The n e w e ng l a n d j o u r na l of m e dic i n e

Original Article

Covid-19 Vaccine Protection among

Children and Adolescents in Qatar
H. Chemaitelly, S. AlMukdad, H.H. Ayoub, H.N. Altarawneh, P. Coyle, P. Tang,
H.M. Yassine, H.A. Al‑Khatib, M.K. Smatti, M.R. Hasan, Z. Al‑Kanaani, E. Al‑Kuwari,
A. Jeremijenko, A.H. Kaleeckal, A.N. Latif, R.M. Shaik, H.F. Abdul‑Rahim,
G.K. Nasrallah, M.G. Al‑Kuwari, H.E. Al‑Romaihi, A.A. Butt, M.H. Al‑Thani,
A. Al‑Khal, R. Bertollini, and L.J. Abu‑Raddad​​

A BS T R AC T

BACKGROUND
The BNT162b2 vaccine against coronavirus disease 2019 (Covid-19) has been autho- The authors’ full names, academic de-
rized for use in children 5 to 11 years of age and adolescents 12 to 17 years of age grees, and affiliations are listed in the Ap-
pendix. Dr. Chemaitelly can be contacted
but in different antigen doses. at ­hsc2001@​­qatar-med​.­cornell​.­edu. Dr.
Abu-Raddad can be contacted at l­ja2002@​
METHODS ­qatar-med​.­cornell​.­edu. Drs. Chemaitelly
We assessed the real-world effectiveness of the BNT162b2 vaccine against infection and Abu-Raddad can also be contacted at
the Infectious Disease Epidemiology
with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children Group, Weill Cornell Medicine–Qatar,
and adolescents in Qatar. To compare the incidence of SARS-CoV-2 infection in the Qatar Foundation–Education City, P.O.
national cohort of vaccinated participants with the incidence in the national cohort Box 24144, Doha, Qatar.
of unvaccinated participants, we conducted three matched, retrospective, target- This article was published on November 2,
trial, cohort studies — one assessing data obtained from children 5 to 11 years of 2022, at NEJM.org.
age after the B.1.1.529 (omicron) variant became prevalent and two assessing data N Engl J Med 2022;387:1865-76.
from adolescents 12 to 17 years of age before the emergence of the omicron variant DOI: 10.1056/NEJMoa2210058
Copyright © 2022 Massachusetts Medical Society.
(pre-omicron study) and after the omicron variant became prevalent. Associations
were estimated with the use of Cox proportional-hazards regression models.
RESULTS
Among children, the overall effectiveness of the 10-μg primary vaccine series against
infection with the omicron variant was 25.7% (95% confidence interval [CI], 10.0 to
38.6). Effectiveness was highest (49.6%; 95% CI, 28.5 to 64.5) right after receipt of
the second dose but waned rapidly thereafter and was negligible after 3 months.
Effectiveness was 46.3% (95% CI, 21.5 to 63.3) among children 5 to 7 years of age
and 16.6% (95% CI, −4.2 to 33.2) among those 8 to 11 years of age. Among adoles-
cents, the overall effectiveness of the 30-μg primary vaccine series against infection
with the omicron variant was 30.6% (95% CI, 26.9 to 34.1), but many adolescents had
been vaccinated months earlier. Effectiveness waned over time since receipt of the
second dose. Effectiveness was 35.6% (95% CI, 31.2 to 39.6) among adolescents 12
to 14 years of age and 20.9% (95% CI, 13.8 to 27.4) among those 15 to 17 years of age.
In the pre-omicron study, the overall effectiveness of the 30-μg primary vaccine se-
ries against SARS-CoV-2 infection among adolescents was 87.6% (95% CI, 84.0 to
90.4) and waned relatively slowly after receipt of the second dose.
CONCLUSIONS
Vaccination in children was associated with modest, rapidly waning protection
against omicron infection. Vaccination in adolescents was associated with stronger,
more durable protection, perhaps because of the larger antigen dose. (Funded by
Weill Cornell Medicine–Qatar and others.)

