More than a decade before the coronavirus pandemic, I began researching how parents decide to reject recommended vaccines for their children. Despite the common assumption that these parents are ignorant or anti-science, I found that most parents who reject some or all vaccines work hard to weigh their understanding of the risk of the disease against their understanding of the risks of the vaccines and possible benefits of vaccination. I met families who rejected all vaccines and others who consented to some and rejected others. Some even developed different vaccine strategies for each child in their family based on their view of each child’s needs and vulnerabilities.
Although their perceptions of risk and benefit may not match actual statistical probability — with an inclination to underestimate the risk of infection and overestimate the risk of an adverse reaction to a vaccine — their views and strategies are not uncommon. Before covid, as many as one-third of American parents were taking a cafeteria-approach to childhood vaccines, accepting some and rejecting others based on their perceptions of safety, perceived seriousness of the disease, and estimated risk of infection. These parents give us some insight into what we should expect with a coronavirus vaccine for young children — and the future of childhood vaccines more generally.
Notably, accessing the two vaccines that the FDA is likely to authorize soon for children under 5 present some challenges, which highlights how parents will need to choose these vaccines and seek them out. Pfizer’s vaccine for children under 5 years will require two visits three weeks apart and a third shot eight or more weeks later. Moderna’s vaccine for children 6 years and younger requires two shots four weeks apart. These visits are unlikely to align with other routine doctor appointments and under existing federal law, vaccines cannot be given to children under age 3 at pharmacies or community sites.
Whether a vaccine against SARS-CoV-2, the virus that causes covid, is seen as a necessary solution is open to interpretation. Throughout the pandemic, children have represented about 19 percent of all covid infections, and represent about 22 percent of the U.S. population. There have thus far been 442 deaths from covid in children 0-4 years. In early June, 2.7 children out of every 100,000 under the age of 5 years were hospitalized with covid, a significant drop from January when the weekly prevalence was 15.3 of every 100,000.
This rate is much lower than the estimated 1-2 percent risk of hospitalizations adults face, but with more than 18.5 million pediatric infections, that is still a large number of children who are very sick. One FDA advisory committee member suggested the number of deaths for young children is similar to the risks of being struck by lightning. Another member argued the risk of infected children is nonetheless significant, explaining, “I know that the death rate from covid among young children may not be extremely high, but it’s absolutely terrifying to parents to have their child be sick and have to go to the hospital or even go to the emergency room or their primary care doctor because they’re sick and having trouble breathing.” Whether parents view these figures as representing a significant risk will influence their decision to seek out vaccines.
Parents do fear covid. A survey earlier this year suggests that about half of parents are afraid their children will become seriously ill because of covid. Parents don’t just fear their child will be one of the tens of thousands of hospitalizations for covid or multisystem inflammation syndrome in children (MIS-C), a condition in which children who were infected — often with mild or no symptoms — experience organ failure weeks later.
Parents also fear their children will miss school, that preschools will close, that parents will miss work or that children will be more infectious to others. Some are aware that covid infection may help trigger longer term health conditions, including Type 1 diabetes. Fear of infection is not equally distributed. As many as 65-70 percent of parents who have incomes below $75,000 or who identify as Black and Hispanic are afraid of infection.
Despite half of parents expressing fear of infection, few parents intend to vaccinate their children against covid. Almost 40 percent of children between 5-11 years are vaccinated (a notable doubling of the number from November), while fewer than 20 percent of parents of children under the age of 5 years express an intent to immunize their children against covid when a vaccine is authorized. How, then, can we understand why almost 93 percent of children are fully vaccinated against polio, a disease not seen in the U.S. since 1993, but fewer than one-third of parents of young children want a vaccine against a virus in wide circulation? Understanding the gap between fear and vaccine choice brings us back to the complicated perceptions of risk and benefit on which parents base their vaccine decisions.
Parents are confident that they are best able to decide what their children need. Any successful vaccine campaign for children will have to address parents’ questions and concerns, and show that the vaccine, for which there is limited trial data, is effective in preventing serious illness and safe for young children. There is, so far, little information about how well the vaccine will prevent infection in young children or how long immunity will last. Even with these uncertainties, most parents have not expressed opposition to a vaccine. Rather, surveys this spring show that more than half of the parents of children under the age of 5 years say they do not have enough information about safety and effectiveness and about 40 percent say they want to wait and see before deciding to vaccinate their young children.
Insisting that parents should vaccinate their children because all vaccines are equally important, a staple of public health messaging, is unlikely to succeed. Parents have become savvy consumers of health information and are increasingly comfortable evaluating each vaccine and picking and choosing the ones they trust while rejecting or postponing others. While health-care providers remain a trusted source of information on vaccines, people also look to friends, news, and schools for information. Information about coronavirus vaccines needs to address parents’ questions and make clear what is known and not yet known.
On this front, there is good news about coronavirus vaccines. Information reviewed by the FDA show that young children had lower rates of complication, including myocarditis, than did teens, which should be reassuring to parents. While children indisputably have lower risk of hospitalization and death than do adults, vaccination may reduce the risk of long-term outcomes of infection. Increasingly, scientists are highlighting how viral infections can cause harms years — even decades — after infection and recovery, including post-polio syndrome, measles’s damage to immune memory, cancer from human papilloma virus infection, or paralysis or hearing loss that can appear years after chickenpox infection (as Justin Bieber appears to be experiencing now). Parents deserve to understand these issues and pediatricians, school nurses, child care workers and others who work with families must be able to answer questions.
Whether parents of young children will see this vaccine series as a useful tool for managing family priorities remains unclear. It is, however, clear that parents deserve straightforward information about the benefits the vaccine may hold for their children and the community as well as the limitations of what is not yet known about boosters and protection from transmission. Given that parents are already evaluating other childhood vaccines in terms of their perceptions of possible benefits, health-care providers and those who work with families should be prepared to discuss these issues honestly.