The case for vaccinating the young first

Dr. Julian W. Tang is honorary associate professor/clinical virologist in respiratory sciences at the University of Leicester.

LEICESTER, United Kingdom — Images of the elderly and vulnerable getting their COVID-19 jabs made for heart-warming news in desperate times — a sign that we are getting close to moving to the other side of this pandemic.

But what if we’re going about our vaccination strategy entirely the wrong way? What if, to get back to “normal,” we should be focusing on another key demographic: the young?

If we had unlimited COVID-19 vaccines, we would probably start our vaccination campaigns by prioritizing both the elderly and the young.

The reasons for vaccinating the elderly are fairly obvious: They are most at risk of severe complications from COVID-19 and death. For the young, the upshot is that vaccinated children could return to school without infecting each other, their teachers and parents — thereby also protecting the elderly and vulnerable. Young adults, meanwhile, could go back to work, but also to be customers for others — the lunchtime sandwich shops, bars, restaurants, cinemas and concert theaters that have all struggled to stay afloat during lockdown.

In this ideal scenario, everyone wins: The elderly are protected, and their younger families and friends are immunized and can then visit them. Workers can earn a living and support other businesses by being their customers.

But with supply of vaccines limited — and their distribution heavily disrupted — we’re far from that ideal scenario.

In response to these less-than-ideal conditions, most countries in the West have opted to prioritize vaccinating the elderly and vulnerable, while keeping the younger population at home in lockdown.

It’s a strategy that makes intuitive sense, but the effects of prolonged lockdown on the younger population are devastating — and may be hampering our overall recovery.

In many places, children have to follow classes remotely, their schooling interrupted for days or weeks at a time when an outbreak forces schools to shut down. Most young adults, meanwhile, are living in limbo — faced with uncertain job prospects and a severely restricted social life.

As the 18-year-old son of a Belgian politician and first-year university student put it in an op-ed earlier this month, the situation is hard for everyone. But for young people, the fear is compounded by the fact that there is no end date on the horizon: “I manage to follow the rules, and I can spend a while alone, but I am afraid.”

Ignoring this heavy burden on children and young people comes at a cost. On a human level, the situation is taking a toll on their mental health and development. On a larger social scale, holding them back also risks impeding the post-pandemic recovery.

There are also other ways to think about whom to prioritize when it comes to vaccinations.  

Front-line health care workers — who are at the highest risk of contracting COVID-19 — should get the jab before anyone else, but after that there is a strong ethical case for vaccinating the young early on.

In a prescient article published last year, a group of academics laid out an argument in favor of prioritizing the young based on the concept of “quality-adjusted life years.”

Intensive care units already rely on this concept to decide which patients to admit: If both an 80-year-old and a 40-year-old patient compete for one ICU bed, for example, staff will tend to give the bed to the patient most likely to recover and return to a normal life — a life that can then contribute more to society. In this example, this clearly would be the 40-year-old.

A similar logic could be applied when it comes to COVID-19 vaccines. Protecting the young person, who has many years of useful life left, may arguably be a better use of a scarce resource.

There is also a practical consideration. Most COVID-19 vaccine trials have shown reduced effectiveness with age. As such, vaccinating the young — for whom the vaccine is more effective — would also enhance the effectiveness of the overall vaccination campaign.

This suggestion may sound inhumane to some. So it’s important to note that prioritizing the young will not necessarily have an adverse effect on the older population.

Granting the younger working population access to vaccines will allow the economy and services to return to normal. This in turn will also benefit the elderly, as well as allowing immune relatives and friends to visit.

There is already somewhat of a precedent for favoring this type of strategy.

A number of countries — including the United States, the United Kingdom, Austria, Finland and Ireland — currently vaccinate children against influenza as a means of protecting the elderly and more vulnerable.

Because kids are more likely to get infected and shed more virus for longer, targeting them in vaccination strategies alleviates the risk to health care workers and the elderly, according to a paper published in 2018. The influenza vaccine — like the COVID-19 vaccines — is also more efficient in young people.

One country, Indonesia, has already decided to prioritize the young in their COVID-19 fight. With the global economy suffering from nearly a year of pandemic restrictions, the idea is to allow the young to go back to work — and also to reduce viral transmission among those who have the most contacts during their daily lives.

In part, the government’s strategy was driven by the limited licensing of the COVID-19 vaccine at their disposal — the Chinese-produced Sinovac — among people over 60. The country’s demographics also make prioritizing young people a less risky approach: While in the U.K. almost 20 percent of the population is over 65, only 5 percent of the Indonesian population falls into that category.

Ultimately, there is no absolute right or wrong path, and the U.K.’s “elderly first” strategy has been embraced by most other countries.

But it would be a mistake to dismiss other suggestions out of hand — or to sideline our youth completely. Rather than thinking of young people as part of the problem — as rulebreakers or super spreaders, for example — we can make them part of the solution to slowing transmission and ending the pandemic.