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    Teens and COVID-19 vaccines: It’s complicated

    As vaccinations lag among teens, a pediatrician and bioethicist wades into some tricky territory, including whether schools should require vaccinations and what happens if parents and teenagers disagree.

    A masked teenager receives a vaccine from a masked provider

    In the United States, teens have the lowest COVID-19 vaccination rates of all age groups. Less than half are fully inoculated, even though COVID-19 shots have been available to people age 12 and up since May.

    That’s worrisome, given that COVID-19 cases have been growing among teenagers. The rate of infections among 16- and 17-year-olds more than quadrupled from June to August, for example.

    Meanwhile, myths swirl on social media, including one that claims vaccines can cause fertility issues for young people. The facts themselves can also be confusing: The Pfizer vaccine is fully approved for those age 16 and up, but it is still under emergency use authorization (EUA) for 12- to 15-year-olds. (The Johnson & Johnson and Moderna vaccines remain under EUA for those age 18 and older.)

    And a teen’s ability to choose vaccination on their own depends on geography. Forty-one states require parental permission for COVID-19 vaccination under the age of 18 (with exceptions for categories like married teens). The rest either let younger teens consent — 15-year-olds in Oregon, for example — or allow providers to determine that a teen is mature enough to do so.

    Douglas Opel, MD, MPH, has spent decades studying vaccine-related issues from ethics and epidemiology to confidence and communication. A pediatrician and interim director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital, he has written extensively about both practice and policy related to childhood vaccines.

    AAMCNews asked Opel his thoughts on such issues as teens’ ability to assess the pros and cons of vaccination, whether schools should require COVID-19 vaccinations for students, and how parents and teens can discuss this potentially fraught topic.

    This interview has been edited for brevity and clarity.

    Douglas Opel, MD, MPH
    Douglas Opel, MD, MPH
    Courtesy: Seattle Children’s Hospital

    What is the “presumptive approach” to vaccination, and does it apply to COVID-19 vaccines?

    This is the format pediatricians generally use for starting the discussion about routine vaccines with parents. It involves telling parents which vaccines will be given to their child­­ — and, if needed, allowing time afterward for questions or further discussion — rather than starting by asking them what they'd like to do about vaccines. This method is effective at improving vaccine acceptance and is a sufficient approach to consent for childhood vaccines given our high certainty that they are high-benefit and low-risk.

    This last point is important. This presumptive approach is really most justifiable when we have high certainty that an intervention is high-benefit and low-risk. Although we are getting there with COVID-19 vaccines, we're just not there yet, especially for younger pediatric age groups. During the time a COVID-19 vaccine is available only under an EUA to patients of a certain age, we need a different approach to discussing vaccination than the presumptive one. Instead, I would lead with listening. That approach helps us achieve the more stringent consent standard we ought to strive for when a vaccine is under an EUA.

    Should pediatricians be trying to “convince” reluctant parents and teens to get a COVID-19 vaccine?

    Yes. We need to lean into these discussions, respectfully and empathetically. Parents trust us and want to hear what we have to say, so we need to be clear that we strongly recommend COVID-19 vaccination and why. But we also need to listen: This has been an unprecedented 18 months that has generated a lot of questions and uncertainty. We can't just assume a posture of persuasion. We need to meet resistance with curiosity to keep parents engaged and to be responsive to their concerns.

    What happens if parents and children disagree over vaccination — the teenager wants to be vaccinated and the parent disagrees or vice versa?

    This happens on occasion. I first try to facilitate a conversation between parent and teen, giving each an opportunity to voice their perspective. Sometimes this alone gets them to reveal more about where they stand than they were able to do when talking at home.

    When a teen wants to be vaccinated but the parent is reluctant, I consider it most helpful to start with the teen’s reasons for wanting the vaccine — why they think it's a good idea. That creates a more productive conversation than working from the reasons not to vaccinate.

    I can then help both sides see the values that the other is bringing to the decision. I can also help dispel myths and correct misinformation that sometimes are at the heart of disagreements between teens and parents.

    What if parents and teens seem unable to agree?

    I often say, “Let’s check in again after you all think and talk through this a bit more. I want to follow up with you by phone in a week. Your task in this intervening week is, based on what we talked about today, to explore how you can move forward.” And I strongly reiterate where I stand: that getting the teen vaccinated is the best choice.

    A teen may want to get vaccinated without parental permission. At what age are teens generally considered capable of making health decisions?

    Generally speaking, the answer depends on what criteria you use.

    Legally, in most states, it’s 18 years old. Eighteen has therefore become synonymous with having the developmental maturity to make your own decisions. But here’s the thing: There's actually little empirical evidence that 18 is an accurate marker of adult capacity.

    If we instead consider psychological criteria — the achievement of adultlike cognitive functions — the ability to make health care decisions occurs closer to 14.

    How did experts conclude that 14-year-olds are capable of health decisions?

    Most people cite studies that assessed the performance of participants of various ages — like 9, 14, 18, and 21 — according to several standards of competency to consent. For example, researchers studied how volunteers responded to hypothetical medical vignettes.

    In the studies, researchers found that 14-year-olds didn't differ significantly from 18- and 21-year-olds in their ability to demonstrate cognitive abilities important to showing competence — but the 9-year-olds did differ.

    Laws sometimes allow young teens to make health choices, like getting birth control, without their parents’ permission. Is getting a COVID-19 vaccine different?

    It’s a bit complicated — and let me unpack why.

    One scenario in which minors are allowed to consent without a parent is when not granting that freedom involves a substantial risk to the teen or to public health. These situations are generally around sensitive or stigmatized services — sexual health, birth control, substance use treatment. And they generally only apply to minors age 14 and older.

    States don’t usually include vaccination as one of these situations. In fact, most don't allow minors under 18 to independently consent to vaccination.

    And I think that needs to change for routine vaccines. These are vaccines that pose minimal personal risk, support the minor's health, and promote public health. Allowing self-consent would be consistent with the reasoning already in place for allowing teens to consent to other services without a parent.

    But I would not put COVID-19 vaccines in this category yet. We need more information and longer-term data across pediatric age groups. For this reason, I think it’s best to require parental permission for adolescent COVID-19 vaccination.

    Do you think schools should require COVID-19 vaccines for students?

    That's a complex question, but in short, I think it's premature to mandate COVID-19 vaccines for elementary and high school students.

    A primary reason for my position is that a prerequisite for mandating a vaccine is having really high confidence that it's safe — and we're just still gathering this data for younger age groups.

    Once we do get there, though, school requirements certainly could become a necessary strategy to ensure that we protect as many children as possible and to protect the broader public as well.