In the United States, the Pfizer-BioNTech mRNA COVID-19 vaccine is approved by the Food and Drug Administration (FDA) for all person ages 16 and older, while children and teenagers ages 5 to 15 became eligible to receive the vaccine under an FDA Emergency Use Authorization (EUA) in October 2021. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend COVID-19 vaccination for all children and adolescents 5 years of age and older who do not have contraindications, including children with previous infection or disease with SARS-CoV-2.1,2 The Pfizer-BioNTech COVID-19 vaccine for children ages 5 through 11 is administered as a two-dose primary series, 3 weeks apart, but is a lower dose (10 mcg) than that used for those ages 12 years and older (30 mcg).
Low Vaccination Uptake Among Children and Adolescents
Unfortunately, pediatric uptake of COVID-19 vaccination remains low, with vaccination rates in both age groups spiking following vaccine authorization but then slowing considerably in the ensuing weeks and months. As of mid-January 2022, only around 28% of children ages 5 to 11 years had received at least one COVID-19 vaccine dose, according to a Kaiser Family Foundation (KFF) survey.3 In this age group, the rate of vaccination peaked before Thanksgiving and then dropped steeply. In another KFF survey from late 2021, just under half (49%) of parents reported that their 12- to 17-year-olds had received at least one dose of the COVID-19 vaccine.4 In this survey, 30% of parents of both teens and younger children said they will “definitely not” get their child vaccinated for COVID-19.
Reasons for Parents’ Reluctance to Vaccinate Children
This KFF survey provides insight into why parents are hesitant to consent to COVID-19 vaccination for their children. Among parents who did not plan to vaccinate their young child (5 to 11 years) right away and parents whose adolescent children (12 to 17 years) had not been vaccinated, the top reasons underlying vaccine hesitancy were: need more information/research (18% and 17%), concern about side effects (14% and 8%), not worried about COVID-19/vaccine not necessary (9% and 8%), want to wait and see (7% and 2%), don’t trust vaccine (6% and 10%), and concerns about safety and/or long-term effects (11% and 4%).4
These data reflect parents’ lack of familiarity with and trust in the COVID-19 vaccines, which were developed and authorized relatively quickly compared with previous vaccines. Throughout the COVID-19 pandemic, healthcare authorities have struggled at times to disseminate accurate information widely in a short period of time. Meanwhile, parents have been barraged with misinformation about COVID-19 and COVID-19 vaccines online and through social media since the start of the pandemic. A KFF survey conducted in October 2021 demonstrated how widespread belief or uncertainty about COVID-19 misinformation is: nearly eight in ten of surveyed adults said they have heard at least one of eight different pieces of misinformation about COVID-19 and either believe them to be true or are not sure whether they are true or false.5
Working With Parents and Caregivers to Increase Pediatric COVID Vaccination Rates
These KFF survey results suggest that pediatric vaccination uptake will remain low until parents become comfortable with COVID-19 vaccines and receive accurate information about the effectiveness and safety of the vaccines and the risks of COVID-19 in children. Despite the misinformation about COVID-19 and increasing manifestations of distrust of science observed in American society over the past 5 years, healthcare providers remain parents’ most trusted source of information on the COVID-19 vaccine for children, and this remains true across race and ethnicity as well as political affiliation.3 However, in the 2021 KFF survey only 40% of parents said that they had talked with their healthcare provider about the vaccine.4 This evidence shows that there is a window of opportunity to influence parents’ and caregivers’ decisions about vaccinations, and the first step is to initiate discussions on the topic. Furthermore, studies indicate that individuals’ minds do change about the vaccine. A recent cohort study that used surveys to measure COVID-19 vaccine hesitancy and biological specimens to measure antibody response and assess the validity of self-reported vaccine receipt concluded that COVID-19 vaccine hesitancy is not a stable trait precluding vaccination but rather is labile.6 In addition, vaccine self-report had 98.2% (638 of 650 respondents) positive predictive value, 97.3% (35 of 1299 respondents) negative predictive value.
