies," she said. "There have been well over 100 million doses of the Pfizer vaccine given around the world ... and we have data coming out around the effectiveness and the safety of that vaccine in those people." Similar findings for 16- to 25-year-olds, she said, make it reasonable to extend approval for those between 12- to 15-years old.

But caution remains key, she added. "We always have to continue monitoring safety of vaccines after they are approved for use in the population, because even with 30,000 people in a study, you can't detect very rare adverse events that occur in one in 100,000 or one in a million."

Top and German pediatrician Axel Gerschlauer agree that vaccines developed for adults are not automatically suitable for children. Top said it's not uncommon that the same vaccine type is administered. Sometimes, as in the case of tetanus vaccinations, babies are given a modified vaccine mix that differs from the one administered to children and teenagers. Sometimes, different age groups receive different amounts of doses. Top said  "individuals under the age of 14 may receive two HPV vaccine doses, at least in Canada; but those 15 and up need a third dose because their reaction is not as strong."

Children's immune systems react differently to vaccines than those of teenagers and adults, according to experts. Finding the safest and most effective vaccine dose is thus essential. BioNTech-Pfizer and Moderna are currently conducting studies with children aged 6 to 11. AstraZeneca is testing its vaccine on younger children, but results are not yet available.

So should children be vaccinated against COVID-19?

Looking beyond the data and expert opinions, it remains an individual decision and one that should be discussed and evaluated with a family doctor or pediatrician. On a case-by case basis, doctors can best assess the benefits as well as the risks for the child and make a recommendation accordingly.

This article has been adapted from German. It was updated on September 9. A previous version of this article had stated: In total about 0.03% of children died. This has been changed to: In total, depending on the state, up to 0.03% of children died.