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 The n e w e ng l a n d j o u r na l
T
he messenger RNA (mRNA) vaccine
BNT162b2 (Pfizer–BioNTech) against coro-
navirus disease 2019 (Covid-19) has been
authorized for use in adolescents 12 to 17 years
of age and in children 5 to 11 years of age but
in antigen doses of 30 μg and 10 μg, respec-
tively.1,2 Qatar launched mass Covid-19 immuni-
zation campaigns using these vaccines, first in-
volving adolescents in several phases starting in
February 2021 and then involving children 5 to
11 years of age starting in February 2022 (Sec-
tion S1 in the Supplementary Appendix, available
with the full text of this article at NEJM.org).
We assessed the real-world effectiveness of the
two-dose primary vaccine series against severe
acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) infection for the 10-μg dose of BNT162b2
vaccine among children and the 30-μg dose of
BNT162b2 vaccine among adolescents. Assessment
was part of a national study in Qatar, a country
that has experienced five SARS-CoV-2 waves,
dominated sequentially by the index virus,3 the
B.1.1.7 (alpha) variant,4 the B.1.351 (beta) vari-
ant,5 the B.1.1.529 (omicron) subvariants BA.1
and BA.2,6 and the omicron subvariants BA.4
and BA.5,7 in addition to a prolonged low-inci-
dence phase dominated by the B.1.617.2 (delta)
variant.8
Me thods
Study Population and Data Sources
We conducted this study in Qatar and analyzed
data from the national, federated databases for
Covid-19 laboratory testing, vaccination, hospital-
ization, and death, retrieved from the integrated,
nationwide, digital-health information platform.
These databases include all SARS-CoV-2–related
data, such as results from all polymerase-chain-
reaction (PCR) tests, and associated demographic
information, with no missing information since
the onset of the pandemic. The databases also
include results from rapid antigen tests that were
conducted at health care facilities starting from
January 5, 2022. Rapid antigen test kits are avail-
able for purchase in pharmacies in Qatar, but
outcomes of home-based testing are not report-
ed or documented in the national databases and
thus were not factored in our study, including in
the estimations of cumulative incidence or inci-
dence rate. Detailed descriptions of the popula-
tion of Qatar and of the national databases have
been reported previously.3,5,6,9,10
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of m e dic i n e
Study Design and Cohorts
Three matched, retrospective cohort studies em-
ulating randomized target trials10,11 were con-
ducted to investigate the effectiveness of the
BNT162b2 vaccine among children 5 to 11 years
of age and among adolescents 12 to 17 years of
age at least 14 days after the receipt of the sec-
ond vaccine dose. The target of estimation was
the effect of being vaccinated among persons
who received the vaccine; the average treatment
effect among treated persons quantifies vaccine
effectiveness among the subpopulation that was
vaccinated.
In each study, the incidence of infection or of
severe,12 critical,12 or fatal13 Covid-19 was com-
pared between the national cohort of previously
uninfected persons who had completed the two-
dose BNT162b2 primary series (designated as the
vaccinated cohort) and the national control cohort
of persons who were previously uninfected and
were unvaccinated (designated as the control co-
hort). The focus of the studies was on vaccine-
related immunity and not on a hybrid immunity
of previous infection and vaccination. Persons with
a record of previous infection were excluded.
Documentation of infection was based on posi-
tive PCR or rapid antigen testing. Laboratory meth-
ods are presented in Section S2. To inform the
national Covid-19 response in Qatar, 5% of posi-
tive cases are targeted for viral-genome sequenc-
ing, and a larger proportion is targeted for geno-
typing with the use of multiplex real-time
reverse-transcriptase PCR variant screening. The
classification of Covid-19 cases as being severe
(acute care hospitalization),12 critical (hospitaliza-
tion in the intensive care unit),12 or fatal13 followed
World Health Organization guidelines (Section S3).
Cohort Matching and Follow-up
Vaccinated persons were matched one to one
with unvaccinated persons in the control cohort
according to sex, age, nationality, and number of
coexisting conditions (none, one, or two or more)
in order to account for differences in SARS-CoV-2
exposure risk in Qatar.3,14-17 Matching according
to these factors was previously shown to provide
adequate control of differences in exposure risk
in Qatar.9,18-21
Matching was also done according to the cal-
endar month of receipt of the second vaccine dose
for the vaccinated cohort and the calendar month
of receipt of a SARS-CoV-2–negative test for the
control cohort. That is, persons who received their
 Covid-19 Vaccine in Children and Adolescents in Qatar
second vaccine dose in a specific month were
matched with unvaccinated persons who had a
record of a SARS-CoV-2–negative test in that same
calendar month, to ensure that these persons
were in Qatar at the same time. Matching was
performed iteratively such that persons in the
control cohort were alive, infection-free, and un-
vaccinated at the start of follow-up.
Each matched pair was followed from the
calendar day on which the vaccinated person
had completed 14 days after receiving the second
dose. To ensure exchangeability,10,22 data on both
members of each matched pair were censored
when the vaccinated participant received a third
(booster) dose or when a control participant re-
ceived a first dose of vaccine. Participants were
followed until the first of any of the following
events: documented SARS-CoV-2 infection (defined
as the first positive PCR or rapid antigen test after
the start of follow-up, regardless of the presence
of symptoms), booster vaccination in participants
who had received the primary vaccine series (with
matched-pair censoring), receipt of the first dose
of vaccine in control participants (with matched-
pair censoring), death, or the end of the study.
Many participants contributed follow-up time
first as unvaccinated persons (before receipt of
the first dose), while being matched with vacci-
nated persons, and subsequently contributed fol-
low-up time as vaccinated persons (after receipt
of the second dose) while being matched with
unvaccinated persons. Allowing such crossover
in the study design may reduce potential differ-
ences arising from unmeasured risk behaviors
related to vaccination or infection status.
Omicron 10-μg BNT162b2 Study
Involving Children
In the omicron study involving children, we es-
timated the effectiveness of the pediatric 10-μg
dose of the BNT162b2 vaccine against omicron
infection among children 5 to 11 years of age.6,10
Virtually all cases of SARS-CoV-2 infection since
the onset of the omicron wave have been due to
omicron subvariants. Any child who had received
two doses of vaccine between February 3, 2022
(earliest record of two-dose vaccination in chil-
dren), and July 12, 2022 (end of study), was eli-
gible for inclusion in the vaccinated cohort on
day 14 after receipt of the second dose, provided
that the child had no record of SARS-CoV-2 in-
fection before the start of follow-up. Any child
with a SARS-CoV-2–negative test during the study
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was eligible for inclusion in the control cohort,
provided that the child had no record of infec-
tion or vaccination before the start of follow-up.
Pre-Omicron 30-μg BNT162b2 Study
Involving Adolescents
In the pre-omicron study, we estimated the ef-
fectiveness of the 30-μg dose of the BNT162b2
vaccine against SARS-CoV-2 infection before the
emergence of the omicron variant (pre-omicron
period) among adolescents 12 to 17 years of age.
Any adolescent who had received two doses of
the BNT162b2 vaccine between February 1, 2021
(earliest record of two-dose vaccination in ado-
lescents), and November 30, 2021 (end of study),
was eligible for inclusion in the vaccinated co-
hort, provided that the adolescent had no record
of infection before the start of follow-up. Follow-
up was from day 14 after receipt of the second
dose until November 30, 2021 (first evidence of
the omicron variant in Qatar6,10), to ensure that
incidence was due to a pre-omicron variant. Any
adolescent with a SARS-CoV-2–negative test dur-
ing the study was eligible for inclusion in the
control cohort, provided that the adolescent had
no record of infection or vaccination before the
start of follow-up.
Omicron 30-μg BNT162b2 Study
Involving Adolescents
In the omicron study involving adolescents 12 to
17 years of age, we estimated the effectiveness
of the 30-μg dose of the BNT162b2 vaccine
against infection with the omicron variant. Any
adolescent who had received two doses of the
BNT162b2 vaccine between February 1, 2021, and
July 12, 2022 (end of study), was eligible for in-
clusion in the vaccinated cohort, provided that
the adolescent had no record of infection or re-
ceipt of a third dose of vaccine before the start
of follow-up. Follow-up was from December 19,
2021 (onset of the omicron wave in Qatar6,10), if
the second dose of vaccine had been received at
least 14 days before this date (i.e., before the
omicron wave) and from day 14 after receipt of
the second dose otherwise. Any adolescent with
a SARS-CoV-2–negative test between February 1,
2021, and July 12, 2022, was eligible for inclusion
in the control cohort, provided that the adoles-
cent had no record of infection or vaccination
before the start of follow-up. The study was
replicated to estimate the effectiveness of a third
(booster) 30-μg dose of the BNT162b2 vaccine
1867
 The n e w e ng l a n d j o u r na l of m e dic i n e