As such, moving parents to COVID-19 vaccine acceptance relies on engaging parents and providing accurate information regarding the benefits and risks of vaccination along with the short- and long-term risks COVID-19 poses for children and adolescents. This needs to be done in a nonjudgmental, open-ended manner. Regardless of the family’s decision, nurse practitioners must make sure that the family is aware that they remain available as a resource. One effective way to open this conversation is with the nonbinary statement, “Great news, we have COVID vaccines for your children. I will arrange for them to get the vaccine today.” This approach can start a dialogue between parent/caregiver and clinician and keeps the discussion from ending with a single “no.” Once the dialogue begins, NPs must be ready to dispel any myths or falsehoods that continue to circulate about COVID-19 and the vaccination.
Four Key Points for Parents and Caregivers
Vaccine Efficacy
Data clearly show that the COVID-19 vaccine can help prevent children from getting COVID-19 and prevent severe illness in those children who do become infected. The FDA’s EUA of the Pfizer-BioNTech COVID-19 Vaccine for children ages 5 to 11 years was based on data showing that the vaccine was 90.7% effective in preventing COVID-19 in this age group.7 For adolescents ages 12 to 15 years, studies have shown that vaccination with two doses of Pfizer-BioNTech vaccine has an efficacy of 100% (95% CI, 75.3%–100%) in preventing outpatient COVID-19 and effectiveness of 93% (95% CI, 83%–97%) against COVID-19 hospitalization.8
Safety and Side Effects
Prior to authorization, the Pfizer-BioNTech COVID-19 vaccine’s safety was studied in approximately 3,100 children ages 5 through 11 years who received the vaccine, and no serious side effects have been detected in the ongoing study.7 In another study sponsored by Pfizer and BioNTech, there were no serious vaccine-related adverse effects among the 1,517 fully vaccinated 5- to 11-year-old participants after a median 2.3-month follow-up.9 Recently, the CDC conducted a review of adverse events reported to the Vaccine Adverse Event Reporting System (VAERS) for the period November 3 through December 19, 2021, during which approximately 8.7 million children ages 5 to 11 years received the Pfizer-BioNTech COVID-19 vaccine. The CDC found 4,149 (97.6%) VAERS reports for nonserious events and 100 (2.4%) for serious events. The most commonly reported conditions and diagnostic findings among the 100 reports of serious events were fever (29; 29.0%), vomiting (21; 21.0%), and increased troponin (15; 15.0%).10
Commonly reported side effects in preauthorization trials for the Pfizer-BioNTech COVID-19 vaccine included injection site pain (sore arm), redness and swelling, fatigue, headache, muscle and/or joint pain, chills, fever, swollen lymph nodes, nausea, and decreased appetite. Side effects are more often reported after the second dose than after the first dose.
Myocarditis
Myocarditis following mRNA-based COVID-19 vaccination is a rare complication, and the inflammation, in most cases, resolves without specific therapy.11 Males ages 12 to 29 years are at highest risk. Among 192,405,448 persons who received a total of 354,100,845 mRNA-based COVID-19 vaccines between December 2020 and August 2021, there were 1,626 confirmed reports of myocarditis.12 It is important to note that myocarditis is a much more common complication of having COVID-19 than it is from getting vaccinated; a study showed that during March 2020 through January 2021, patients with COVID-19 had nearly 16 times the risk for myocarditis compared with patients who did not have COVID-19.13 According to the CDC, the risk of myocarditis after infection with COVID-19 is 146 cases per 100,000, while the risk of post-vaccine myocarditis is 2.13 cases per 100,000 vaccinated, which is within the range usually seen in the general population.14 In the CDC’s study of VAERs reports from November through December 2021, when 8.7 million children ages 5 to 11 received the Pfizer-BioNTech COVID-19 vaccine, among 15 preliminary reports of myocarditis identified during the period, 11 were verified (by provider interview or medical record review) and met the case definition for myocarditis; of these 11 children, seven recovered and four were recovering at time of the report. In addition, when children develop myocarditis after COVID-19 infection, it is typically much more severe than when it occurs after vaccination. However, in light of the small risk of myocarditis posed by mRNA COVID-19 vaccines, CDC’s Advisory Committee on Immunization Practices expressed support for increasing the recommended interval between the first and second doses of mRNA COVID-19 vaccines from 3 or 4 weeks to 8 weeks to reduce the risk of myocarditis.15 Lengthening the interval between doses is also expected to increase vaccine effectiveness and antibody responses.
