Good justification if risk of SARS-CoV-2 infection is high

Risk of harm from vaccination lower than risk of harm from COVID-1991

Clear benefit for children with risk factors for severe COVID-1941

Risk of hospitalisation and death from COVID-19 is commensurate with or higher than other diseases in routine immunisation programme42

Higher disease burden of COVID-19 in children in LMICs with comorbidities that impact immunity33

Higher immunogenicity of mRNA vaccines in children might mean one or lower dose sufficient25

Adolescents have a higher frequency of infection and disease burden than younger children

Children are less likely to get infected after a SARS-CoV-2 exposure77 111–114

Most children have asymptomatic or mild COVID-191–8

A large proportion of children might already be immune to SARS-CoV-2 in many regions of the world

Risk of COVID-19 in children might be less if large proportion of adult population is vaccinated

Risk of severe COVID-19 in children with underlying diseases is not negligible1–8

Risk of severe COVID-19 in healthy children might be higher with SARS-CoV-2 current or future variants of concern

Risk of severe COVID-19 in healthy children is low1–8

At-risk children could be protected by targeted rather than universal vaccination

No long-term data on children with PIMS-TS; if sequelae are important, the risk–benefit of COVID-19 vaccination might change

No data yet on whether vaccination prevents PIMS-TS

Risk of PIMS-TS is low, and children mainly recover without sequelae11–19

COVID-19 vaccination might increase risk of PIMS-TS (no evidence to date)

Long COVID-19 can occur even after mild or asymptomatic infection55 57 58 61 65 66

Not well studied yet; could affect a large number of children

The incidence of long COVID-19 is still to be accurately determined21

Difficult to separate infection-associated from pandemic-associated symptoms55 61 65

Children, even young children, can transmit SARS-CoV-2115

Prevention of transmission to other children and older age groups

Prevention of transmission to high-risk household members

Herd immunity likely inachievable without vaccinating children and adolescents

Reduction in the risk of new VOC emerging

Risk of transmission might be changing with emergence of new VOC (eg, Delta)

Potential considerable indirect benefit (eg, schools remaining open) to children even if no direct benefit (see (6))

‘No one is safe until we are all safe’

No data yet on whether vaccination prevents transmission in children

Transmission in educational settings is rare and index cases are often adults78–81

Index cases in households much more likely to be a parent or adolescent6

Community transmission will decrease if sufficient adults are vaccinated69

Subjecting children to potential risk of vaccine adverse effects to drive indirect effects with little or no direct benefit might be ethically questionable

Effect of vaccination on transmission might decrease with waning immunity and emergence of VOC

Primary infection at young age when the disease is mild combined with boosting exposure from ongoing transmission at older age might be better strategy90

Transmission in school can contribute to the circulation of SARS-CoV-277

Lockdowns and school closures have a major impact on physical and mental health of children116

Vaccinated children might be exempt from quarantine

COVID-19 vaccination might become a requirement for international travel

Might not be sufficient to prevent school closures and lockdowns (especially if a large proportion of adults are not vaccinated)

Might not be necessary to prevent school closures and lockdowns, especially if adult staff are all immunised

Myocarditis after mRNA vaccines is transient and usually without sequelae91

No reports of thrombosis after viral vector vaccines in children and adolescents to date99

No reports of PIMS-TS after vaccination to date

Myocarditis after mRNA vaccines including need for intensive care91–98 117

Potential risk of thrombosis after viral vector vaccines

Potential trigger for PIMS-TS (no evidence to date)

Adverse effects of vaccines usually occur early

Long-term safety in children, including following myocarditis, unknown

If concerns arise, this might lead to decrease in vaccine confidence and vaccine uptake, including against other diseases102

No studies to date have evaluated co-administration with other vaccines

One dose or a reduced dose might be sufficient in children

Current limited vaccine supply should be prioritised for people at high risk of severe disease and death

Vaccine supply might be better used for adults in LMICs where <5% of population have been vaccinated103

Greater herd immunity likely better for returning to pre-pandemic economic stability

Likely higher cost–benefit ratio in children

Could be combined with the administration of other routine vaccines

Implementation of universal COVID-19 vaccination programme in children could cause delays in the routine immunisation programmes by using up existing delivery resources and personnel