against omicron infection among adolescents 12 for the matching factors with the stcox command
to 17 years of age. in Stata software, version 17.0. Schoenfeld residu-
als and log–log plots for survival curves were used
Oversight to test the proportional-hazards assumption.
The institutional review boards at Hamad Medical Confidence intervals were not adjusted for mul-
Corporation and Weill Cornell Medicine–Qatar tiplicity; thus, they should not be used to infer
approved this retrospective study with a waiver definitive differences between groups. Interactions
of informed consent. The study was reported were not considered. Vaccine effectiveness was
according to the Strengthening the Reporting of estimated as 1 minus the adjusted hazard ratio
Observational Studies in Epidemiology (STROBE) and is presented as a percentage.
guidelines (Table S1). The authors vouch for the Effectiveness was also estimated against symp-
accuracy and completeness of the data and for tomatic infection. Subgroup analyses were con-
the fidelity of the study to the protocol. The data ducted to investigate the durability of vaccine pro-
set used in this study is the property of the Min- tection. Adjusted hazard ratios were calculated,
istry of Public Health of Qatar and was provided with stratification according to the number of
to the researchers through a restricted-access months since receipt of the second vaccine dose
agreement for the preservation of confidentiality or according to subgroups of persons vaccinated
of patient data. The funders had no role in the at different times. Subgroup analyses were also
study design; the collection, analysis, or interpreta- conducted to investigate differences in vaccine
tion of the data; or the writing of the manuscript. protection according to year of age and accord-
ing to age groups. The number needed to vacci-
Statistical Analysis nate to prevent one documented infection was
The eligible and matched cohorts were described calculated by dividing the number of vaccinated
with the use of frequency distributions and mea- persons by the number of averted infections. The
sures of central tendency; the study groups within number of averted infections was estimated from
the cohorts were compared with the use of stan- the difference in the cumulative incidence curves.
dardized mean differences. A standardized mean The incidence of vaccine-preventable infection was
difference of 0.1 or less indicated adequate estimated as the vaccine effectiveness multiplied by
matching. The Kaplan–Meier estimator method the incidence rate among control participants.23
was used to estimate the cumulative incidence of Sensitivity analyses with adjustment for the
infection, which was defined as the proportion effectiveness estimates for differences in testing
of persons who became infected, out of those frequency between cohorts were conducted. Sta-
who were at risk; the primary end point during tistical analyses were conducted with the use of
follow-up was a breakthrough infection in the Stata/SE software, version 17.0 (StataCorp).
vaccinated cohort or an infection in the control
cohort. The incidence rate of infection in each R e sult s
cohort, defined as the number of identified in-
fections divided by the number of person-weeks Omicron 10-μg BNT162b2 Study Involving
contributed by all persons in the cohort, was Children
estimated, with a corresponding 95% confidence Figure S1 shows the process of selection of the
interval, with the use of a Poisson log-likelihood study population. Table 1 describes the charac-
regression model with the stptime command in teristics of the participants in the full study popu-
Stata software, version 17.0. Both the cumulative lation and the matched cohorts. Each matched
incidence and incidence rate were estimated cohort included 18,728 children. The study was
strictly for infections that had been documented conducted in the total pediatric population of
at health care facilities. These measures did not Qatar; thus, the study population is broadly rep-
include the incidence of undiagnosed infections resentative of the pediatric population of Qatar
or of infections that were diagnosed on the basis (Table S2).
of home-based testing. The median follow-up was 69 days (interquar-
Hazard ratios comparing the incidence of tile range, 31 to 97) in the vaccinated cohort and
infection in the cohorts, along with their corre- 69 days (interquartile range, 30 to 97) in the con-
sponding 95% confidence intervals, were calculat- trol cohort (Fig. 1A). During follow-up, there were
ed with the use of Cox regression with adjustment 184 infections in the vaccinated cohort and 248

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 Covid-19 Vaccine in Children and Adolescents in Qatar

Table 1. Baseline Characteristics of Children 5 to 11 Years of Age in the Study of Effectiveness of the 10-μg Dose of the BNT162b2 Vaccine
against Infection with a SARS-CoV-2 Omicron Subvariant.*

Characteristic Full Eligible Cohorts Matched Cohorts†

Vaccinated Cohort Control Cohort Vaccinated Cohort Control Cohort
(N = 21,888) (N = 91,870) SMD‡ (N = 18,728) (N = 18,728) SMD‡
Age
Median (IQR) — yr 8 (7–10) 8 (6–9) 0.32§ 8 (7–10) 8 (7–10) 0.00§
Distribution — no. (%) 0.36 0.00
5 yr 1,874 (8.6) 17,503 (19.1) 1,802 (9.6) 1,802 (9.6)
6 yr 2,768 (12.6) 14,190 (15.4) 2,512 (13.4) 2,512 (13.4)
7 yr 3,175 (14.5) 13,526 (14.7) 2,769 (14.8) 2,769 (14.8)
8 yr 3,381 (15.4) 12,555 (13.7) 2,850 (15.2) 2,850 (15.2)
9 yr 3,331 (15.2) 12,099 (13.2) 2,847 (15.2) 2,847 (15.2)
10 yr 3,593 (16.4) 10,903 (11.9) 2,946 (15.7) 2,946 (15.7)
11 yr 3,766 (17.2) 11,094 (12.1) 3,002 (16.0) 3,002 (16.0)
Sex — no. (%) 0.01 0.00
Male 11,026 (50.4) 46,950 (51.1) 9,374 (50.1) 9,374 (50.1)
Female 10,862 (49.6) 44,920 (48.9) 9,354 (49.9) 9,354 (49.9)
Nationality — no. (%)¶ 1.18 0.00
Bangladeshi 567 (2.6) 1,033 (1.1) 373 (2.0) 373 (2.0)
Egyptian 718 (3.3) 10,289 (11.2) 718 (3.8) 718 (3.8)
Filipino 2,918 (13.3) 2,123 (2.3) 1,542 (8.2) 1,542 (8.2)
Indian 12,822 (58.6) 23,924 (26.0) 11,951 (63.8) 11,951 (63.8)
Nepalese 144 (0.7) 193 (0.2) 76 (0.4) 76 (0.4)
Pakistani 1,227 (5.6) 5,607 (6.1) 1,190 (6.4) 1,190 (6.4)
Qatari 128 (0.6) 18,921 (20.6) 128 (0.7) 128 (0.7)
Sri Lankan 350 (1.6) 1,096 (1.2) 311 (1.7) 311 (1.7)
Sudanese 95 (0.4) 2,837 (3.1) 95 (0.5) 95 (0.5)
Other‖ 2,919 (13.3) 25,847 (28.1) 2,344 (12.5) 2,344 (12.5)
No. of coexisting conditions — no. (%) 0.11 0.00
0 17,954 (82.0) 71,929 (78.3) 16,030 (85.6) 16,030 (85.6)
1 3,345 (15.3) 15,973 (17.4) 2,362 (12.6) 2,362 (12.6)
≥2 589 (2.7) 3,968 (4.3) 336 (1.8) 336 (1.8)

