As summer vacations wind down, the days get shorter and children prepare to go to school, preschool and day care, they could encounter an unwelcome classmate: COVID. Yet despite the prospect of another fall surge in cases, a remarkably low percentage of young children have been vaccinated against the disease. The U.S. Centers for Disease Control and Prevention recommends children get vaccinated for COVID. So why have so few parents refrained from getting their child the shot?
The Food and Drug Administration authorized COVID vaccines for children six months through four years old—the last age group to become eligible—in June. Yet just 3.5 percent of U.S. kids in that group have received at least one dose, according to the CDC. And only about a third of children ages five through 11 have received one or more doses.
In a Kaiser Family Foundation (KFF) survey of parents conducted in July, more than four in 10 of those with children aged six months through four years said they will “definitely not” get their child vaccinated against COVID. Others said they will only do so if school or childcare requires them to or that they want to wait and see how the vaccine is working. Of parents of children in this age group, nearly two thirds of Republicans and of people who are unvaccinated themselves said they would not vaccinate their child. But even among parents who are vaccinated themselves, more than a quarter said they would not make the same choice for their little ones.
Although children are at a lower risk for severe COVID than adults, the risk is not zero. As of late August, more than 1,400 children in the U.S. had died from COVID, including more than 500 under age five. Studies suggest one in 3,000 to 4,000 kids have been hospitalized with multisystem inflammatory syndrome in children (MIS-C), a condition in which multiple organs can become inflamed. Others have developed long COVID.
Reasons for Not Vaccinating
In the KFF survey, parents gave a wide range of reasons for not vaccinating their young children. Some were concerned that the vaccines are too new and that there has not been enough testing and research. The Pfizer and Moderna vaccines have been tested in thousands of children without causing serious adverse effects. But occasionally very rare complications can show up only after millions of people have been vaccinated. For example, myocarditis—an inflammation of the heart muscle—only appeared among some teenagers and young adults after vaccinations became widely available. Most of these cases resolved on their own.
Other parents specified concerns about short-term side effects of the vaccine, which might mean they would have to take time off work to care for their child. In clinical trials, the side effects in children younger than age five were similar to those seen in older children and adults. These included pain and redness at the injection site, headache, fatigue and fever. With the exception of fever, most were milder than those seen in older children.
But a significant proportion of parents of children younger than age five in the KFF survey—more than 10 percent—said they felt their child did not need the vaccine or that they weren’t that worried about COVID itself. Many children have gotten COVID already, and most of them have had relatively mild cases and recovered on their own. By the time vaccines became available for the youngest children, they were less effective at preventing infection—so the benefits of vaccination were harder to see. “Pretty much everybody knows somebody who’s gotten COVID despite being vaccinated,” says survey co-author Liz Hamel, vice president and director of public opinion and survey research at KFF. “The promise of what the vaccine will do for you is different now.”
Hamel and her colleagues asked parents whether getting the vaccine or getting infected would be a bigger risk to their child’s health. Parents of kids who had already had COVID were much more likely to say the vaccine would be a bigger risk.
Michelle Fox is the mother of a two-year-old boy in Hopedale, Mass.* Her son got COVID in May, just before his age group became eligible for a COVID vaccine, and she and her husband have not gotten him vaccinated yet. “I think if he hadn’t had COVID, we would have got him vaccinated as soon as we possibly could,” she says. But she hasn’t been in a great rush, in part because her son already has some immunity to SARS-CoV-2, the virus that causes COVID, and in part because her husband has some reservations. He’s British, and Fox says he is somewhat wary because of the fact that the U.K. has not yet approved the vaccine for use in young children. “We’re generally people who definitely trust what the doctors say,” she says. But Fox had a complicated pregnancy that resulted in her son being born prematurely—so her and her husband’s calculus on the risk of rare but serious outcomes has changed somewhat, she says. Nevertheless, she adds, as the weather gets cooler and her son spends more time indoors, where COVID risk is higher, that might play into her decision about whether or not to vaccinate him.
A subset of parents have been extremely eager to get their young children vaccinated against COVID. Allison Moy, a microbiologist and mother in Pittsburgh, Pa., vaccinated her nearly two-year-old son as soon as he was eligible. He has had two out of three doses of the Pfizer vaccine. As a scientist with a background in microbiology, Moy says she felt confident in the science behind the mRNA vaccines and did not have any safety concerns. For her, getting her son vaccinated wasn’t just about protecting him but also about protecting those around him. “My parents are getting older; my husband’s parents are getting older,” she says. “It was more about doing our part to protect the vulnerable.”
