While many people celebrate this decision, as South Africa has both an adequate Pfizer vaccine supply as well as sufficient capacity at vaccination stations, many parents have concerns that need to be addressed. At this stage, only a single Pfizer dose has been approved for teenagers, but it is likely that a second dose will be offered at a later date. Dr Sheri Fanaroff, a General Practitioner in Gauteng, gives us some information on the vaccination of the 12 – 17 age group.
The issue that needs to be addressed here is “Do the benefits outweigh the risks, both individually and collectively?”
● Individual Risk vs Benefit
- Vaccination reduces the risk of teenagers dying. We know that older adults are at much higher risk for dying of COVID-19; however recent mortality figures from the US across all age groups are concerning. The Peterson-KFF Health System tracker reported that in September 2021, COVID-19 was the LEADING cause of death in the 35 to 54 age group (the age of teen parents) and the 2nd leading cause of death in 25 to 34 year olds. Although they are not at the same high risk as adults, teenagers can also die from COVID-19: the virus was the 4th leading cause of death for those aged 15 to 24 and the 6th leading cause for those aged 5 to 14.
- Vaccination reduces the risk of severe infections, hospitalisation and need for oxygen and ICU in teenagers. Recent figures from the US show the hospitalisation rate among unvaccinated adolescents (aged 12–17 years) was 10 times higher than that among fully vaccinated adolescents. Multisystem inflammatory syndrome is a possible severe form of COVID-19 in teenagers that is preventable by vaccination.
- Vaccination helps to avoid Long COVID (fatigue, brain fog, chronic lung disease, chronic loss of smell or taste). Long COVID can occur even in young healthy people who have mild or asymptomatic infections. In some children and teens who have had COVID, it has gone on to trigger autoimmune diseases such as juvenile arthritis - the vaccine can prevent this.
- Vaccines can help to improve the symptoms in those previously infected and already suffering from long COVID.
● Collective Risk vs Benefit
- Vaccination reduces the risk of transmission and helps to develop community protection. By vaccinating teenagers, they are less likely to transmit the virus to their parents, peers and teachers at school and to others in the community. (Although vaccines only partially reduce the risk of getting infected, the less likely the teen is to be infected, the less likely they are to transmit; if they are infected they shed less viable virus and for a shorter period of time). Teenagers are a social group who congregate together, and many outbreaks in the community have occurred after parties or sports events, where teens have been unable to stick to COVID-19 protocols. More unvaccinated people in the population leads to more virus transmission for everyone (both vaccinated and unvaccinated).
- Even if older adults in a household are vaccinated, unvaccinated teenagers pose a risk to them. This is because no vaccine is 100% effective, and if exposed to an unvaccinated teenager, the vulnerable adult may still have a breakthrough infection. Although they have protection from their own vaccine, infectious strains like delta (and potential new variants still to come) do still pose some risk and could cause severe illness.
This is something that has received a lot of media attention and caused understandable anxiety amongst parents, but really needs to be looked at with proper understanding and perspective.
● Myocarditis is a rare inflammation of the heart muscle, usually caused by an infection (viral or bacterial). It can lead to a rapid or irregular heartbeat and can cause the heart muscle to weaken. Symptoms include chest pain, shortness of breath, a fast, irregular heart rate and fatigue. Acute myocarditis usually resolves on its own in a few days, and can be treated with medications, supportive therapy and rest.
● Pericarditis is an inflammation of the thin membrane that surrounds the heart, usually caused by infections, autoimmune disorders or trauma. Symptoms include sharp chest pain, shortness of breath, fever, weakness and palpitations.
● The risk of myocarditis and pericarditis from primary COVID-19 infection itself, occurs at a rate of up to 450 cases per million in young males.
● According to the Cominarty Pfizer package insert, the risk of myocarditis and pericarditis following vaccination with Pfizer (up to 21 May when 283 cases had been documented following vaccination from 177 million doses of Pfizer) is 1.6 people per million. More recent studies, including two done in Israel and published in October in the NEJM show that the risk of myocarditis following vaccination is higher than this, (but still low) at 1 in 50 000 in young males. In the cases of myocarditis reported, most were mild and resolved completely.
