The decision taken by the JCVI is understandable in some contexts, but what remains unclear is why a rare vaccine side effect which occurs in an estimated 1 in 20,000 teenagers vaccinated is included in their decision making, but the impact of persistent, disabling symptoms more than 15 weeks following COVID-19 (Long Covid), which based on data released by the CLoCK study this week appears to occur in 1 in 7 children and young people, is not.

Clarification of why this is not being sufficiently considered in the decision making, when knowledge of this condition and estimated figures of prevalence from the Office of National Statistics have been available for many months, would be of value.

While Long Covid has gained recognition greatly over the last year, we must now realise that hospitalisation and death are not the only negative outcomes following COVID-19 and it is time the risks and impact of Long Covid are factored into public health decision making in relation to mitigating the long term burden of COVID-19.

JCVI has determined that the health benefits of COVID-19 vaccination do not sufficiently outweigh the risks for healthy 12-15 year olds to justify wholesale vaccination of this age group.

The broadening of the criteria of children within this age group who are expected to benefit from vaccination will have been based on careful analysis of severe COVID-19 cases in children.

However, whether the reductions in mild infections, and reductions in virus transmission, that might be achieved by widespread vaccination of secondary school-aged children will be sufficient to materially enhance their educational experience over the next few months, or will have any substantial impact on virus transmission within the wider community, is something that also needs to be taken into account.

This is not something that JCVI is designed to assess; these broader public health questions will be addressed by public health professionals, presumably after discussions with SAGE.

The JCVI decision today to extend COVID vaccination in 12-15 year olds with medical conditions increasing their risk of severe disease is to be welcomed. Children of 12 and over are those most affected by the rising infection rate and many parents of children with chronic disorders will be very relieved today that their child will now qualify for covid vaccination as the schools reopen and the winter approaches.

The decision of whether or not to extend vaccination further to include healthy children is more finely balanced, given the potential risk of heart inflammation, although one study has suggested that the risk of myocarditis in children with covid is at least 6 times greater than the risk associated with vaccination (reference Singer ME, Taub IB, Kaelber DC. Risk of Myocarditis from COVID-19 Infection in People Under Age 20: A Population-Based Analysis. medRxiv [Preprint]. 2021 Jul 27:2021.07.23.21260998. doi: 10.1101/2021.07.23.21260998. PMID: 34341797; PMCID: PMC8328065.).

The JCVI have proposed that the Chief Medical Officers of the four nations of the UK consider and provide further advice on the societal and educational benefits of vaccination in healthy 12-15 year olds. While this is probably a reasonable division of labour between a group of scientists with specific expertise in infectious disease, immunology and effects of vaccines and a group of doctors with specific training in public health, perhaps these two specialities should have been able to convene together before now to provide conjoined advice to government ministers.

The Joint committee on Vaccination and Immunisation has today announced that it will NOT at present recommend vaccination of healthy 12-15 year olds.

This decision will disappoint many, as this age group is particularly socially active – they have more contacts with other people than other age groups other than young adults. As such, they are particularly effective as “vectors”, transmitting the infection between households. Now that the much more infectious delta variant is prevalent we will struggle to control the virus with vaccination alone – and we certainly won’t succeed if this age group is unvaccinated.

I commented on this recently (1, 2) As far as I am concerned, nothing significant has changed. I agree with Gurdasani et al that more needs to be done to make schools safe (3); and think that JCVI has appropriately placed a lot of weight on the risks of vaccination, but has not given sufficient weight to the possible long-term sequelae (as discussed on SMC recently) (4). See also…(5)

Like Independent Sage, I believe that the risk that a significant proportion of children will suffer long-term sequelae means that we should be rolling out mitigations in schools, and also vaccination (declared safe and effective for 12-15 year-olds by the MHRA), as soon as possible (6).

While relatively few children suffer serious acute (short-term) illness as a result of Covid-19, a higher proportion (including of children who did not have serious primary disease) suffer long-term sequelae; and there is evidence that such sequelae can be prevented by vaccination (4, 7-12)

As I said in my previous comment (1):

Children also stand to benefit from:

- Ending the pandemic and inevitable restrictions sooner;

- Avoiding the harms relating to the secondary cases (people infected by the children), especially if teachers, parents or carers are infected;

- Reducing the effects of Covid-19 (directly or through self-isolation etc) on loss of school;

- And, crucially, given the growing evidence of its severity and frequency, by preventing the long term consequences on the children and adolescents of “Long Covid”.  As Dr Tom Frieden in the USA tweeted: “The most certain way not to get long Covid is not to get Covid. The most certain way to not get Covid is to get vaccinated.” (13)

The risks of disease are all the greater when transmission rates are high – and in the UK transmission rates are far too high, and seem to be rising, even before most English schools reopened for the winter. It is while the risk is highest that protection from vaccination would have been most useful.

The advice from JCVI could – and I suspect will – change as further information comes in from other countries on the safety (or otherwise) of vaccination, and as evidence mounts about the longer term sequelae of the disease.

It appears that the JCVI has deliberately left the door open for government (likely on the advice of the chief medical officer and/or SAGE) to take into consideration the sort of indirect benefits (less disruption to schooling, [grand-] parental illness, etc.), and to implement vaccination in this age group. The JCVI is not the final decision-maker on this issue.