* Shown are the baseline characteristics of the eligible and matched vaccinated and control cohorts in the study of the effectiveness of the 10-μg
dose of the BNT162b2 vaccine against infection with a B.1.1.529 (omicron) subvariant of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) among children 5 to 11 years of age. IQR denotes interquartile range.
† Vaccinated and control cohorts were matched in a 1:1 ratio according to sex, age, nationality, number of coexisting conditions, and calendar
month of receipt of the second dose of vaccine for the vaccinated participant or the SARS-CoV-2–negative test for the control participant.
‡ The standardized mean difference (SMD) is the difference in the mean of a covariate between groups divided by the pooled standard deviation.
An SMD of 0.1 or less indicates adequate matching.
§ The SMD is for the mean difference between groups, divided by the pooled standard deviation.
¶ Nationalities were chosen to represent the most populous groups in Qatar.
‖ This group included up to 140 other nationalities in the unmatched cohorts and 66 other nationalities in the matched cohorts.

infections in the control cohort. None of the
infections progressed to severe, critical, or fatal
Covid-19. The incidence of infection coincided
with the time when cases were due to the omicron
BA.1, BA.2, BA.4, and BA.5 subvariants but after
the peak of the major wave of infections with the
BA.1 and BA.2 subvariants in mid-January 2022.6,7,10
The cumulative incidence of infection at 110 days
after the start of follow-up was 2.1% (95% con-
fidence interval [CI], 1.7 to 2.4) in the vaccinated
cohort and 2.4% (95% CI, 2.0 to 2.7) in the control
cohort (Fig. 1A).
The overall hazard ratio for infection, which
was adjusted for sex, age, nationality group, num-

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 The n e w e ng l a n d j o u r na l of m e dic i n e

38.6). Effectiveness decreased with time after

A Omicron Infection in Children 5–11 Yr of Age
100 2.5
receipt of the second vaccine dose (Fig. 1B). Ef-
Control
fectiveness was highest (49.6%; 95% CI, 28.5 to
90
64.5) right after receipt of the second dose but
2.0
80 waned rapidly thereafter and was 11.0% (95% CI,
Cumulative Incidence (%)

70 −26.8 to 37.5) by the third month after receipt of

1.5
the second dose.
60 Vaccinated
Vaccine effectiveness was 46.3% (95% CI, 21.5
50 1.0 to 63.3) among children 5 to 7 years of age and
40 16.6% (95% CI, −4.2 to 33.2) among those 8 to 11
30
0.5 years of age. The median date of the second vac-
cine dose was April 14, 2022, among children 5 to
20
0.0 7 years of age and April 10, 2022, among those
10 0 10 20 30 40 50 60 70 80 90 100 110 8 to 11 years of age. Overall, effectiveness accord-
0 ing to year of age showed a declining trend (Fig.
0 10 20 30 40 50 60 70 80 90 100 110 S2A). Effectiveness against symptomatic infection
Days since Start of Follow-up was 36.9% (95% CI, −29.9 to 69.4). The number
needed to vaccinate to prevent one infection was
B Effectiveness of the 10-µg Dose of BNT162b2 Vaccine against
Omicron Infection
333.3. The incidence rate of vaccine-preventable
100.0 infection was 3.7 cases per 10,000 person-weeks.
90.0
Pre-Omicron 30-μg BNT162b2 Study
80.0
Involving Adolescents
70.0
Figure S3 shows the process of selection of the
60.0
study population. Table 3 describes the character-
Effectiveness (%)

50.0 49.6
40.0
30.0
23.0
20.0
10.0
0.0
−10.0
−20.0
−30.0
1 2
Months after Start of Follow-up
Figure 1. Omicron Infection in Children 5 to 11 Years of Age, According
to Vaccination Status, and Effectiveness of the 10-μg Vaccine Dose.
Panel A shows the cumulative incidence of infection with the B.1.1.529
(omicron) variant of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) among children 5 to 11 years of age who had received two
10-μg doses of the BNT162b2 vaccine, as compared with unvaccinated chil-
dren (control). The inset shows the same data on an expanded y axis. Panel B
shows the vaccine effectiveness against omicron infection among children
who had received two 10-μg doses according to the number of months af-
ter the start of follow-up. Follow-up began 14 days after receipt of the sec-
ond dose. The lower boundary of the 95% confidence interval (I bar) for
the data at month 4 or later has been truncated.
ber of coexisting conditions, and calendar month
of the second vaccine dose or the SARS-CoV-2–
negative test, was 0.74 (95% CI, 0.61 to 0.90)
(Table 2). The overall vaccine effectiveness against
omicron infection was 25.7% (95% CI, 10.0 to
istics of the participants in the full study popula-
tion and the matched cohorts. Each matched co-
hort included 23,317 adolescents.
The median follow-up was 45 days (interquar-
11.0
tile range, 16 to 88) in the vaccinated cohort and
43 days (interquartile range, 15 to 85) in the
−9.5 control cohort (Fig. 2A). During follow-up, there
were 67 infections in the vaccinated cohort and
523 infections in the control cohort. None of the
3 ≥4
infections progressed to severe, critical, or fatal
Covid-19. Infections coincided with the time that
the alpha, beta, and especially delta variants were
predominant.8,9,24 The cumulative incidence of in-
fection at 135 days after the start of follow-up
was 0.8% (95% CI, 0.6 to 1.0) in the vaccinated
cohort and 4.1% (95% CI, 3.7 to 4.6) in the con-
trol cohort (Fig. 2A).
The overall adjusted hazard ratio for infection
was 0.12 (95% CI, 0.10 to 0.16) (Table 2). The
overall vaccine effectiveness against pre-omicron
infection was 87.6% (95% CI, 84.0 to 90.4). Ef-
fectiveness decreased with time after receipt of
the second vaccine dose (Fig. 3A). Effectiveness
was highest (95.3%; 95% CI, 92.0 to 97.2) right
after the second dose but waned slowly thereafter.
Vaccine effectiveness was 89.4% (95% CI, 84.5
to 92.7) among adolescents 12 to 14 years of age
and 85.7% (95% CI, 79.7 to 89.8) among those

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 Covid-19 Vaccine in Children and Adolescents in Qatar

Table 2. Effectiveness of the BNT162b2 Vaccine against SARS-CoV-2 Infection among Children and Adolescents in Qatar.