● However, the benefits of having a vaccination still far outweighs this small risk. Studies have shown that even young males, who are more susceptible than the general population to myocarditis and pericarditis post vaccine, are six times more likely to develop myocarditis from COVID infection than from the COVID-19 vaccine.
● Cases of myocarditis reported have been most common in male adolescents and young adults, usually within several days of vaccination and more often after the second dose. In the unlikely event that your teenager develops chest pain, shortness of breath or a fast beating or fluttering heart within two weeks of a vaccine, you should seek medical care.
● There is no biological reason or proof that a COVID-19 vaccine can interfere with the progression of puberty or growth. There is also no biological mechanism whereby hormones associated with puberty can impact immune responses to COVID-19 vaccines.
● If a vaccine was able to interfere with teens’ development, it would need access to their DNA. The Pfizer vaccine does not contain live coronavirus - it is composed of mRNA (composed of nucleic acids found naturally in our bodies) that does not enter the nucleus of our cells where the DNA is kept. The mRNA teaches the body to make protective antibodies and then disintegrates very quickly.
● There is no evidence that the vaccine has any impact on fertility: this has been addressed thoroughly in other research and is applicable to teenagers.
● Vaccines can cause an irregular menstrual cycle, and slightly heavier periods in some females: this is thought to be an immune response and only lasts for a month or two.
● Side effects experienced by teenagers are similar to those in adults, and include pain, redness and swelling at the injection site, fatigue, headache, muscle and joint pain, fever, nausea, dizziness and swollen “glands” under the arm.
● Side effects should resolve within a few days of vaccine.
● 1 or 2 Panados (depending on weight) taken six hourly will relieve most symptoms. Ibuprofen (Nurofen) can also be used if side effects are not managed with panado.
● Any severe side effects should be discussed with your doctor and reported to SAHPRA as an adverse event.
● More severe side effects such as anaphylaxis and myocarditis are possible but are extremely rare.
● In the history of all vaccines, serious adverse events have only occurred in the first 2 months of receiving the vaccine. With tens of millions of teens already vaccinated worldwide more than 8 months ago already, we do not expect to see new, unknown side effects occurring.
● The timing of the vaccine should be carefully considered. You need to take into account that there is a possibility of side effects (e.g. a sore arm or fatigue the day before an exam), planned sporting events or training, but also the fact that it takes 3 to 4 weeks to develop some immunity before the holiday period and end of year parties, particularly as a fourth wave is expected in December or January.
● There are no current official guidelines on exercise post vaccination.
● Out of caution, some countries (e.g. Singapore) have advised adolescents and patients under 30 years to avoid strenuous physical activity (intense exercise).
● My advice is for teens to avoid very strenuous activity e.g. Intense running, cycling, and other cardiovascular activity for 5 to 7 days. Within this period, they should monitor their heartrates and how they are feeling when participating in milder forms of exercise. Should resting heartrate be elevated, or heartrate go up more than usual while exercising, they should rather rest for at least a full week.
● (Note that the recommendation following COVID-19 infection is to not do strenuous exercise for two weeks post recovery).
● For teens participating in competitive sports or intense training, the timing of the vaccine should be carefully considered. However, there have been several outbreaks in inter-school activities, and vaccinating the participants can reduce this. Vaccines will also hopefully allow parents back as spectators at sporting events.
● During the Department of Health briefing on Friday, Nicholas Crisp stated that based on the Children’s Act that allows children aged 12 to 17 to give their own consent for medical treatment, children in this age group do not require their parents’ consent to have a COVID vaccine. In other words, a teenager can register and consent to being vaccinated without their parent’s permission.
● At this stage, vaccines will not be administered at schools; however a schools vaccination programme is being looked at by NDOH and DBE for next year.
● Some of the private schools may be able to make arrangements with community outreach vaccination programmes in order to administer vaccines at school.
