Shots for Tots: Halakhah and COVID-19 Vaccination for Kids

Should children receive the COVID-19 vaccine? This question has generated intense debate among parents, physicians, policy makers, governments, and medical organizations. In clinical trials, the Pfizer vaccine was 100% effective in preventing infection in children ages 12-15. The FDA and EU regulator subsequently authorized it for this population. Among children ages 5-11, Pfizer recently reported 90.7% vaccine efficacy against symptomatic disease. There were no cases of severe disease in either the control group or the experimental group. In light of this, the FDA has authorized its use in this population and the US and Israel have begun vaccinating these children. Pfizer is currently conducting trials of the vaccine for children aged six months to four years and expects to apply for FDA authorization in this age group in the next few weeks. Other vaccines are or will be available around the world to children of all ages. Those who advocate vaccinating children point out that their being vaccinated will reduce the risks of infection, severe disease, long-term sequelae and complications, and transmission to others, including the immunocompromised, and will contribute to herd immunity. Those against vaccinating children argue that children benefit less than adults (the disease in children is milder), the vaccine has only received Emergency Use Authorization for use in children (not full FDA authorization), the long-term side effects of vaccination are unknown, and vaccination might cause myocarditis, inflammation of the heart. In light of children’s lower COVID-19 morbidity, they also advocate redistribution of the vaccines intended for children in wealthy countries to higher-risk adults and health care workers in poorer countries.^[1]

To date, the US, UK, Canada, France, Germany, Austria, Spain, Sweden, Greece, Finland, Switzerland, Norway, New Zealand, Australia, Japan, the Philippines, Israel, Italy, Poland, and Romania have already authorized and encouraged vaccination for children of ages 12-15. The WHO has urged wealthier countries to postpone vaccinating children and donate these doses to the rest of the world.

An exploration of how halakhah might resolve this debate raises the following questions:

1. Does Halakhah obligate parents to vaccinate their children against COVID-19?
   2. Does Halakhah obligate children to receive a COVID-19 vaccination?

To answer these questions, we will begin with some additional scientific background.

Medical Arguments For and Against COVID-19 Vaccination

In Israel, one out of every three cases of COVID-19 occurs in children, but the disease is typically less severe for them than it is in adults. However, with the emergence of the Delta variant, the rates of children’s infection and hospitalization rose. In Israel, in October 2021 more than 50% of COVID-19 cases occured in children. Data presented at the FDA advisory panel in October indicated that among US children ages 5-11, COVID-19 infection poses a major threat to public health – nearly 2 million children in this age group have been infected with COVID-19. However, blood samples obtained from this population suggest that the true number of children infected might be six times higher than reported. Eight thousand children in this age group were hospitalized, and one in three of these hospitalized children required admission to the intensive care unit. In addition, one in three of hospitalized children had no underlying medical conditions. CDC reported that COVID-19 infection was the eighth leading cause of death in US children ages 5-11. However, data from September 2021 ranked COVID-19 infection as the sixth leading cause of death in US children ages 5-14. Among children ages 1-4, COVID-19 infection became the seventh leading cause of death during this period having previously ranked number 13.

Although children and adults share similar side effects of the vaccine – headaches, fatigue, body aches, and chills – those against vaccinating children argue that the Pfizer vaccine trial was too small and the follow-up too short to identify any rare side effects.^[2] They note that the initial AstraZeneca vaccine trials did not discover an increased risk of blood clots, which became apparent only after millions of people had received the vaccine. They contend that the lack of sufficient data regarding the risks of vaccination requires longer follow-up of a larger number of vaccinated children in order to determine the true risks of the vaccine, and that a longer wait is not harmful considering that the risks of infection in children are less than those of adults.

