Vaccinating Young Children in the Netherlands: How to Balance the Interests?

On 10 December 2021, the Dutch Government decided that children aged from five to 11 are eligible to receive Covid-19 vaccination. Earlier this month, the Health Council of the Netherlands already advised that children of this age group with an increased medical risk be offered vaccination. The invitations for a vaccination with an adjusted, lower dosage of the BioNTech/Pfizer vaccine are expected to be sent in the second half of January 2022. For children under the age of 12, the consent of either parents or guardians is required for medical treatment and, thus, for vaccination.

Vaccinating children between the ages of five and 11 is a complex issue that involves social, medical, ethical, and legal considerations. A balance must be struck between the child’s interests and possible health benefits for the general population. In the Dutch debate, different perspectives become apparent with respect to the issue of how to cope with the risks of the virus and its possible spread by children.

Since the beginning of the pandemic, Parliament has critically assessed the Government’s Covid-19 policies. Following the EMA’s positive advice on 25 November 2021 to vaccinate children aged five to 11, Jan Paternotte (Democrats 66) and Attje Kuiken (PvdA, Labour Party) introduced a parliamentary motion in which parents are provided with the opportunity to have this particular group of children vaccinated. A large majority of the parties in the House of Representatives adopted the motion, and Paternotte called it an ‘important signal’. The Minister of Health, Welfare and Sport, Hugo de Jonge, was initially hesitant and said: ‘If everyone over the age of 12 does what they are asked to do, it is not necessary for those under the age of 12’. He also stated that he wanted to wait for the advice of the Health Council of the Netherlands, which is an independent scientific advisory body whose legal task consists in advising the Dutch ministers and Parliament in the field of public health and healthcare research. The positive advice followed a day after the Minister’s statement.

The Health Council’s advice was in line with the wishes of the Parliament, namely, offering vaccination to (the parents or guardians of) children aged five to 11 on a voluntary basis. In its advice, the Council considers several factors as relevant. It notes that Covid-19 runs a very mild course with most children in this age group; however, it leads to complications requiring hospitalisation for a small group. In some cases, it can even lead to Multisystem Inflammatory Syndrome in Children, which is a rare but life-threatening complication of Covid-19. The Council’s main argument is that it considers it plausible that vaccination prevents this severe illness and hospitalisation. The Council also stresses that vaccination may prevent children from developing long-term effects after infection. According to the Council, the BioNTech/Pfizer vaccine works well with children aged from five to 11 and is considered ‘sufficiently safe’. It seems that the Council weighs this health benefit against the ‘limited burden of vaccination’, such as possible side effects that will usually be short-term and mild. The risk of Myocarditis (inflammation of the heart muscle) after vaccination with the five- to 11-year-old is considered to be very low; consequently, it seems to be negligible.

Prior to the Council’s advice, the Dutch Medicine and Evaluation board already gave a positive evaluation regarding the vaccination of children in this age group. Summarising the advice, President Ton de Boer said that ‘the benefits outweigh the risks’. Evidently, it must be questioned whose benefits prevail. If the risks of children becoming severely ill due to a Covid-19 infection are minimal, one may question why they should be vaccinated at all. A utilitarian perspective seems to be the issue here: are the Dutch children to be vaccinated for the public good?

According to Dutch statistics, children in this age group are (momentarily) responsible for the highest number of infections; though, they seem to transmit the virus more to their peers than to adults. However, as the Council rightly emphasises, reducing virus transmission is in itself an insufficient reason for vaccinating children and considers it an ‘additional benefit’. In Article 3 of the United Nations Convention on the Rights of the Child, it is also enshrined that the child’s best interests must be a primary consideration in State vaccinations programs; the Council’s advice seems to be in line with this.

Recently, the European Court of Human Rights has ruled on the issue of possible mandatory vaccination regarding children. In the landmark case Vavřička and Others v the Czech Republic, the Court ruled that the Czech Republic did not violate the right to private life (Article 8 of the European Convention on Human Rights) by imposing a vaccination mandate on children under the age of 15. Although this case did not concern Covid-19 vaccinations, but rather vaccinations against (currently) more severe illnesses, such as polio, hepatitis B, and tetanus, the ruling may be a prelude to legitimising mandatory vaccination. Evidently, certain conditions must be met, such as a pressing social need for the compulsory vaccination of children in the particular State. No such need currently exists in the Netherlands. Accordingly, there seems to be sufficient reason to endorse the Dutch Government policy when focussing on parents’ freedom of choice to have their children vaccinated.

Countries have adopted a wide array of perspectives regarding voluntary or mandatory vaccination of children aged from five to 11. Within the European Union, various countries, such as Germany, Greece, Hungary, Spain, and Poland, have started vaccinating this age group on a voluntary basis, and other States are about to follow. Outside the European Union, for example, in the United States, state governments are offering incentives for Covid-19 vaccinations for children. In New York, parents may enter children aged from five to 11 in a series of drawings for full-ride college scholarships to a public college or university in the state. On the website of NYC Health + Hospitals, which is, according to their website, the largest public health care system in the United States, it is ‘advertised’ that children are offered a gift voucher or free tickets to city attractions when vaccination is received. This policy is not surprising given present mayor Bill de Blasio’s adamant stance with regards to his vaccination strategy. Children aged from five to 11 must have received at least one dose before 14 December 2021 to enter restaurants and participate in extracurricular school activities. Although the vaccination is not mandatory, a form of pressure is applied since not being vaccinated results in social exclusion. In Costa Rica, children from the age of five are already compulsorily vaccinated. The issue of mandatory vaccination for Covid-19 for children is, consequently, no longer a theoretical one. Recently, Lex-Atlas: Covid-19 published legal, constitutional, and ethical principles addressing this subject, outlining the conditions to which mandatory vaccination policy must adhere. The authors rightly point out the importance of taking the various rights seriously.

In the Netherlands, Covid-19 vaccination for adults is also on a voluntary basis. Last month, the Government attempted to pass a more restrictive Covid-19 policy, such as 2G, and a Covid-19 entry pass for high-risk locations, for access to the workplace and vocational and higher education (see the insightful blog Blaming the unvaccinated? by Ronald Janse). The suggested measures are currently on hold, but no guarantee can be given that mandatory vaccination will not be imposed should dire circumstances demand their introduction. Accordingly, the Prime Minister does not rule it out.

Since 19 December 2021, we have been in a ‘hard lockdown’ to curb the spread of the new Omicron variant until (at least) 14 January 2022. This means a stay-at-home order, social distancing, and all locations (including educational institutions) are closed except for essential stores, such as supermarkets and pharmacies. A maximum of two guests over the age of 13 may be received each day at home, with the exception of four guests during the holidays. Once again, it will be a year with few family and friends during the festivities, but at least we are staying safe. Early 2022 will tell how much inclination there will be among Dutch parents to vaccinate their young children.