Effectiveness of COVID-19 Pfizer-BioNTech BNT162b2 mRNA Vaccination in Preventing COVID-19–Associated Emergency Department and Urgent Care Encounters and Hospitalizations Among Nonimmunocompromised Children and Adolescents Aged 5–17 Years — VISION Network, 10 States, April 2021–January 2022

The efficacy of the BNT162b2 (Pfizer-BioNTech) vaccine against laboratory-confirmed COVID-19 exceeded 90% in clinical trials that included children and adolescents aged 5-11, 12-15, and 16-17 years (1-3). Limited real-world data on 2-dose mRNA vaccine effectiveness (VE) in persons aged 12-17 years (referred to as adolescents in this report) have also indicated high levels of protection against SARS-CoV-2 (the virus that causes COVID-19) infection and COVID-19-associated hospitalization (4-6); however, data on VE against the SARS-CoV-2 B.1.1.529 (Omicron) variant and duration of protection are limited. Pfizer-BioNTech VE data are not available for children aged 5-11 years. In partnership with CDC, the VISION Network* examined 39,217 emergency department (ED) and urgent care (UC) encounters and 1,699 hospitalizations† among persons aged 5-17 years with COVID-19-like illness across 10 states during April 9, 2021-January 29, 2022,§ to estimate VE using a case-control test-negative design. Among children aged 5-11 years, VE against laboratory-confirmed COVID-19-associated ED and UC encounters 14-67 days after dose 2 (the longest interval after dose 2 in this age group) was 46%. Among adolescents aged 12-15 and 16-17 years, VE 14-149 days after dose 2 was 83% and 76%, respectively; VE ≥150 days after dose 2 was 38% and 46%, respectively. Among adolescents aged 16-17 years, VE increased to 86% ≥7 days after dose 3 (booster dose). VE against COVID-19-associated ED and UC encounters was substantially lower during the Omicron predominant period than the B.1.617.2 (Delta) predominant period among adolescents aged 12-17 years, with no significant protection ≥150 days after dose 2 during Omicron predominance. However, in adolescents aged 16-17 years, VE during the Omicron predominant period increased to 81% ≥7 days after a third booster dose. During the full study period, including pre-Delta, Delta, and Omicron predominant periods, VE against laboratory-confirmed COVID-19-associated hospitalization among children aged 5-11 years was 74% 14-67 days after dose 2, with wide CIs that included zero. Among adolescents aged 12-15 and 16-17 years, VE 14-149 days after dose 2 was 92% and 94%, respectively; VE ≥150 days after dose 2 was 73% and 88%, respectively. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations, including a booster dose for those aged 12-17 years.

VE against COVID-19-associated ED and UC encounters was substantially lower during the Omicron predominant period than the B.1.617.2 (Delta) predominant period among adolescents aged 12-17 years, with no significant protection ≥150 days after dose 2 during Omicron predominance. However, in adolescents aged 16-17 years, VE during the Omicron predominant period increased to 81% ≥7 days after a third booster dose. During the full study period, including pre-Delta, Delta, and Omicron predominant periods, VE against laboratory-confirmed COVID-19-associated hospitalization among children aged 5-11 years was 74% 14-67 days after dose 2, with wide CIs that included zero. Among adolescents aged 12-15 and 16-17 years, VE 14-149 days after dose 2 was 92% and 94%, respectively; VE ≥150 days after dose 2 was 73% and 88%, respectively. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations, including a booster dose for those aged 12-17 years.