One particular side effect frequently cited by those who oppose the vaccine is myocarditis, inflammation of the heart muscle, which can require hospitalization and is potentially life threatening. Data from the Israel Ministry of Health confirmed myocarditis in 136 people out of over five million citizens who received both doses of the vaccine (though in 129 of those people, symptoms resolved with minimal intervention). Data from the Clalit Health Fund, Israel’s largest HMO, indicate that the overall rate of myocarditis among its two million subscribers was 2.13 per 100,000 vaccinated, 0.23 per 100,000 women and 4.12 per 100,000 men. Among men between the ages of 16-29, the incidence of myocarditis was 10.69 per 100,000. Those who argue against vaccination are concerned about any risk of myocarditis in this previously healthy population. These two Israeli studies provide the most comprehensive information regarding the risk of myocarditis after COVID-19 vaccination for adults, but less is known regarding the risk in children ages 5-11. Data from the Israel Ministry of Health reported 12 cases of myocarditis among 331,538 vaccinated children between the ages of 12-15; all of these children recovered fully.^[3] There were no cases of myocarditis among the 3,082 children ages 5-11 who received the vaccine in the Pfizer trial.^[4] Although this study lacked the statistical power to address the true risk of myocarditis, the risk of myocarditis from the vaccine in this population is likely less than that of those aged 12-17.

However, when assessing the risks of myocarditis associated with vaccination, one must also consider the risk of similar symptoms from COVID-19 infection. Over 5,000 children aged 5-11 have been diagnosed with multisystem inflammatory syndrome, a condition that often leads to admission to intensive care and is potentially life threatening. 28% of adult patients hospitalized with COVID-19 demonstrate myocardial heart injury. Since the risk of myocarditis from the COVID-19 vaccine is quite rare, is usually self-limited, improves quickly with minimal treatment, and carries less risk than that of cardiac complications from COVID-19 infection,^[5] the FDA and the CDC continue to recommend vaccination for children based on current scientific evidence, as the benefits of preventing severe illness far outweigh the risks of the vaccine. Because children get sicker from COVID-19 infection than they do from myocarditis, FDA modeling data favors COVID-19 vaccination.

Although the majority of cases in children are mild, those who advocate COVID-19 vaccination for this age group contend that vaccination would spare children and parents the anxiety of infection and hospitalization (a primary argument for vaccinating children against the flu) and would protect them from long COVID. Long COVID is defined as long-term sequelae that arise or persist after the typical convalescence period of the disease, which can last from weeks to many months and possibly longer. A British study estimated that long COVID occurs in one in seven children diagnosed with COVID-19. In Italy, more than half of the children diagnosed with COVID-19 report at least one long COVID symptom 120 days or more after COVID-19 infection.^[6]

Vaccination inhibits the development of variants, a critical element for ending this pandemic. The vaccine prevents lockdowns that disrupt the educational system and harm children’s mental health. One million US children have been affected by school closures this year alone. Achieving fast and sustainable herd immunity can only occur when children are vaccinated, especially in light of the emergence of the Delta variant. Herd immunity will ultimately benefit children directly by enabling a return to routine that will foster their mental health and well-being, while restoring the economy and enabling parents to remain in the workforce.^[7]

Moral Obligations

Perhaps the most compelling argument for children to undergo COVID-19 vaccination is the moral obligation based on the ethical principle of the duty of easy rescue, which requires an individuals to intervene on behalf of others if one can help in a significant way at little personal cost.^[8] They fulfill this duty with flu and rubella vaccinations, through which they protect others from infection with minimal personal risk. In England, as well as several other democratic countries, including the US and Israel, children receive an annual flu vaccine primarily to protect their grandparents, even though two out of every million vaccinated individuals will develop Guillain-Barre syndrome, a potentially life threatening condition. Rubella, a mild disease in children, can lead to congenital birth defects. The WHO and all major medical organizations routinely recommend rubella vaccination for children, even though on rare occasions the vaccine causes a severe allergic reaction. Some have argued that children should take similar steps and vaccinate to protect others from COVID-19. However, others counter that children have made substantial sacrifices during the pandemic, compromising their mental health and education so as to protect adults, and that they must not make more.

Does Halakhah Obligate Parents to Vaccinate their Children against COVID-19?

Virtually all modern poskim believe that Halakhah permits personal COVID-19 vaccination; some argue that Halakhah obligates it.^[9] Vaccination fulfills the mitzvot of ve-nishmartem, lo ta’amod al dam re’ekha, ve-hashevota lo, and ve-ahavta le-re’akha kamokha.

The following three halakhic concepts promote a parent’s obligation to vaccinate their children against COVID-19:

1. Halakhah’s approach to parents in providing their children with medical care and protecting them from danger;
   2. Halakhah’s approach to parents and routine childhood vaccinations;
   3. Halakhah’s approach to parents and vaccination during a pandemic.

