By Colleen M. Flood, Bryan Thomas, and Kumanan Wilson

Health Canada has authorized Pfizer’s COVID-19 vaccine for children aged 5-11, concluding that the benefits—90.7 percent efficacy in preventing the disease—outweigh the risks.  The state of California has already announced plans to require vaccination for school children.

To date, no Canadian province has followed suit, despite entreaties from prominent public health experts.

On the surface, there are many compelling reasons for mandating pediatric vaccinations for in-school attendance.  While children are far less likely to develop serious illness from COVID-19 than adults, the risk is nonetheless greater than for other vaccine preventable diseases for which there are school mandates in some provinces. 

There is also an increased risk that unvaccinated children will contract and transmit the virus to other children, causing school closures, and they are at higher risks of transmitting the infection, both to their families and the broader population.

All of this has become even more apparent with the Omicron outbreak. The number of children falling ill and requiring hospitalization continues to put pressure on the pediatric health system.  Assuming the data continues to show vaccination protecting children from severe illness from Omicron, a mandate seems justifiable—particularly next to existing mandates for much rarer diseases.

The primary concern with the Pfizer children’s vaccine is the risk of myocarditis, an inflammation of the heart muscle leading to shortness of breath and chest pain.  Older boys and young men receiving the vaccine have experienced myocarditis at a rate of 1 in 10,000, and most recover quickly.

The long-term effects of COVID-19 vaccination are not yet known, but vaccines rarely have long-term side effects. By comparison, the risks from COVID-19, both for children themselves and for broader society, are much greater.

In the face of a COVID-19 vaccination mandate, there is bound to be legal misinformation disseminated by opponents, for example, claiming any mandate would necessarily be contrary to the Charter of Rights and Freedoms.

In Ontario and New Brunswick, school vaccination mandates (such as for measles, mumps, rubella) are mitigated by allowing parents to request exemptions on either medical or nonmedical (such as religious or philosophical) grounds.

This is an imperfect solution: with vaccine-hesitant parents requesting non-medical exemptions in growing numbers, Ontario has seen outbreaks of once well-controlled diseases like measles.  Some public health experts have urged the elimination of non-medical exemptions.  

It is unlikely that prevailing forms of vaccine hesitancy, rooted in mistrust of the pharmaceutical industry and government regulators, will qualify for Charter protection.  In an early Charter ruling, the Supreme Court explained that protections for conscience apply only to “comprehensive value systems,” and “profoundly personal beliefs that govern one’s perception of oneself, humankind, nature.”

Over the years, courts have cited this doctrine when rejecting conscience claims from people skeptical of the science around seatbelts; provincial human rights tribunals have recently echoed the point in explaining why vaccine hesitancy is not a trait protected against discrimination.  

All efforts must be made to keep schools safe, including N95 masking, ventilation, and other measures, but also by increasing vaccination rates.

And to be clear, prior to any vaccination mandate for school attendance, all efforts should be made to make vaccination convenient for those who want it, by ensuring easy access within schools themselves, following up to ensure second doses are received, and requiring employers to give time off work to parents taking their kids for shots. A hastily implemented vaccine mandate could do more harm than good, if it means, for example, that children from low-income families are cut off from school food programs.

As a first step, provincial governments could empower schools to require that students register their vaccination status but allow the unvaccinated to attend except in the event of an outbreak.  This approach has the benefit of minimizing or even eliminating school closures for those who have been vaccinated.  Meanwhile, the prospect of being sent home from school for days or weeks at a time may provide the incentives needed for many to get vaccinated. 

If our primary aim is to incentivize vaccination, the provinces have another option at their disposal: like adults, younger people could be required to show proof of vaccination when entering non-essential settings like restaurants and movie theatres – an approach recently announced by New York City.

Whatever policy path is chosen, we must develop and refine policy options now regarding childhood vaccination in order to prepare ourselves for the emergency of new variants, and in the process, dispel legal misinformation. Not acting quickly will have serious negative consequences on our children’s health