“Prof Pagel explains this well in this short twitter thread. (14)“

References

1. English PMB, Royal College of Paediatrics and Child Health, Brown D, Ghani A, Ferguson B, Ward P, et al. Expert reaction to JCVI interim advice on whether children and young people aged 12-17 years should be offered the COVID-19 vaccine. Science Media Centre 2021; Updated 21 Jul 2012 (Originally published 19 Jul 2021); Accessed: 2021 (21 Jul): (https://www.sciencemediacentre.org/expert-reaction-to-jcvi-interim-advice-on-whether-children-and-young-people-aged-12-17-years-should-be-offered-the-covid-19-vaccine/).

2. Covid Action Group, Gurdasani D, McKee M, Michie S, Pagel C, Reicher S, et al. Open letter to Secretary of State for Education (UK) May 4, 2021. 2021; Updated 04 May 2021; Accessed: 2021 (04 May): (https://covidactiongroup.net/open-letter-to-secretary-of-state-for-education-uk-may-4-2021/).

3. Gurdasani D, Bar-Yam Y, Denaxas S, Greenhalgh T, Griffin S, Haque Z, et al. England’s schools must be made safe: An open letter to the education secretary. thebmjopinion 2021; Updated 03 Sep 2021; Accessed: 2021 (03 Sep): (https://blogs.bmj.com/bmj/2021/09/03/englands-schools-must-be-made-safe-an-open-letter-to-the-education-secretary/).

4. Strain D, MacDermott N, Altmann D, Absoud M, Bishop N. Expert reaction to preprint from the CLoCk study looking at long COVID in children. Science Media Centre 2021; Updated 01 Sep 2012; Accessed: 2021 (02 Sep): (https://www.sciencemediacentre.org/expert-reaction-to-preprint-from-the-clock-study-looking-at-long-covid-in-children/).

5. Alwan N. @Dr2NisreenAlwan: The updated headline: “Long Covid in children 'nowhere near scale feared'”. What was the scale feared then? The study shows that symptoms are more common in those who tested positive. 30% in test positive vs 16% in test negative had 3+ symptoms at 3 months. Twitter thread 2021; Updated 02 Sep 2021; Accessed: 2021 (03 Sep): (https://twitter.com/Dr2NisreenAlwan/status/1433318405164126208 or https://threadreaderapp.com/thread/1433318405164126208.html).

6. Independent SAGE. The Independent SAGE Schools redux: September 2021: An Urgent Plan for Safer Schools. Education, Short statements 2020; Updated 03 Sep 2021; Accessed: 2021 (03 Sep): (https://www.independentsage.org/wp-content/uploads/2021/09/Schools-redux-Sept-2021.pdf or via https://www.independentsage.org/september-2021-an-urgent-plan-for-safer-schools/).

7. Strain D, Openshaw P, Head M, Maxwell E. Expert reaction to study looking at long COVID, including in those who weren’t hospitalised with the disease. Science Media Centre 2021; Updated 23 Jun 2012; Accessed: 2021 (24 Jun): (https://www.sciencemediacentre.org/expert-reaction-to-study-looking-at-long-covid-including-in-those-who-werent-hospitalised-with-the-disease/).

8. Terence S, Terence S, Snehal Pinto P, Roz S, Bianca De S, Natalia R, et al. Long COVID - the physical and mental health of children and non-hospitalised young people 3 months after SARS-CoV-2 infection; a national matched cohort study (The CLoCk) Study [preprint]. Nature Portfolio 2021. (https://www.researchsquare.com/article/rs-798316/v1).

9. Molteni E, Sudre CH, Canas LS, Bhopal SS, Hughes RC, Antonelli M, et al. Illness duration and symptom profile in symptomatic UK school-aged children tested for SARS-CoV-2. The Lancet Child & Adolescent Health 2021. (https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(21)00198-X/fulltext).

10. Huang L, Yao Q, Gu X, Wang Q, Ren L, Wang Y, et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet 2021;398(10302):747-758. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01755-4/fulltext).

11. The L. Understanding long COVID: a modern medical challenge. Lancet 2021;398(10302):725. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01900-0/fulltext).

12. Antonelli M, Penfold RS, Merino J, Sudre CH, Molteni E, Berry S, et al. Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: a prospective, community-based, nested, case-control study. The Lancet Infectious Diseases 2021. (https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00460-6/fulltext).

13. Frieden T. @DrTomFrieden: The most certain way not to get long Covid is not to get Covid. The most certain way to not get Covid is to get vaccinated. Tweet 2021; Updated 19 Jul 2021; Accessed: 2021 (19 Jul): (https://twitter.com/DrTomFrieden/status/1417183808114282499).

14. Pagel C. @chrischirp: THREAD on Child Vax: Interviewed on @BBCNews about the JCVI decision not to vaccinate 12-15 year olds. This was my initial reaction - that it was out of step with most other similar countries. And that they do not seem to have considered long covid at all. 1/6. Twitter thread 2021; Updated 03 Sep 2021; Accessed: 2021 (03 Sep): (https://twitter.com/chrischirp/status/1433824925723340800 or https://threadreaderapp.com/thread/1433824925723340800.html).

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