A case for vaccinating adolescent girls for protection against COVID-19 during pregnancy and childbirth in resource-limited settings

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The effects of the coronavirus disease 2019 (COVID-19) pandemic have been devastating and far reaching, with over 6 million deaths recorded to date (Coronavirus Resource Centre). The rapid development, implementation, and rollout of COVID-19 vaccines for adults has been estimated to save over 500,000 lives in Europe alone (see here).

Pregnant women are more vulnerable to severe COVID-19 disease than non-pregnant women, with a higher risk of intensive care admission and death. Severe COVID-19 during pregnancy is also associated with poor neonatal outcomes including stillbirth and preterm birth^1,2. COVID-19 vaccination during pregnancy has been shown to be safe and effective in preventing severe diseases outcomes in this high-risk group, and is recommended globally³. Conversely, the value of vaccinating adolescents against COVID-19 remains under debate due to both concerns about a small but serious risk of vaccine-associated myocarditis, albeit mainly after the second dose of mRNA vaccines in adolescent and young adult males (Centers for Disease Control and Prevention), and marginal risk-benefits of vaccination, especially with the emergence of the Omicron variant which can evade both natural and vaccine-induced immunity⁴.

In low-resources settings, access and uptake of COVID-19 vaccines has been hampered by vaccine inequity⁵. In Africa, only 17.1% of the population has been fully vaccinated compared to 72.6% in Europe at the time of writing (Africa CDC, European Centre for Disease Prevention and Control). Currently, the World Health Organization (WHO) recommends that countries should prioritise vaccinating children only when maximal primary vaccination has been achieved in higher priority groups (see WHO SAGE Roadmap here). In these settings, therefore, adolescents will wait longer than their peers in high-income countries to be offered vaccination (Data Futures).

In this context, roughly 21 million girls aged 15–19 years in low-resource settings become pregnant each year, leading to an estimated 12 million births (WHO). Pre-pandemic, the estimated global adolescent fertility rate had declined, though there was high variation between regions. This remains today, with the largest number of teenage births reported in Eastern Asia and Western Africa⁶. Adolescent pregnancy can negatively impact a girls’ education, mental health, livelihood, and their overall health⁷. Globally, pregnancy or maternal-related conditions are among the top causes of disability-adjusted life years (DALYs) and death among girls aged 15–19 years⁸.

The physical and mental health effects of COVID-19 and the pandemic itself on adolescent pregnancy are not yet fully understood, but it is well-known that education is known to protect girls from child marriage and prevent unplanned pregnancy⁹. School closures, a common component of COVID-19 lockdown restrictions, may have increased the risk of adolescent pregnancy on an unprecedented scale. During the 2014 Ebola outbreak in Sierra Leone, adolescent pregnancy increased by up to 65% in some communities¹⁰. In the current pandemic, too, girls have been disproportionately affected by school closures¹¹, and a rise in adolescent pregnancy has been noted in several African countries¹² (see example here). In Ethiopia, researchers found an increase in adolescent marriages, with both boys and girls reporting increased pressure from their parents to marry during the lockdown period. Additionally, school closures meant an absence of teachers and local authorities who often play a critical role in preventing adolescent marriages¹³. Adolescent marriages in turn lead to adolescent pregnancies. A longitudinal study found that girls in the last two years of secondary school (mean age, 17.2 years) in Western Kenya had a 2.11-fold (95% CI, 1.13-3.95; P=0.019) higher risk of becoming pregnant if they experienced COVID-related school closures and restrictions¹⁴.

With reduced antenatal care attendance due to pandemic restrictions¹ and lack of vaccine confidence in many low- and middle-income countries (LMICs), adolescents may face both an increased risk of pregnancy and reduced opportunity to be vaccinated, putting their pregnancy and life at increased risk.

Given the disruption to routine immunisations globally, efforts to vaccinate women during pregnancy, including against COVID-19, should continue to receive maximum attention in African countries. There is, however, an additional urgent need to consider roll-out of COVID-19 vaccination to adolescent girls as a priority group to supplement the COVID-19 immunisation programme for pregnant women. Vaccination should ideally be with mRNA vaccines, which are authorised for adolescents and protect against severe disease, with a good safety profile in young women^3,14. However, given that adenoviral vector vaccines are the most widely available in African countries (AstraZeneca), we also need to urgently evaluate their safety, effectiveness against new variants and duration of protection in adolescence and during pregnancy. Additionally, further research is needed into the timing and schedule of vaccination in adolescents to provide optimum protection during their highest risk period. We call on international organisations to recognise that adolescent girls are an at-risk group during this and future pandemics for pregnancy care and vaccination.

Data availability

No data are associated with this article.