COVID-19 vaccination in children and adolescents Did we have everything under control?

Background: The COVID-19 pandemic posed special challenges for the existing structures for vaccination prevention in Germany with respect to 1) understanding the role and aims of those involved and the interests of the children and 2) the definition of adequate criteria and assessment of the risk of severe diseases in children. Objectives: Do the priorities of different groups of interest differ in the recommendations for COVID-19 vaccination? Which data on the pathogenicity of different variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are necessary and how did they change during the pandemic? Methods: The tasks, objectives and perception of politics and the German national vaccination advisory committee regarding vaccination of children are discussed in the face of summarized recent data on clinical manifestations of pediatric SARS-CoV-2 infections among children and adolescents in Germany, which could be estimated by combining different German data sources. Results: The perspectives of politics and children differ but are legitimate when they are clearly stated. The decisive risk for a severe course or the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) per 10,000 SARS-CoV-2 infections for the decision on vaccination fromthe perspective of children, decreased during the course of the pandemic with dominance of the omicron variant. Severe courses of COVID-19 still predominantly affect children with underlying diseases. The age- stratified analysis of vaccinated and nonvaccinated children showed that the alterations in the pathogenicity of the virus in the course of the pandemic is particularly reflected in the reduction in the risk of PIMS-TS. The general reduction of severe courses of COVID-19 again can be explained by the characteristics of variants of concern (VOC) as well as increasing vaccination rates and immunity following a SARSCoV-2 infection. Conclusion: The primary goal of COVID-19 vaccination in children and adolescents is the prevention of severe courses of the disease. In pediatric risk groups the best possible immunity or immune protection by vaccination should be strived for. It is currently unclear whether catch-up vaccination in already infected or vaccinated children or whether forthcoming healthy children will need vaccination, aiming for hybrid immunity.