Halakhah Obligates Parents to Promote the Health and Well-Being of their Children

Minhat Yitzhak 6:150 and Tzitz Eliezer 20:47 rule that Halakhah obligates parents to provide medical care for their children. They derive this obligation from a father’s duty to feed his children, and link medical care with nutrition based on the principle “refuah bikhlal mezonot” – medical care is synonymous with feeding. They offer several additional reasons why a parent must provide healthcare for his child: failure to do so is a form of cruelty; it violates both lo ta’amod al dam re’ekha – do not stand idly by your neighbor’s blood– and ve-hashevota lo – the mitzvah to return lost property; and it is forbidden “to see the child’s sorrow and not use every available resource to save him.”^[10] Although lo ta’amod al dam re’ekha applies to all individuals, Rav Yaakov Emden in Migdal Oz, Even Bohen Pina 1, suggests that the closer the family relationship, the greater the obligation to rescue. Thus, the obligation of parents to save their children from harm transcends their obligation to all others. In Melamed Le-Ho’il 1:104, Rabbi David Hoffman suggests that when doctors recommend a life-saving treatment for a child, parents may not refuse, since “We do not find anywhere at all in the Torah that parents have a right to endanger the lives of their children by preventing the doctor from treating them.” It is noteworthy that Tzitz Eliezer’s teshuvah addresses the father’s obligation to provide orthodontia, a preventative measure, suggesting that a parent’s obligation to provide medical care is not limited to the treatment of active, present disease but applies also to preventative measures, which include vaccinations.

Halakhah Obligates Parents to Vaccinate their Children against Routine Childhood Diseases

The vast majority of poskim rule that Halakhah obligates parents to vaccinate their children against routine childhood diseases. Citing Minhat Yitzhak 6:150 and Tzitz Eliezer 20:47, Rabbi JD Bleich concludes that, “Vaccination of one’s children is unquestionably a parental responsibility.”^[11],^[12] Rabbi Elyashiv rules that parents must vaccinate their children since immunization of children against routine childhood diseases is normal practice throughout the world. Failure to do so is “out of order halakhically and irresponsible… and amounts to negligence.”^[13] He believes that parents of vaccinated students may insist that all other classmates be vaccinated in order to minimize the risks to their own children.^[14]

Rav Neuwirth as cited in Nishmat Avraham Hoshen Mishpat 427:3 disagrees. He believes that parents may not be forced to vaccinate their children, although physicians should strongly encourage vaccination. Rabbi Shlomo Zalman Auerbach has been quoted as ruling against compelling parents to vaccinate their children because the vast majority of students do get vaccinated, presumably creating herd immunity that makes the risk to any given unvaccinated child relatively small. Indeed, as we have not yet achieved herd immunity from COVID-19 and are unlikely to reach this milestone without vaccinating children, Rav Auerbach might rule differently for COVID-19 vaccination potentially supporting efforts to compel parents to vaccinate their children against COVID-19.^[15]

Poskim criticize parents who refuse to contribute to herd immunity by vaccinating their children. These parents argue that the world will achieve this milestone regardless of whether their children are vaccinated. Rav Yaakov Ariel suggests that the assumption that we will achieve herd immunity against COVID-19 in the absence of vaccination is mistaken and that even if this were possible, waiting for herd immunity in the absence of vaccination will lead to the deaths of hundreds of thousands. In addition, Rabbi Asher Weiss, in his discussion regarding the measles vaccine, strongly criticizes those who benefit from herd immunity without contributing to it. He cites Bava Batra 8a, which obligates all citizens, even the orphan, to contribute to the construction of a wall to fortify the city, as evidence that when it comes to issues of public safety, all members of society must contribute. He compares those who refuse to vaccinate their children and contribute to herd immunity to the Noahide generation and the inhabitants of Sodom where individuals would steal one apple or one orange worth less than a prutah, an amount that does not constitute gezel. However, if everyone engaged in this practice the merchant would not survive. He concludes that whatever is forbidden for the many is forbidden for the individual. Similarly, all citizens must contribute to herd immunity.