The KFF survey also found that vaccination rates among young children were divided along political party lines: parents who identified as Republican were less likely to have vaccinated their child or to have been vaccinated themselves, compared with parents who identified as Democratic. Even among Democrats and vaccinated parents, however, a sizable proportion had not vaccinated their kids.
Racial and ethnic demographics also played a role. More than four in 10 Black parents of children younger than age five cited access barriers such as having to take time off work to care for a child with side effects—compared with fewer than a third of Hispanic parents and fewer than a fifth of white parents. More than four in 10 Hispanic parents of such children said they were concerned about not being able to get their child vaccinated at a place they trust, compared with more than a quarter of Black parents and about a sixth of white parents. And both Hispanic and Black parents were more likely than white parents to say they were worried about having to pay out of pocket for the vaccines—which are available for free in the U.S. regardless of insurance status. “People are not used to getting things for free in health care in this country,” Hamel says.
Other research supports the KFF survey’s findings. Jessica Calarco, an associate professor of sociology at Indiana University Bloomington, and her colleagues surveyed parents in Indiana about their decisions on vaccination. In data that have not yet been published, they found that, from relatively early on in the pandemic, parents were not all that concerned about their kids getting COVID. Parents told the researchers that messaging in the media suggested that children—especially white children without preexisting conditions—had a very low likelihood of getting severely ill or dying, Calarco says.
“Parents really latched onto those early messages, in part because it allowed them to feel comfortable sending kids back to in-person schooling and in-person day care,” Calarco says. As the pandemic progressed, an increasing percentage of parents told Calarco and her colleagues that they consumed less news about COVID. According to a not-yet-published national survey that was also conducted by Calarco and her colleagues, “the more parents who perceive COVID itself as a lower threat to children, [the more] they are significantly less likely to have chosen to vaccinate their children,” she says.
In both Calarco’s Indiana and national surveys, there was a strong correlation between parents being vaccinated themselves and their kids being vaccinated. But there were a number of parents who had only gotten vaccinated because their workplaces required it. National gender data suggest women are more likely to be vaccinated than men, Calarco says, but her surveys of parents found that stay-at-home mothers with young children had much lower vaccination rates, Calarco says. Parents told Calarco and her colleagues they were more likely to vaccinate their older children, who were going to school and extracurricular activities, than their younger kids, who were staying at home. Many parents also believed that kids were less likely to transmit COVID to others, as early studies showed. But more recent studies suggest that kids can—and do—spread the disease to others in their household.
Increasing Vaccination through Trusted Sources
The fact that many parents feel less urgency about vaccinating their children may be a product of how the vaccines were tested and rolled out, says Sallie Permar, chair of Pediatrics at Weill Cornell Medicine and pediatrician-in-chief at NewYork-Presbyterian Komansky Children’s Hospital. “The youngest kids were the ones who were tested the last” for vaccines, Permar says. “And I think that the message that parents got through that process is that it wasn’t so important.”
KFF survey data suggest that pediatricians are the most trusted source of information on the COVID vaccine for children, yet 70 percent of parents of children younger than age five said they hadn’t yet talked to their child’s health care provider about the COVID vaccine. That could change when they take their kids in for annual checkups.
Permar sees a crucial role for pediatricians in communicating to parents that COVID vaccines are safe and recommended for kids. “I do we think that pediatricians do need to lead this messaging to parents,” she says, because “the data shows that parents really trust that source of information.” But staffing shortages and a lack of resources have made it difficult to get the word out. Most healthy children only see their pediatrician once a year. “We really have to go beyond the pediatrician being the sole provider and messenger to these parents,” Permar says.
Meanwhile the FDA has authorized updated booster shots that target the Omicron subvariants of SARS-CoV-2. But Pfizer’s booster is only authorized for kids age 12 and older, and Moderna’s booster is only authorized for those age 18 and older. So the youngest kids will have to wait a bit longer for these updated shots.
“I’m just worried that we're going down the same pathway of demonstrating to parents that this is a low priority, that children are a low priority,” Permar says. “I think the FDA and other policy makers should think about ‘What are the requirements for approval of the vaccines in young children?’ so that all parents and their pediatricians and providers can go in with their eyes open this fall as to what we should be recommending to children.”
*Editor’s Note (9/8/22): This sentence was edited after posting to correct Michelle Fox’s location.