Vaccinated Control Effectiveness

Epidemiologic Measure Cohort Cohort (95% CI)
%
Children 5–11 yr of age, omicron study
Total follow-up — no. of person-wk 173,451 173,082
Incidence rate of infection per 10,000 person-wk 10.6 (9.2–12.3) 14.3 (12.7–16.2)
(95% CI)
Hazard ratio for infection with an omicron subvariant
(95% CI)
Unadjusted analysis 0.74 (0.61–0.90) — 25.7 (10.0–38.6)
Adjusted analysis* 0.74 (0.61–0.90) — 25.7 (10.0–38.6)
Adolescents 12–17 yr of age, pre-omicron study
Total follow-up — no. of person-wk 192,309 185,751
Incidence rate of infection per 10,000 person-wk 3.5 (2.7–4.4) 28.2 (25.8–30.7)
(95% CI)
Hazard ratio for infection with a pre-omicron
subvariant (95% CI)
Unadjusted analysis 0.13 (0.10–0.16) — 87.5 (83.8–90.3)
Adjusted analysis* 0.12 (0.10–0.16) — 87.6 (84.0–90.4)
Adolescents 12–17 yr of age, omicron study
Total follow-up — no. of person-wk 338,838 319,291 —
Incidence rate of infection per 10,000 person-wk 74.4 (71.5–77.3) 104.5 (101.0–108.1) —
(95% CI)
Hazard ratio for infection with an omicron subvariant
(95% CI)
Unadjusted analysis 0.72 (0.69–0.76) — 27.7 (23.8–31.3)
Adjusted analysis* 0.69 (0.66–0.73) — 30.6 (26.9–34.1)

* The Cox regression analysis was adjusted for sex, age, nationality, number of coexisting conditions, and calendar month of
receipt of the second vaccine dose for the vaccinated participant or the SARS-CoV-2–negative test for the control p­ articipant.

15 to 17 years of age. The median date of the sec-
ond vaccine dose was August 23, 2021, among
adolescents 12 to 14 years of age and July 14, 2021,
among those 15 to 17 years of age. Effectiveness
according to year of age was stable (Fig. S2B).
Effectiveness against symptomatic infection was
91.2% (95% CI, 84.8 to 94.9). The number needed
to vaccinate to prevent one infection was 30.3. The
incidence rate of vaccine-preventable infection was
24.7 cases per 10,000 person-weeks.
Omicron 30-μg BNT162b2 Study
Involving Adolescents
Figure S4 shows the process of selection of the
study population. Table 3 describes the character-
istics of the participants in the full study popula-
tion and the matched cohorts. Each matched co-
hort included 17,903 adolescents.
The median follow-up was 162 days (interquar-
tile range, 48 to 205) in the vaccinated cohort and
149 days (interquartile range, 34 to 205) in the
control cohort (Fig. 2B). During follow-up, there
were 2520 infections in the vaccinated cohort, of
which 1 progressed to critical Covid-19, and 3337
infections in the control cohort, of which 1 pro-
gressed to severe Covid-19 and another to critical
Covid-19. The incidence of infection coincided
initially with the major wave of infections caused
by the omicron BA.1 and BA.2 subvariants in
January 2022 (Fig. 2B).6,10 Subsequently, the inci-
dence of infection was due to the omicron BA.1,
BA.2, BA.4, or BA.5 subvariants.6,7,10 The cumula-
tive incidence of infection at 195 days after the
start of follow-up was 15.9% (95% CI, 15.3 to 16.4)
in the vaccinated cohort and 20.7% (95% CI, 20.1
to 21.3) in the control cohort (Fig. 2B).
The overall adjusted hazard ratio for infection
was 0.69 (95% CI, 0.66 to 0.73) (Table 2). The over-

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 Table 3. Baseline Characteristics of Adolescents 12 to 17 Years of Age in Two Studies of Effectiveness of the 30-μg Dose of the BNT162b2 Vaccine.*

1872
Characteristic Pre-Omicron Study Omicron Study
Full Eligible Cohorts Matched Cohorts† Full Eligible Cohorts Matched Cohorts†
Vaccinated Control Vaccinated Control Vaccinated Control Vaccinated Control
Cohort Cohort Cohort Cohort Cohort Cohort Cohort Cohort
(N = 81,647) (N = 66,006) SMD‡ (N = 23,317) (N = 23,317) SMD‡ (N = 89,505) (N = 86,280) SMD‡ (N = 17,903) (N = 17,903) SMD‡
Age
Median (IQR) — yr 15 (14–16) 14 (12–15) 0.50§ 14 (13–16) 14 (13–16) 0.00§ 15 (13–16) 14 (12–15) 0.47§ 13 (12–15) 13 (12–15) 0.00§
Distribution — no. (%) 0.71 0.00 0.64 0.00
12 yr 3,174 (3.9) 18,636 (28.2) 2,767 (11.9) 2,767 (11.9) 7,865 (8.8) 28,852 (33.4) 6,003 (33.5) 6,003 (33.5)
13 yr 16,581 (20.3) 11,190 (17.0) 5,767 (24.7) 5,767 (24.7) 17,713 (19.8) 13,530 (15.7) 3,389 (18.9) 3,389 (18.9)
14 yr 16,427 (20.1) 10,382 (15.7) 4,535 (19.4) 4,535 (19.4) 17,218 (19.2) 12,403 (14.4) 2,677 (15.0) 2,677 (15.0)
15 yr 15,675 (19.2) 9,861 (14.9) 3,870 (16.6) 3,870 (16.6) 16,259 (18.2) 11,866 (13.8) 2,254 (12.6) 2,254 (12.6)
16 yr 14,998 (18.4) 8,257 (12.5) 2,734 (11.7) 2,734 (11.7) 15,447 (17.3) 10,136 (11.7) 1,790 (10.0) 1,790 (10.0)
17 yr 14,792 (18.1) 7,680 (11.6) 3,644 (15.6) 3,644 (15.6) 15,003 (16.8) 9,493 (11.0) 1,790 (10.0) 1,790 (10.0)
The