VISION Network VE methods have been previously published (7). In brief, eligible medical encounters were defined as ED and UC encounters and hospitalizations among persons aged ≥5 years with a COVID-19-like illness diagnosis ¶ who had received SARS-CoV-2 molecular testing (primarily by reverse transcription-polymerase ¶ Medical events with an encounter or discharge code consistent with COVID-19like illness were included, using International Classification of Disease, Ninth Revision and International Classification of Diseases, Tenth Revision (ICD-10). Four categories of codes were considered: 1) acute respiratory illness, including COVID-19, respiratory failure, viral or bacterial pneumonia, asthma exacerbation, influenza, and viral illness not otherwise specified; 2) nonrespiratory COVID-19-like illness diagnoses including cause-unspecified gastroenteritis, thrombosis, and acute myocarditis; 3) respiratory signs and symptoms consistent with COVID-19-like illness, including hemoptysis, cough, dyspnea, painful respiration, or hypoxemia; 4) signs and symptoms of acute febrile illness. One code in any of the four categories was sufficient for inclusion. Clinician-ordered molecular assays (e.g., real-time reverse transcription-polymerase chain reaction) for SARS-CoV-2 occurring ≤14 days before to <72 hours after the encounter date were included. chain reaction assay) during the 14 days before through 72 hours after the encounter. For adolescents aged 16-17 years, the study period began when COVID-19 vaccines were recommended and became available to persons aged ≥16 years at each study site (April-May 2021).** For children aged 5-11 years and adolescents aged 12-15 years, the study period began 5 weeks after the Pfizer-BioNTech vaccine was recommended for their age group. † † The dates when the Delta and Omicron variants became predominant (accounted for >50% of sequenced viruses) were determined for each study site based on state and national surveillance data. § § Patients were excluded if they 1) were vaccinated before the CDC recommendation date for their age group, 2) received a third dose before booster doses were recommended for their age group, 3 Among children aged 5-11 years, VE of 2 doses received 14-67 days earlier against COVID-19-associated ED and UC encounters was 46% (Table 2). Among adolescents aged 12-15 and 16-17 years, VE of 2 doses 14-149 days earlier against COVID-19associated ED and UC encounters was 83% and 76%, respectively; VE was significantly lower for 2 doses received ≥150 days earlier (38% and 46%, respectively). Among adolescents aged 16-17 years, VE after receipt of a third dose ≥7 days earlier increased to 86%, significantly higher than the VE of 2 doses received ≥150 days earlier.
The number of observations was insufficient to estimate 3-dose VE for adolescents aged 12-15 years. Compared with the Delta predominant period, estimated 2-dose VE for adolescents aged 12-15 and 16-17 years declined significantly once Omicron became the predominant variant: among adolescents aged 16-17 years, VE of 2 doses received ≥150 days earlier against COVID-19-associated ED and UC encounters declined from 77% during Delta predominance to a null VE (-3%) during Omicron predominance; however, effectiveness of a third dose received ≥7 days earlier against COVID-19-associated ED and UC encounters during Omicron predominance was 81%. Among children aged 5-11 years, VE of 2 doses received 14-67 days earlier against COVID-19-associated ED and UC encounters during Omicron predominance was 51%. *** With a test-negative design, vaccine performance is assessed by comparing the odds of antecedent vaccination among case-patients with acute laboratory-confirmed COVID-19 and control-patients without acute COVID-19. This odds ratio was adjusted for age, geographic region, calendar time (days from January 1), and local virus circulation in the community and weighted for inverse propensity to be vaccinated or unvaccinated. † † † 45 C.F.R. part 46; 21 C.F.R. part 56. Abbreviations: ED = emergency department; ICD-9 = International Classification of Diseases, Ninth Revision; ICD-10 = International Classification of Diseases, Tenth Revision; SMD = standardized mean or proportion difference; UC = urgent care. * Medical events with an encounter or discharge code consistent with COVID-19-like illness were included, using ICD-9 and ICD-10. Four categories of codes were considered: 1) acute respiratory illness, including COVID-19, respiratory failure, viral or bacterial pneumonia, asthma exacerbation, influenza, and viral illness not otherwise specified; 2) nonrespiratory COVID-19-like illness diagnoses including cause-unspecified gastroenteritis, thrombosis, and acute myocarditis; 3) respiratory signs and symptoms consistent with COVID-19-like illness, including hemoptysis, cough, dyspnea, painful respiration, or hypoxemia; and 4) signs and symptoms of acute febrile illness. One code in any of the four categories was sufficient for inclusion. Clinician-ordered molecular assays (e.g., real-time reverse transcription-polymerase chain reaction) for SARS-CoV-2 occurring ≤14 days before to <72 hours after the encounter date were included. † Vaccination was defined as having received the listed number of doses of COVID-19 Pfizer-BioNTech BNT162b2 vaccine ≥14 days (for 2 doses) or ≥7 days (for 3 doses) before the medical event index date, which was the date of respiratory specimen collection associated with the most recent positive or negative SARS-CoV-2 test result before medical event or the admission date if testing only occurred after the admission.  . Pre-Delta refers to the period before Delta predominance. † † Indicates the reference group used for standardized mean or proportion difference calculations for dichotomous variables. § § Other race includes Asian, Native Hawaiian or other Pacific islander, American Indian or Alaska Native, Other not listed, and multiple races. ¶ ¶ Chronic respiratory condition was defined as the presence of discharge code for asthma, sleep apnea, or other lung disease using ICD-9 and ICD-10 diagnosis codes. *** Chronic nonrespiratory condition was defined as the presence of discharge code for heart failure, ischemic heart disease, hypertension, other heart disease, stroke, other cerebrovascular disease, diabetes type I or II, other diabetes, metabolic disease, clinical obesity, clinically underweight, renal disease, liver disease, blood disorder, immunosuppression, organ transplant, cancer, neurologic disorder, musculoskeletal disorder, Down Syndrome, congenital heart disease, neurologic conditions, muscular dystrophy, sickle cell disease, prematurity (<24 weeks), developmental delay, technology dependence, or chronic gastrointestinal disease/irritable bowel syndrome.