Risks of COVID-19 in Children
Since the start of the pandemic, more than 12.3 million children have tested positive for COVID-19— more than 2.9 million of these cases having occurred in the 4-week period from mid-January to mid-February 2022. Although severe illness due to COVID-19 is uncommon among children, more data are needed to assess the severity of illness related to new variants as well as the longer-term impacts of COVID-19 disease. Also, as of February 16, 2022, there have been 970 deaths from COVID-19 in children ages 0 to 18 years since the start of the pandemic.1
Regarding longer-term impacts, children are susceptible to multisystem inflammatory syndrome in children (MIS-C), a potentially severe inflammatory syndrome seen 4 to 6 weeks after a typically mild or asymptomatic infection with SARS-CoV-2. Risks for MIS-C is much higher among unvaccinated children, according to a recent study, which showed that the effectiveness of two doses of Pfizer-BioNTech vaccine against MIS-C was 91%.16 In this study, 95% of MIS-C patients were unvaccinated, and all 38 MIS-C patients requiring life support were unvaccinated.
Debunking Five Common Myths and Falsehoods17,18
COVID-19 vaccines were developed too quickly and are not safe to use.
The technology used to develop the new mRNA COVID-19 vaccines is not new. It’s been studied and used for cancer research, and the original research on messenger RNA (mRNA) vaccines is decades old. In addition, the vaccines that are now being deployed have undergone strict and rigorous clinical trials involving thousands of human participants and approval from medical experts.
The vaccine isn’t necessary if you’ve already had COVID-19.
How long a natural infection with COVID-19 provides immunity from the disease remains uncertain. COVID-19 vaccination, on the other hand, causes a more predictable immune response than infection. In fact, one study showed persons who already had COVID-19 and do not get vaccinated after their recovery are more than two times as likely to get COVID-19 again than those who get fully vaccinated after their recovery.18 The CDC recommends getting the COVID-19 vaccine 90 days after being infected.
COVID-19 vaccines contain dangerous ingredients, including microchips and heavy metals.
Pfizer-BioNTech and Moderna COVID-19 vaccines contain mRNA, which give instructions to cells in the body to create an immune response. COVID-19 vaccines do not contain preservatives, tissues (like aborted fetal cells), antibiotics, food proteins, medicines, latex, or metals. There are no electronic components, microchips, or tracking devices in the vaccines. This falsehood is related to long-running conspiracy theories regarding the world-affairs discussion groups the Trilateral Commission and the Bilderberg Meeting that became amplified on social media.
COVID-19 vaccine can affect fertility.
There are no data that COVID-19 vaccines can cause infertility in men or women and no credible scientific theories for how the vaccines could cause female infertility. This myth is based on an assumption that the vaccine could cause the body to attack syncytin-1, a protein in the placenta that shares a small piece of genetic code with the spike protein of the coronavirus, but this has been debunked as implausible.19
COVID-19 vaccines can alter my DNA.
Both mRNA and viral vector COVID-19 vaccines work by delivering instructions (genetic material) to cells to start building protection against the virus that causes COVID-19. The genetic material delivered by mRNA vaccines never enters the nucleus of your cells, which is where DNA is stored.
Conclusion
The keys to moving parents from “no” to “yes” on COVID-19 vaccination for their children include engaging them about the issue, listening to their concerns with empathy, and providing accurate information in a nonjudgmental manner. Through active listening and conversations with parents and caregivers, nurse practitioners can help increase the pediatric COVID-19 vaccination rate one child at a time.