Sex — no. (%) 0.02 0.00 0.02 0.00

Male 41,919 (51.3) 34,594 (52.4) 12,083 (51.8) 12,083 (51.8) 45,936 (51.3) 44,941 (52.1) 9,258 (51.7) 9,258 (51.7)
Female 39,728 (48.7) 31,412 (47.6) 11,234 (48.2) 11,234 (48.2) 43,569 (48.7) 41,339 (47.9) 8,645 (48.3) 8,645 (48.3)
Nationality — no. (%)¶ 0.26 0.00 0.24 0.00
Bangladeshi 1,054 (1.3) 967 (1.5) 391 (1.7) 391 (1.7) 1,182 (1.3) 1,521 (1.8) 414 (2.3) 414 (2.3)
Egyptian 8,894 (10.9) 7,538 (11.4) 3,379 (14.5) 3,379 (14.5) 9,835 (11.0) 9,460 (11.0) 2,051 (11.5) 2,051 (11.5)
Filipino 3,029 (3.7) 1,118 (1.7) 280 (1.2) 280 (1.2) 3,372 (3.8) 1,896 (2.2) 345 (1.9) 345 (1.9)
Indian 12,943 (15.9) 6,569 (10.0) 2,812 (12.1) 2,812 (12.1) 15,084 (16.9) 9,434 (10.9) 2,735 (15.3) 2,735 (15.3)
Nepalese 102 (0.1) 46 (0.1) 9 (<0.1) 9 (<0.1) 120 (0.1) 76 (0.1) 7 (<0.1) 7 (<0.1)
Pakistani 5,089 (6.2) 2,876 (4.4) 982 (4.2) 982 (4.2) 5,622 (6.3) 3,932 (4.6) 1,051 (5.9) 1,051 (5.9)
n e w e ng l a n d j o u r na l

Qatari 22,927 (28.1) 22,196 (33.6) 7,531 (32.3) 7,531 (32.3) 24,210 (27.0) 26,578 (30.8) 5,024 (28.1) 5,024 (28.1)

The New England Journal of Medicine

of

Sri Lankan 603 (0.7) 260 (0.4) 73 (0.3) 73 (0.3) 700 (0.8) 494 (0.6) 100 (0.6) 100 (0.6)
Sudanese 3,130 (3.8) 2,253 (3.4) 829 (3.6) 829 (3.6) 3,395 (3.8) 2,855 (3.3) 616 (3.4) 616 (3.4)
Other‖ 23,876 (29.2) 22,183 (33.6) 7,031 (30.2) 7,031 (30.2) 25,985 (29.0) 30,034 (34.8) 5,560 (31.1) 5,560 (31.1)

n engl j med 387;20  nejm.org  november 17, 2022

No. of coexisting conditions 0.02 0.00 0.06 0.00

Copyright © 2022 Massachusetts Medical Society. All rights reserved.

m e dic i n e

— no. (%)
0 64,614 (79.1) 52,741 (79.9) 19,183 (82.3) 19,183 (82.3) 71,144 (79.5) 70,646 (81.9) 15,185 (84.8) 15,185 (84.8)
1 or 2 13,478 (16.5) 10,344 (15.7) 3,309 (14.2) 3,309 (14.2) 14,592 (16.3) 12,239 (14.2) 2,208 (12.3) 2,208 (12.3)
≥3 3,555 (4.4) 2,921 (4.4) 825 (3.5) 825 (3.5) 3,769 (4.2) 3,395 (3.9) 510 (2.8) 510 (2.8)

* Shown are the baseline characteristics of the eligible and matched cohorts in the studies of the effectiveness of the 30-μg dose of the BNT162b2 vaccine among adolescents 12 to 17 years

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of age against infection with a pre-omicron variant of SARS-CoV-2 and against infection with an omicron subvariant.
† Vaccinated and control cohorts were matched in a 1:1 ratio according to sex, age, nationality, number of coexisting conditions, and calendar month of receipt of the second vaccine
dose for the vaccinated participant or the SARS-CoV-2–negative test for the control participant.
‡ The SMD is the difference in the mean of a covariate between groups divided by the pooled standard deviation. An SMD of 0.1 or less indicates adequate matching.
§ The SMD is for the mean difference between groups, divided by the pooled standard deviation.
¶ Nationalities were chosen to represent the most populous groups in Qatar.
‖ In the pre-omicron study, this group included up to 135 other nationalities in the unmatched cohorts and 75 other nationalities in the matched cohorts. In the omicron study, this group
included up to 143 other nationalities in the unmatched cohorts and 73 other nationalities in the matched cohorts.
 Covid-19 Vaccine in Children and Adolescents in Qatar

all vaccine effectiveness against omicron infection A SARS-CoV-2 Infection in Adolescents 12–17 Yr of Age — Pre-Omicron Study
was 30.6% (95% CI, 26.9 to 34.1). Effectiveness 100 5
decreased with time after receipt of the second
90 Control
dose (Fig. 3B). It was highest (51.3%; 95% CI, 4
80
34.9 to 63.6) among participants who had received

Cumulative Incidence (%)

70
their second dose most recently (between Janu- 3
ary 1, 2022, and July 12, 2022) but was negligible 60
2
(−1.7%; 95% CI, −16.9 to 11.5) among those who 50
had completed their primary series between Feb- 40
1 Vaccinated
ruary 1, 2021, and June 30, 2021. The overall vac- 30
cine effectiveness was 35.5% (95% CI, 5.2 to 56.1) 20 0
among adolescents who had been vaccinated be- 10
0 15 30 45 60 75 90 105 120 135
tween February 3, 2022, and July 12, 2022, which 0
is the same time period during which vaccination 0 15 30 45 60 75 90 105 120 135
was rolled out for children 5 to 11 years of age. Days since Start of Follow-up
Vaccine effectiveness was 35.6% (95% CI, 31.2
to 39.6) among adolescents 12 to 14 years of age B SARS-CoV-2 Infection in Adolescents 12–17 Yr of Age — Omicron Study
and 20.9% (95% CI, 13.8 to 27.4) among those 100 25
15 to 17 years of age. The median date of the sec- 90 Control
20
ond vaccine dose was November 11, 2021, among 80
Cumulative Incidence (%)

adolescents 12 to 14 years of age and September 15

70
Vaccinated
19, 2021, among those 15 to 17 years of age. Ef- 60 10
fectiveness according to year of age showed a 50
5
declining trend (Fig. S2C). Effectiveness against
40
symptomatic infection was 43.6% (95% CI, 35.1 0
30 0 15 30 45 60 75 90 105 120 135 150 165 180 195
to 50.9). The number needed to vaccinate to pre-
20
vent one infection was 20.8. The incidence rate
of vaccine-preventable infection was 32.0 cases 10