● The FDA has fully approved the Pfizer Cominarty vaccine for use in individuals 16 years and over. (Full approval was only granted on 23 August 2021- prior to this it was under Emergency Use Authorisation).
● The Pfizer vaccine is approved for individuals aged 12 to 15 years under Emergency Use Authorization, but is expected to soon receive full approval.
● SAHPRA (South African Health Products Regulatory Authority) has approved the use of the Pfizer Cominarty Vaccine in terms of section 21 to include individuals 12 years and older (this was on 10 September 2021 as a consequence of a review of updated safety and efficacy information).
● 13.4 million US children under age 18 have received at least one dose of a COVID-19 vaccine, representing 57% of 12 to 17 year olds in the US. In many countries in Europe, including France, Italy and Spain, more than 60% of adolescents have already been safely vaccinated. So our teens in South Africa are not the first to get their vaccines.
● Parents can feel reassured that paediatric associations around the world, including the American Academy of Paediatrics, the Royal College of Paediatricians in the UK and the South African Paediatric Association have “done the research” for them: they have evaluated the safety and efficacy of vaccinations and recommend COVID-19 vaccines for all teenagers aged 12 to 17 years.
My teen has already had covid-19 infection - surely he still has immunity and doesn’t need to vaccinate?
● Having COVID-19 infection does confer immunity, however the immune response mounted is extremely variable and unpredictable. People who had mild infections may not mount a high enough immune response.
● In contrast, the vaccine is designed to induce a standardised, controlled immune response to the body.
● The antibodies created and T-cells stimulated by the vaccine provide a more reliable, robust immunity that is longer lasting and more efficient at dealing with new variants of virus encountered. (There are several studies available that confirm this point).
● In a teenager who has had COVID-19 infection, following up with a dose of Pfizer vaccine is extremely effective in boosting the immune response (one dose of vaccine acts as a “booster”).
● A teenager who has had COVID-19 infection should wait at least 30 days after recovering from a mild infection or 90 days after recovering from a severe infection before having a vaccine.
● We are still waiting for clarity on this.
● The EVDS is being adapted and teens will be able to register electronically with an ID number or a passport number. (ID numbers appear on birth certificates and SA passports). EVDS is expected to open to 12 years and over in the next few days.
● They will need to take a birth certificate, identity document (if they are over 16 and have this) or a passport to the vaccination site.
● Teens will be able to register themselves on the EVDS system, or a parent can register them.
● As only one Pfizer dose is currently being offered, it is likely that they will be able to download a vaccine certificate immediately.
● Some overseas countries may not accept only one Pfizer dose in teenagers, so this is something that needs to be checked with each country before travel is planned.
● Once more adolescents have been vaccinated, there will be less need to wear masks and socially distance in small groups. In larger crowds, where it is less certain who is vaccinated, masks will still be recommended while the pandemic continues, until a higher proportion of the population is immune.
● Teenagers who are vaccinated will have freedom to travel to other countries, attend sporting events and enter nightclubs and restaurants that may not allow unvaccinated patrons.
● Two of our leading South African universities (Wits and UCT) have already proposed vaccine mandates from next year for students wishing to attend campus in person. This is after overwhelming evidence analysed by the scientists and academics at these institutions confirmed that vaccines are both safe and effective. Some schools, cultural and sports clubs may follow suit, making it difficult for unvaccinated teenagers to participate. (I’d like to point out here that vaccines such as measles and meningitis, hepatitis for medical students and others, have for many years been compulsory for children attending schools, so this is not a new concept).
As a Family Physician, over the last 18 months, I have seen many outbreaks in teenagers (some severe), many instances of “long Covid”, and many teens who have transmitted COVID-19 to elderly family members. I have seen teenagers forced to quarantine after exposures, teenagers isolated from the world and missing out on their best years, and teenagers struggling with depression and anxiety. The ‘take-home’ message from my post is that the risk of getting COVID infection far outweighs the risk of vaccination in teenagers. I can say without hesitation that I will be relieved to have my own teenagers at the front of the queue to get vaccinated, so that they can return to a more normal lifestyle.
Dr Sheri Fanarof