TABLE 2. (Continued) COVID-19 Pfizer-BioNTech vaccine effectiveness* against laboratory-confirmed COVID-19-associated † emergency department and urgent care clinic encounters and hospitalizations among children aged 5-17 years, by number and timing of vaccine doses § and predominant circulating SARS-CoV-2 variant -VISION Network, 10 states, ¶ April 2021 to January 2022
Abbreviations: ED = emergency department; NC = not calculated; Ref = referent group; UC = urgent care; VE = vaccine effectiveness. * VE was calculated as [1 − odds ratio] x 100%, estimated using a test-negative design, adjusted for age, geographic region, calendar time (days since January 1, 2021), and local virus circulation (percentage of SARS-CoV-2positive results from testing within the counties surrounding the facility on the date of the encounter) and weighted for inverse propensity to be vaccinated or unvaccinated. Generalized boosted regression trees were used to estimate the propensity to be vaccinated based on sociodemographic characteristics, underlying medical conditions, and facility characteristics. † Medical events with an encounter or discharge code consistent with COVID-19-like illness were included, using International Classification of Disease, Ninth Revision and International Classification of Diseases, Tenth Revision. Four categories of codes were considered: 1) acute respiratory illness, including COVID-19, respiratory failure, viral or bacterial pneumonia, asthma exacerbation, influenza, and viral illness not otherwise specified; 2) nonrespiratory COVID-19-like illness diagnoses including causeunspecified gastroenteritis, thrombosis, and acute myocarditis; 3) respiratory signs and symptoms consistent with COVID-19-like illness, including hemoptysis, cough, dyspnea, painful respiration, or hypoxemia; and 4) signs and symptoms of acute febrile illness. One code in any of the four categories was sufficient for inclusion. Clinician-ordered molecular assays (e.g., real-time reverse transcription-polymerase chain reaction) for SARS-CoV-2 occurring ≤14 days before to <72 hours after the encounter date were included. § Vaccination was defined as having received the listed number of doses of an mRNA-based COVID-19 Pfizer-BioNTech vaccine ≥14 days (for 2 doses) or ≥7 days (for 3 doses) before the medical event index date, which was the date of respiratory specimen collection associated with the most recent positive or negative SARS-CoV-2 test result before medical event or the admission date if testing only occurred after the admission.   Abbreviations: ICD-9 = International Classification of Diseases, Ninth Revision; ICD-10 = International Classification of Diseases, Tenth Revision; SMD = standardized mean or proportion difference. * Medical events with an encounter or discharge code consistent with COVID-19-like illness were included, using ICD-9 and ICD-10. Four categories of codes were considered: 1) acute respiratory illness, including COVID-19, respiratory failure, viral or bacterial pneumonia, asthma exacerbation, influenza, and viral illness not otherwise specified; 2) nonrespiratory COVID-19-like illness diagnoses including cause-unspecified gastroenteritis, thrombosis, and acute myocarditis; 3) respiratory signs and symptoms consistent with COVID-19-like illness, including hemoptysis, cough, dyspnea, painful respiration, or hypoxemia; and 4) signs and symptoms of acute febrile illness. One code in any of the four categories was sufficient for inclusion. Clinician-ordered molecular assays (e.g., real-time reverse transcription-polymerase chain reaction) for SARS-CoV-2 occurring ≤14 days before to <72 hours after the encounter date were included. † Vaccination was defined as having received the listed number of doses of COVID-19 Pfizer-BioNTech vaccine ≥14 days (for 2 doses) or ≥7 days (for 3 doses) before the medical event index date, which was the date of respiratory specimen collection associated with the most recent positive or negative SARS-CoV-2 test result before medical event or the admission date if testing only occurred after the admission. . Pre-Delta refers to the period before Delta predominance. † † Indicates the reference group used for SMD calculations for dichotomous variables. § § Other race includes Asian, Native Hawaiian or other Pacific islander, American Indian or Alaska Native, Other not listed, and multiple races. ¶ ¶ Chronic respiratory condition was defined as the presence of discharge code for asthma, sleep apnea, or other lung disease using ICD-9 and ICD-10 diagnosis codes. *** Chronic nonrespiratory condition was defined as the presence of discharge code for heart failure, ischemic heart disease, hypertension, other heart disease, stroke, other cerebrovascular disease, diabetes type I or II, other diabetes, metabolic disease, clinical obesity, clinically underweight, renal disease, liver disease, blood disorder, immunosuppression, organ transplant, cancer, neurologic disorder, musculoskeletal disorder, Down Syndrome, congenital heart disease, neurologic conditions, muscular dystrophy, sickle cell disease, prematurity (<24 weeks), developmental delay, technology dependence, or chronic gastrointestinal disease/irritable bowel syndrome.

