After a rapid start, the pace of the United Kingdom’s (UK) covid-19 vaccination programme has slowed down while the UK still faces high infection, hospitalisation, and death rates, and a more transmissible Delta SARS-CoV-2 variant. Now that vaccination of children aged 12-15 has started, it is essential to achieve a high uptake of vaccination in this group, and also in young adults, to both protect them and to move the UK closer towards population level immunity. [1,2] Despite two doses of Pfizer-BioNTech, Moderna, and AstraZeneca vaccines offering good protection against the Delta variant—with Pfizer-BioNTech and AstraZeneca vaccines between 92-96% effective in preventing hospitalisations—many young people remain unvaccinated by choice, raising their risk of infection, hospitalisation, and long-term complications from covid-19. [3-5]
The UK population is among the most willing to receive a covid-19 vaccine; as of 11 October 2021, over 49 million individuals (85.6% of people aged 16 and over) had received at least one dose of a covid-19 vaccine. [6,7] However, the covid-19 vaccination programme—the largest ever launched by the NHS—is reaching a “demand” ceiling in adolescents and young adults, finding itself well behind other Western European countries, and hampering efforts to achieve population level immunity. If vaccination uptake is also slow in 12-15 years old children, this will further hinder efforts to reach population immunity.
Vaccination rates in younger people are lower and increasing more slowly than was seen in older age groups when they were first offered vaccination. [1,8] According to the Office for National Statistics, 14% of those aged 16-17 years, 10% of those aged between 22-25 years, and 9% of those aged between 18-21 years consider themselves “hesitant” compared to 4% observed across all other age groups.  This mirrors concerning findings from the USA which demonstrate that one in four of those aged between 18 and 25 “probably will not” or “definitely will not” receive a covid-19 vaccine, despite their heightened infection risk in recent months.  Given their increased tendency to socialise, strategies that improve vaccine acceptance in adolescents and young adults remain essential to control the pandemic globally as well as in the UK. 
Historically, vaccine hesitancy exists on a spectrum and is listed by the WHO as one of the top 10 global health threats.  The groups that are among the currently most affected by the virus are also the ones with the lowest vaccination rates.  With ideal conditions for SARS-CoV-2 to spread, the risk of emergence of “super variants” that could potentially escape vaccines and jeopardise the health of the most vulnerable in society remains a risk. Vaccine hesitancy in young people in the UK may be further increased by the delay in approving vaccination for 12–15 year-olds, with the UK starting vaccination later than many other European and North American countries. The message from the UK’s Joint Committee on Vaccination and Immunisation (JCVI) that covid-19 vaccination in this group offers only “marginal benefits” will also have contributed to this, with many parents and children questioning why they should be vaccinated if this is the case.  The benefits and potential risk from vaccination will therefore need to be discussed carefully with children and their parents to dispel any unwarranted negative views. 
This has been successfully done in Portugal; despite Portuguese parents not being safe from vaccine misinformation and disinformation, the country has managed to emerge as the world’s vaccination front-runner, with 86% of its population vaccinated (98% of whom are aged 12 years and over).  Its successful vaccine rollout is, in part, attributed to the country’s comprehensive monitoring system;vaccine compliance is monitored nationally by healthcare facilities, schools, daycare centres, summer camps, and other child institutions, allowing the country to develop and tailor educational information to hesitant parents or parents known to have refused a vaccine in the past.  This has generated favourable conditions for paediatric immunisation across the country.
Concerns about side effects are an important factor in vaccine hesitancy in children, adolescents, and young adults, particularly the risk of condition such as myocarditis.  Although rare, the myocarditis and pericarditis reports in adolescents and young adults, following the administration of Pfizer-BioNTech and Moderna vaccines, will have amplified fears of vaccines in this group.  However, the risk of developing complications, such as blood clots and myocarditis, from covid-19 illness remains greater than the risk from vaccines.  Genuine concerns about the side effects of vaccines should be addressed by academics and clinicians proactively listening to young people, and sharing risks and benefits in a manner that aligns intention with action.  It is also essential that moving forwards, the UK’s covid-19 vaccination programme is embedded in primary care to create a cost-effective, sustainable infrastructure for vaccine delivery; and to avoid making the many mistakes that were made in other parts of the covid-19 response, such as Test and Trace and the Nightingale Hospitals. 
To offset optimistic bias, including adolescents and young adults perceiving the risk of disease being lower than the risk of receiving a covid-19 vaccine, communication should speak to mechanism of action, effectiveness, and safety relevant to these age groups and the wider societal benefits of vaccination in protecting their older family members, and vulnerable friends and colleagues. [10,21] Further, public health messaging will be more effective if the benefits of controlling the pandemic, including freedom to attend festivals, sporting events and entertainment venues, as well as the ability to travel are reinforced. Targeted health messaging and public education campaigns will also require harnessing social media, schools and universities to counter the covid-19 infodemic.  To increase vaccination rates, messages should be tailored for families financially burdened by the pandemic, families with lower parental education and incomes, and adolescents and young adults with adverse childhood experiences. 
While the risk of severe disease and death from covid-19 is lower in young people, high infection rates and low vaccination rates mean this group remains vulnerable to long covid and its debilitating symptoms, regardless of the symptoms shown during their covid-19 infection.  With the majority of covid-19 deaths occurring in those aged 75 years and over throughout the pandemic, a youthful sense of invincibility will be an important barrier to overcome; young adults need to be mindful that although their symptoms may not be as severe, 57%, 39% and 30% of individuals have stated that long covid has negatively impacted their wellbeing, ability to exercise and ability to work, respectively. [22,23] Recent evidence suggests more people expressed fear and concern about the risk to health of those close to them.  Therefore, emphasising the protection that vaccines offer to those particularly vulnerable will likely have a positive effect on adolescents and young adults and their parents.
The pandemic is a “collective action problem,” requiring personal responsibility and responsible communication by governments and public health authorities that break through optimistic bias without prompting feelings of anxiety. The UK’s mixed messages on mitigation measures including face masks and working from home are likely to provide a false sense of security that discourages vaccination uptake at a time when infection rates remain much higher in the UK than other European countries. The race between vaccinations and mutations requires consistent, clear, and data-based messages that dispel misinformation, and promote informed decision-making, civic awareness, voluntary cooperation and a sense of collective purpose. This will improve vaccine uptake in all sections of the population, including children, adolescents, and young adults, at a key time when vaccination is being extended in many countries to younger age groups.
Tasnime Osama, Honorary Clinical Research Fellow in Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @itasnimeo
Mohammad S Razai, NIHR In-Practice Fellow in Primary Care, Population Health Research Institute, St George’s University of London. Twitter @MohammadRazai
Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed
Competing Interests: None declared.
Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. MSR is funded by the NIHR as an In-Practice Fellow. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
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