Other reasons that Halakhah might require parents to vaccinate their children against routine childhood diseases include dina de-malkhuta dina (the halakhic requirement to adhere to the laws of the presiding government) when governments legislate vaccination, and the possibility that vaccine refusal will contribute to hilul Hashem, desecration of G-d’s name.

While the halakhic principle shomer peta’im Hashem – that G-d protects the simple – can be used to justify risky behavior, it may not be invoked to justify COVID-19 vaccine refusal, since the principle does not apply when the danger can easily be averted. Indeed, the danger of COVID-19 infection can easily be avoided by vaccination.^[16] Rabbi Bleich notes that parents may not invoke this principle to justify withholding vaccination from their children since one “does not enjoy the prerogative of accepting danger on behalf of another when prudence dictates that it be accepted in order to avoid greater danger. Duties to children, in particular, require scrupulous exercise of prudence.”^[17] He points out that in fact shomer peta’im should be invoked to justify vaccination, as the vaccination carries low risks and this principle will protect against possible adverse effects.

The Obligation to Vaccinate One’s Children is Magnified During a Pandemic^[18]

Although some poskim rule that parents cannot be compelled to vaccinate their children under normal circumstances, Rabbi Asher Bush argues that they would do so if the risk of infection were unusually high, for example, during a pandemic.^[19] Rabbi Bush adds that parents who do not remove their children from danger commit a grave sin.

What is the halakhic status of a parent who refuses to vaccinate his child during a pandemic? Prior to the discovery of the smallpox vaccine, parents had few interventions to protect their children from infection. Quarantine and fleeing the endemic area were the only options for minimizing the risk of infection. Magen Avraham Orah Hayyim 576:3 and Mishnah Berurah Orah Hayyim 576:14 believe that parents who do not evacuate their child from a smallpox epidemic, are hayavim b-nafsham,^[20] which Rabbi Immanuel Jakobovits interprets as meaning “criminally negligent.”^[21] More recently, with the introduction of vaccines, Teshuvah Me-Ahavah no. 135, declares that one who does not vaccinate his children against smallpox has “the blood of his children on his head” suggesting that such a parent is directly responsible for any danger resulting from failure to vaccinate.^[22] Similarly, the Lakewood Statement on Immunization declares that, “Children who are not vaccinated are potential carriers of the very organisms that they were not immunized against – they are potential rodfim because they may expose others to grave risk, especially under-immunized children, immunocompromised people and the elderly. It is irresponsible to withhold immunizations from one’s child and thus place one’s child as well as others at risk of contracting dangerous and life-threatening diseases.”^[23], ^[24] These poskim use the harshest terms to describe such parents. Thus, we believe that Halakhah would require parents to vaccinate their children against COVID-19 to fulfill their obligation to provide medical care, which includes preventive measures and ensuring vaccination to protect them and others from disease, especially during a pandemic.

Does Halakhah Obligate Children to Get COVID-19 Vaccinations? The “Rubella Umbrella”

Although Halakhah would obligate parents to vaccinate their children against COVID-19, we will focus the remainder of our discussion on a much more dramatic and often overlooked halakhic issue, the possibility that Halakhah obligates children themselves to undergo vaccination. American history has shown us the power of children to take initiative and become vaccinated en masse. In 1970, the city of New York instituted the “rubella umbrella campaign,” encouraging children to get vaccinated in order to avoid infecting their mothers and other women. Rubella is usually a mild illness in children, but poses a major risk to the health of a fetus should a pregnant woman get sick. The New York City Department of Public Health ran advertisements on the local TV channel WPIX during children’s programming that appealed to children directly to undergo rubella vaccination to protect their mommies. In the advertisement, a young girl appears carrying a white umbrella with red spots. An adult male voiceover asks, “Hey, little girl, what are you carrying?” “My rubella umbrella,” she answers and proceeds to explain to the adult what rubella is and why children must undergo vaccination to protect their mommies. Advertisements also appeared with Andy, a vaccinated eight-year old boy, proudly displaying his official rubella fighter membership card and proclaiming that by being immunized he protects other children and mothers against the spread of rubella. The Department of Public Health even initiated a rubella umbrella contest, offering a sizable prize to the child who could draw the most authentic rubella umbrella. Twenty-three thousand children submitted drawings. Demonstrating the campaign’s success, more than 530,000 children received the vaccine. Prior to the campaign, only 15% of parents knew what rubella was. At its conclusion 65% of parents were familiar with this infectious disease. Why was this public health campaign so successful? Just as advertisements for sugary cereals and toys target children who then turn to their parents begging them to purchase these products, the rubella advertisements appealed to children. Convinced of the importance of vaccination, these children harangued and badgered their parents into arranging for vaccination. The Department of Public Health “sold New Yorkers on the rubella vaccine in the same way that American advertising sells breakfast cereals and toys — to the parents through their children.” One mother filed a complaint with the New York City Department of Public Health declaring, “Thanks to you, my kid is driving me crazy. I’m home sick, and all he wants to do is go out to get his rubella vaccine.”