per 10,000 person-weeks. Despite the lower vac- 0

cine effectiveness against omicron infection than
against infection with a pre-omicron variant, many
infections were averted by vaccination owing to
the very high incidence of infection during the
omicron BA.1 and BA.2 wave.
Figure S5 shows the process for selecting the
study population for the additional analysis to
estimate booster effectiveness. Table S3 describes
the characteristics of the participants in the full
study population and the matched cohorts. In this
additional analysis, the overall vaccine effective-
ness against omicron infection was 36.7% (95% CI,
24.6 to 46.9). The cumulative-incidence curves sug- follow-up time as also unvaccinated ranged be-
gested a rapid waning of effectiveness 4 months tween 7.0% and 11.3%.
after receipt of the booster dose (Fig. S6).
Sensitivity Analyses and Crossover Design
Sensitivity analyses with adjustment for differ-
ences in testing frequency between study groups
in the three cohort studies yielded results that were
similar to those of primary analyses (Table S4).
Across the three studies, the percentage of partici-
pants in the vaccinated cohorts who contributed
0 15 30 45 60 75 90 105 120 135 150 165 180 195
Days since Start of Follow-up
Figure 2. SARS-CoV-2 Infection in Adolescents 12 to 17 Years of Age,
According to Vaccination Status, in the Pre-Omicron and Omicron Studies.
Shown is the cumulative incidence of SARS-CoV-2 infection among adoles-
cents 12 to 17 years of age who had received two 30-μg doses of the BNT162b2
vaccine, as compared with unvaccinated adolescents (control) in studies
assessing data during the period before the omicron variant became preva-
lent (pre-omicron study, Panel A) and after the omicron variant became
prevalent (omicron study, Panel B). In both panels, the inset shows the
same data on an enlarged y axis.
Discussion
The 10-μg dose of the BNT162b2 vaccine in chil-
dren was associated with only modest protection
against omicron infection, with a vaccine effective-
ness of approximately 25%. This protection was
also short-lived, decreasing from approximately
50% right after receipt of the second dose to neg-

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 The n e w e ng l a n d j o u r na l of m e dic i n e

cron infection and with slower waning. The protec-

A Effectiveness of the 30-µg Dose of BNT162b2 Vaccine against SARS-CoV-2
Infection — Pre-Omicron Study tion that was associated with this dose was ap-
100.0 proximately 30%, but some of the adolescents had
95.3
90.0 been vaccinated months earlier. The vaccine effec-
86.8
80.0 tiveness would have been higher in closer proxim-
70.0 72.3 70.6 ity to the second dose. Among adolescents who
60.0
had been vaccinated concurrently with children,
protection was approximately 35%. These findings
Effectiveness (%)

50.0
suggest that the antigen dose is a determinant in
40.0
the effectiveness of the vaccine. This effect remains
30.0 28.0 to be investigated directly by comparison of the
20.0
dose effects in same-age children or in same-age
10.0
adolescents. The effectiveness of the booster dose
0.0 among adolescents showed a similar level and pat-
−10.0 tern to that of the primary vaccine series.
−20.0 Protection with the 30-μg dose of BNT162b2
−30.0 among adolescents was stronger against pre-omi-
1 2 3 4 ≥5
cron infection than against omicron infection and
Months after Start of Follow-up
waned slowly. Protection was approximately 95%
B Effectiveness of the 30-µg Dose of BNT162b2 Vaccine against Omicron Variant right after receipt of the second dose and remained
Infection — Omicron Study strong at more than 50% for at least 5 months.
100.0 Overall, the protection and waning patterns that
90.0 were associated with the 30-μg dose among ado-
80.0 lescents paralleled those among adults,6,9,25 al-
70.0 though protection seemed to be slightly stronger
60.0 among adolescents than among adults.
Effectiveness (%)

50.0 51.3 Protection against omicron infection was high-

40.0 41.1 er among younger participants than among older
30.0 participants. Protection was approximately 45%
20.0
24.2 among children 5 to 7 years of age but was only
10.0
approximately 15% among those 8 to 11 years of
0.0
age, although the median vaccination date was
−1.7
similar in the two cohorts. Protection was ap-
−10.0
proximately 35% among adolescents 12 to 14 years
−20.0
of age but was only approximately 20% among
−30.0
Jan. 1 to July 12, Oct. 1 to Dec. 31, July 1 to Sept. 30, Feb. 1 to June 30, those 15 to 17 years of age, with the caveat that
2022 2021 2021 2021 the cohort of those 15 to 17 years of age had a
Date of Receipt of Second Vaccine Dose median vaccination date that was 2 months earlier
than that for the cohort of those 12 to 14 years of
Figure 3. Effectiveness of the 30-μg Vaccine Dose in Adolescents 12 to
age. The study findings are consistent with evi-
17 Years of Age before and after the Emergence of the Omicron Variant.
dence about vaccine protection among children
Panel A shows the effectiveness of the 30-μg dose of BNT162b2 vaccine
against SARS-CoV-2 infection before the emergence of the omicron variant and adolescents in other countries.2,26-30
(pre-omicron study) among adolescents according to the number of months Our study has limitations. With the lower sever-
after receipt of the second dose. Follow-up began 14 days after receipt of ity of SARS-CoV-2 infection among children than
the second dose. The lower boundary of the 95% confidence interval (I bar) among adults29,31 and the lower severity of omicron
for the data at month 4 has been truncated. Panel B shows the effectiveness
of the 30-μg dose against omicron infection among adolescents according to
infections than infections with pre-omicron vari-
date of receipt of the second dose. The date groups are shown in the order ants,32,33 too few severe,12 critical,12 or fatal13 cases
of increasing time since receipt of the second dose. I bars indicate 95% of Covid-19 were observed for us to estimate the
confidence intervals. vaccine effectiveness against severe Covid-19. Other
studies have shown high vaccine effectiveness
ligible levels after 3 months. However, the 30-μg against severe Covid-19 among children and ad-
dose of the BNT162b2 vaccine in adolescents was olescents.30,34-36
associated with stronger protection against omi- We investigated the incidence of documented