Summary
What is already known about this topic?
Two doses of Pfizer-BioNTech vaccine provided protection against COVID-19 in persons aged 12-17 years during Delta predominance, but data during Omicron predominance and among children aged 5-11 years are lacking.
What is added by this report?
Two doses protect against COVID-19-associated emergency department and urgent care encounters among children and adolescents. However, vaccine effectiveness (VE) was lower during Omicron predominance and decreased with time since vaccination; a booster dose restored VE to 81% among adolescents aged 16-17 years. Overall, 2-dose VE against COVID-19associated hospitalization was 73%-94%.
What are the implications for public health practice?
All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations, including a booster dose for those aged 12-17 years.

Discussion
In a multistate analysis of 39,217 ED and UC encounters with COVID-19-like illness among nonimmunocompromised patients aged 5-17 years through January 29, 2022, estimates of Pfizer-BioNTech VE against COVID-19-associated ED and UC encounters varied by time since vaccination and by predominant circulating SARS-CoV-2 variant. Among adolescents aged 12-17 years during the full study period including pre-Delta, Delta, and Omicron predominant periods, 2-dose VE estimates were higher (76%-83%) 14-149 days after receipt of a second dose, and significantly lower (38%-46%) at ≥150 days postvaccination. However, a third vaccine dose restored VE against COVID-19-associated ED or UC encounters to 86% among adolescents aged 16-17 years. Among children aged 5-11 years during the full study period, VE of 2 doses (14-67 days earlier) against COVID-19-associated ED or UC encounters was 46%, which was significantly lower than overall estimates for adolescents aged 12-17 years. However, most encounters among children aged 5-11 years occurred during Omicron predominance, when VE significantly declined for adolescents aged 12-17 years. During Omicron predominance, VE of a second dose received 14-149 days earlier was 45% and 34% for adolescents aged 12-15 and 16-17 years, respectively, suggesting that the lower VE observed among children aged 5-11 years was likely driven by the predominant variant rather than differences in VE across age groups. During Omicron predominance, there was no evidence of protection for adolescents aged 12-17 years from 2 doses received ≥150 days earlier; however, a third vaccine restored VE to 81% among adolescents aged 16-17 years.
Receipt of 2 Pfizer-BioNTech vaccine doses in persons aged 12-17 years provided a high level of protection (>90%) against COVID-19-associated hospitalizations within 149 days of receipt of the second dose. VE point estimates for second dose received ≥150 days earlier were 73% to 88%; however, differences by time since vaccination were not statistically significant. Additional data are needed to better understand duration of protection against COVID-19-associated hospitalization in adolescents aged 12-17 years, the protection from 3 doses, and the level of protection among children aged 5-11 years.
These findings are consistent with previously published data showing high effectiveness of the Pfizer-BioNTech vaccine among adolescents before Omicron became the predominant variant (4)(5)(6), and with data from adults demonstrating relatively higher protection against more severe outcomes (7). These findings are also consistent with data showing a decline in mRNA VE over time since receipt of the second dose among adolescents and adults (8)(9)(10). The findings in this report also align with studies among adults that report lower VEs during Omicron variant predominance (9,10) and an increase in VE after receipt of a third vaccine dose (9,10).
The findings in this report are subject to at least six limitations. First, comparison of VE estimates between age groups should be made with caution because of differences in the timing of vaccine availability and predominant variants when the vaccine became available to different age groups. Second, statistical power for estimating VE against COVID-19-associated hospitalizations was limited, resulting in wide CIs for some groups, particularly children aged 5-11 years. Third, among adolescents aged 16-17, the estimated 3-dose VE was based on a relatively short period after vaccination. Fourth, despite adjustments to balance the differences between unvaccinated and vaccinated persons, unmeasured and residual confounding (e.g., mask use and physical distancing) might have biased the estimates. Fifth, genetic characterization of patients' viruses was not available, and Delta and Omicron predominance periods were based on surveillance data. Finally, although the facilities in this study serve heterogeneous populations in 10 states, the findings might not be generalizable to the U.S. population.