How might Halakhah view the actions of children during the rubella umbrella campaign? Does Halakhah require children to take an active role in COVID-19 vaccination, much as they did during the rubella umbrella campaign?

The Mitzvah of Hinnukh

While according to Torah law, boys younger than 13 and girls younger than 12 are not obligated to perform mitzvot,^[25] hakhamim established a requirement for them to be trained in performing mitzvot for hinnukh – educational – purposes. Thus, the Mishnah states that a katan who no longer needs his mother is obligated to sit in the sukkah (Mishnah Sukkah 2:8), and a katan who knows how to shake the lulav is obligated in this mitzvah (Mishnah Sukkah 3:15) because it will train him for future mitzvot.^[26] Similarly, Mishnah Hagigah 1:1 obligates a katan in the mitzvah of re’iyah – appearing at the Temple and sacrificing an offering on the three Festivals. As a result of this mitzvah of hinnukh, perhaps a katan who receives a COVID-19 vaccination fulfills potential obligations in the mitzvot of lo ta’amod al dam re’ekha, ve-hashevota lo, and ve-ahavta le-re’akha kamokha.

A deeper analysis of the mitzvah of hinnukh reveals the importance of this mitzvah and the seriousness with which Halakhah approaches a katan’s obligation in mitzvot, purely based on his obligation in hinnukh.

Who is Obligated in Din Hinnukh – the Parent or the Child?

Does the obligation of hinnukh devolve exclusively upon the parent or is it the child’s responsibility? If the former, the child would have no obligation to get vaccinated; the obligation would rest solely upon the parent, and the child would merely need to show up for the vaccination. If the obligation of hinnukh belongs to the child, the role of parents would be solely to help their children to fulfill their obligation, for example by setting up the appointment. The child, on the other hand, may be required by Halakhah to take a more active role, pressuring their parents to get them vaccinated against COVID-19, as they did in the rubella vaccination campaign in the 1970s.

Poskim disagree about whether the mitzvah of hinnukh falls upon the parent or the child. They address this question by answering a related question: may a katan fulfill a mitzvah on behalf of an adult? To fulfill a mitzvah on behalf of another, Halakhah requires that the one who fulfills the mitzvah has the same obligation as the individual for whom he is fulfilling it.

Two gemarot reach conflicting conclusions. Berakhot 20b rules that a child may fulfill his father’s obligation in birkat ha-mazon – the blessing after meals – suggesting that a child has an obligation in mitzvot based on hinnukh.^[27] In contrast, the first opinion in Mishnah Megillah 2:4, which prohibits a katan from reading the megillah (Rabbi Yehudah permits this), suggests that perhaps a child does not have an obligation in mitzvot.

Rishonim offer various explanations to resolve this apparent contradiction between Berakhot 20b and Megillah 19b. Ritva (Megillah 19b) believes that hakhamim obligated the father, not the child, in hinnukh, meaning that a child cannot fulfill a parent’s obligation.^[28] He argues that the case in Berakhot 20b where the child is allowed to recite birkat ha-mazon for his father is one where the son is already an adult. For those who believe that the mitzvah of hinnukh falls upon the parent, children have a minimal role, at best, in vaccination. On the other hand, Tosafot (Megillah 19b s.v. “Rebbi Yehudah Makhshir”) rule that the mitzvah of hinnukh applies to the child. Regarding Megillah 19b, they explain that a child is prevented from fulfilling this mitzvah on behalf of his parent because of a technical detail specific to that in the mitzvah. Those who believe that the mitzvah of hinnukh falls upon the child and that he can fulfill a mitzvah on behalf of his parent might expect all children to follow the example of the rubella umbrella campaign and rally their parents to arrange for COVID-19 vaccinations.