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 Covid-19 Vaccine in Children and Adolescents in Qatar

infections and defined our cohorts as being pre-
viously uninfected on the basis of an absence of
a record of previous infection, but other infec-
tions may have occurred and gone undocument-
ed. Some members of the cohorts may have had
a previous infection that was never documented.
Testing frequency differed between the cohorts,
mainly owing to different testing guidelines for
travel for vaccinated persons as compared with
unvaccinated persons, but sensitivity analyses that
were conducted with adjustment for these differ-
ences showed overall findings that were similar to
those of the primary analyses (Table S4). Home-
based rapid antigen testing is not documented
and thus was not factored in our analyses. How-
ever, it is unlikely that home-based testing would
have had a differential effect on the followed co-
horts. Matching was done to control for confound-
ers that are known to affect infection exposure in
Qatar,3,14-17 and this procedure may have also
controlled for or reduced any differences in home-
based testing between the cohorts, given that
matching was performed on the basis of key so-
ciodemographic factors of the population of Qatar.
Because the studies were observational, the
participants in the investigated cohorts were not
unaware of their status, nor was there random-
ization; therefore, unmeasured or uncontrolled
confounding cannot be ruled out. In the studies
involving adolescents, the size of the matched
cohorts was substantially smaller than the size
of the eligible cohorts, largely because of the rapid
scale-up of vaccination, a situation that perhaps
reduced the representativeness of the cohorts rela-
tive to the total population.
Although the cohorts were matched accord-
ing to sex, age, nationality, and number of coex-
isting conditions, such matching was not possible
for other factors (e.g., geographic region) because
such data were unavailable. Matching was done to
control for measured confounders that are known
to affect infection exposure in Qatar.3,14-17 Differ-
ences due to unmeasured confounders are pos-
sible. However, we had estimated that a relaxing
of the matching criteria in additional analyses
would have increased the size of the adolescent
cohorts by approximately 15% but would have
led to similar effectiveness estimates. This out-
come suggests that there was insensitivity of the
matching method to the observed confounders.
Moreover, the matching prescription had al-
ready been investigated in previous studies with
different epidemiologic designs and designs that
included control groups to test for null effects.9,18-21
These control groups included unvaccinated co-
horts that were compared with vaccinated cohorts
within 2 weeks after receipt of the first dose,9,18-20
when vaccine protection is negligible,1 and cohorts
that received the mRNA-1273 vaccine (Moderna)
that were compared with those that received the
BNT162b2 vaccine, also in the first 2 weeks after
receipt of the first dose.21 These studies have
shown repeatedly and at different times during the
pandemic that this matching prescription provides
adequate control of the differences in infection
exposure,9,18-21 a finding that suggests that the
matching method may also control for differenc-
es in infection exposure in the present studies.
In this observational study, we found that the
10-μg dose of the BNT162b2 vaccine in children
was associated with modest and rapidly waning
protection against omicron infection. However,
the 30-μg dose in adolescents was associated with
stronger and more durable protection, a finding
that suggests a role for the antigen dose in de-
termining protection. Protection with the 30-μg
dose was strong against pre-omicron infection
and waned relatively slowly. Age appeared to in-
fluence vaccine protection. Our findings suggest
the need to reconsider the value and strategies of
vaccinating healthy children in the omicron era
with the use of currently available vaccines.
The contents of this article are solely the responsibility of
the authors.
Supported by the Biomedical Research Program and the
Biostatistics, Epidemiology, and Biomathematics Research Core
at Weill Cornell Medicine–Qatar and by the Ministry of Public
Health in Qatar, Hamad Medical Corporation, and Sidra Medi-
cine. The Qatar Genome Program and Qatar University Biomedi-
cal Research Center provided the reagents for the viral genome
sequencing.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank the staffs at the Hamad Medical Corporation, the
Ministry of Public Health in Qatar, Primary Health Care Corpo-
ration, Qatar Biobank, Sidra Medicine, and Weill Cornell Medi-
cine–Qatar for the diligent efforts and contributions that made
this study possible.

Appendix
The authors’ full names and academic degrees are as follows: Hiam Chemaitelly, Ph.D., Sawsan AlMukdad, M.Sc., Houssein H. Ayoub,
Ph.D., Heba N. Altarawneh, M.D., Peter Coyle, M.D., Patrick Tang, M.D., Ph.D., Hadi M. Yassine, Ph.D., Hebah A. Al‑Khatib, Ph.D.,
Maria K. Smatti, M.Sc., Mohammad R. Hasan, Ph.D., Zaina Al‑Kanaani, Ph.D., Einas Al‑Kuwari, M.D., Andrew Jeremijenko, M.D.,
Anvar H. Kaleeckal, M.Sc., Ali N. Latif, M.D., Riyazuddin M. Shaik, M.Sc., Hanan F. Abdul‑Rahim, Ph.D., Gheyath K. Nasrallah,
Ph.D., Mohamed G. Al‑Kuwari, M.D., Hamad E. Al‑Romaihi, M.D., Adeel A. Butt, M.B., B.S., Mohamed H. Al‑Thani, M.D., Abdullatif
Al‑Khal, M.D., Roberto Bertollini, M.D., M.P.H., and Laith J. Abu‑Raddad, Ph.D.

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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
 Covid-19 Vaccine in Children and Adolescents in Qatar

The authors’ affiliations are as follows: the Infectious Disease Epidemiology Group (H.C., S.A., H.N.A., L.J.A.-R.) and the World
Health Organization Collaborating Center for Disease Epidemiology Analytics on HIV/AIDS, Sexually Transmitted Infections, and Viral
Hepatitis (H.C., S.A., H.N.A., L.J.A.-R.), Weill Cornell Medicine–Qatar, Cornell University, Qatar Foundation–Education City, the Mathe-
matics Program, Department of Mathematics, Statistics, and Physics, College of Arts and Sciences, Qatar University (H.H.A.), and the
Biomedical Research Center (P.C., H.M.Y., H.A.A.-K., M.K.S., G.K.N.) and the Departments of Biomedical Science (H.M.Y., H.A.A.-K.,
M.K.S., G.K.N.) and Public Health (H.F.A.-R., L.J.A.-R.), College of Health Sciences, QU Health, Qatar University, Hamad Medical Corpo-
ration (P.C., Z.A.-K., E.A.-K., A.J., A.H.K., A.N.L., R.M.S., A.A.B., A.A.-K.), the Department of Pathology, Sidra Medicine (P.T., M.R.H.),
Primary Health Care Corporation (M.G.A.-K.), and the Ministry of Public Health (H.E.A.-R., M.H.A.-T., R.B.) — all in Doha, Qatar; the
Departments of Population Health Sciences (H.C., H.N.A., A.A.B., L.J.A.-R.) and Medicine (A.A.B.), Weill Cornell Medicine, Cornell Uni-
versity, New York; and the Wellcome–Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, United Kingdom (P.C.).

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