At What Age Does the Mitzvah of Hinnukh Begin?

The COVID-19 vaccine is now available to children ages 5-11. Does the mitzvah of hinnukh apply to children in this age group? Mishnah Hagigah 1:1 references a disagreement between Beit Hillel and Beit Shamai over the age at which a child is obligated in the mitzvah of re’iyah. According to Beit Shamai, this obligation begins when a child can be carried by his father to the Beit Hamikdash. Beit Hillel believes that it is not incumbent until the child can hold his father’s hand and ascend on foot to Jerusalem. Mishnah Sukkah 2:8 suggests that the age of hinnukh for the mitzvah of sukkah begins when the child no longer requires his mother. Tosafot (Sukkah 28b s.v. “Kan b-Katan”) suggest that there is no fixed age for hinnukh; instead, it varies according to the specific mitzvah. They cite as proof the gemara’s position that a child begins to perform the mitzvah of the four species when he knows how to shake the lulav; he begins to wear a tallit when he knows how to wrap himself in it; and he learns Torah from when he knows how to speak.

On average then, hinnukh in most mitzvot would begin at age five or six, the age at which most mitzvot, including lo ta’amod al dam re’ekha and the mitzvah of vaccination, can be performed.^[29]

What about for younger children? Pfizer is conducting COVID-19 vaccine trials on children as young as six months and will likely apply for FDA authorization of the vaccine for these children soon. Does din hinnukh apply to the very young?

Sukkah 28b reports that Shamai performed the mitzvah of sukkah for his one-day old grandchild, suggesting that hinnukh may begin at birth. What is the purpose of introducing a baby to mitzvot? Poskim offer a variety of explanations for Shamai’s position. Ran and Ritva suggest that the child is obligated in the mitzvah whenever it is possible for him to perform it. Since a one-year-old can perform the mitzvah merely by being in the sukkah, Shamai rules that he is obligated. Just as a one-day old baby can fulfill the mitzvah of sukkah by sitting on a parent’s lap in the sukkah, a six-month old baby can fulfill the mitzvah of lo ta’amod al dam reekha by undergoing vaccination. Alternatively, a kabbalistic explanation for beginning hinnukh at birth is that the kedushah of the mitzvah sanctifies the baby, and this holiness will inspire him to perform mitzvot as an adult.

Halakhah does not rule according to Shamai. Nevertheless, Shelah Shaar Ha-Otiyot Ot Derekh Eretz strongly recommends that parents begin to instruct children in mitzvot as early as age two or three, even though hinnukh does not begin until later. “One who does so is praiseworthy.” A parent must help the child become accustomed to mitzvot, and should instruct him from the moment he can speak. Therefore, while there would be no obligation of hinnukh for children younger than five to receive the vaccine, instruction in the mitzvot of lo ta’amod al dam re’ekha, ve-hashevota lo, and ve-ahavta le-re’akha kamokha can begin even before the mitzvah of hinnukh starts.

Conclusion

As the world debates whether to vaccinate children against COVID-19, Halakhah rules on the side of vaccination. Halakhah obligates parents to vaccinate their children against COVID-19 to fulfill their duty to provide medical care and their obligation to ensure that they are vaccinated, especially during a pandemic. Halakhah might classify a parent who refuses to vaccinate his child as a rodef. Halakhah might obligate children to undergo COVID-19 vaccination so that they or their parents can fulfill the mitzvah of hinnukh. COVID-19 vaccination provides a unique opportunity for parents to instruct their children in lo ta’amod al dam re’ekha, ve-ahavta le-re’akha kamokha, and ve-hashevota lo. The possibility that the mitzvah of hinnukh devolves upon the child suggests that children should take an active role in fulfilling lo ta’amod, even if their obligation only arises from hinnukh.

The implications of a child’s obligation in these mitzvot as they relate to COVID-19 are far reaching. Halakhah seems strongly to encourage, if not require, children to take an active role in COVID-19 vaccination, similar to the children who responded to the rubella umbrella campaign. May the zekhut of tinokot shel bet raban serve to bring us the end of the COVID-19 pandemic.