; C4591007 Clinical Trial Group. Thank you for taking the time to confirm your preferences. This may include adverts from us and 3rd parties based on our understanding. Department of Health and Human Services. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations, including a booster dose for those aged 1217 years. part 56. You will be subject to the destination website's privacy policy when you follow the link. During that period, the FDA asserts it conducted an intense, robust, and thorough analysis of those documents to assure the public that the Pfizer vaccine was safe and effective. Adverse events are health problems that occur after vaccination but aren't necessarily caused by the vaccine. Olson SM, Newhams MM, Halasa NB, et al. Corresponding author: Anne M. Hause, eocevent416@cdc.gov. VISION Network VE methods have been previously published (7). Most reports of administration errors mentioned that no adverse event was associated with receipt of an incorrect dose. 2022 Nov 25;10(12):2012. doi: 10.3390/vaccines10122012. To date, there have been 17-million people vaccinated in South Africa. sharing sensitive information, make sure youre on a federal This report provides real-world evidence of protection by the Pfizer-BioNTech vaccine against COVID-19associated ED and UC encounters and hospitalizations among children and adolescents aged 517 years and supports the role of third (booster) doses in maintaining high levels of VE in the setting of Omicron predominance. PRAC hi ghlights of March 2022. Views equals page views plus PDF downloads. 2023 Kagiso Media Ltd. All rights reserved. Vaccinations prevented severe clinical complications of COVID-19. part 46, 21 C.F.R. Limited real-world data on 2-dose mRNA vaccine effectiveness (VE) in persons aged 1217 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-19associated hospitalization (46); however, data on VE against the SARS-CoV-2 B.1.1.529 (Omicron) variant and duration of protection are limited. NEW YORK and MAINZ, GERMANY, March 1, 2023 Pfizer Inc. (NYSE: PFE) and BioNTech SE (Nasdaq: BNTX) today submitted an application to the U.S. Food and Drug Administration (FDA) for Emergency Use Authorization (EUA) of a booster (fourth) dose of the companies' Omicron BA.4/BA.5-adapted bivalent COVID-19 vaccine in children 6 months through 4 years of age (also referred to as under 5 years). Atlanta, GA: US Department of Health and Human Services, CDC; 2021. "It was a 1 in 9,000 risk of GBS, which is concerning," said committee chair Dr. Hana El Sahly, who voted against the shot based on its safety profile but in favor of the shot based on its efficacy. and transmitted securely. Saving Lives, Protecting People, https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic, https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr, https://www.meddra.org/how-to-use/basics/hierarchy, https://www.fda.gov/media/150386/download, https://doi.org/10.1016/j.vaccine.2015.07.035, https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-09-22/02-COVID-Gruber-508.pdf, https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html, Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, Unable to perform normal daily activities, Inappropriate schedule of product administration, Insufficient data to make a clinical impression, Exacerbation of existing genetic disorder. ** Estimated date of Delta and Omicron predominance at contributing sites: California (Delta: June 23, 2021; Omicron: December 21, 2021); Colorado (Delta: June 3, 2021; Omicron: December 19, 2021); Indiana (Delta: June 23, 2021; Omicron: December 26, 2021); Minnesota and Wisconsin (Delta: June 28, 2021; Omicron: December 25, 2021); New York (Delta: June 30, 2021; Omicron: December 18, 2021); Oregon and Washington (Delta: June 30, 2021; Omicron: December 24, 2021); Texas (Delta: July 3, 2021; Omicron: December 16, 2021); Utah (Delta: June 1, 2021; Omicron December 24, 2021). Fatigue, headache, muscle pain. During December 9, 2021February 20, 2022, approximately 2.8 million U.S. adolescents received a Pfizer-BioNTech booster dose. During this period, receipt of 3,418 Pfizer-BioNTech booster doses were reported to v-safe for adolescents. Bookshelf mmwrq@cdc.gov. N Engl J Med 2021;385:135571. The U.S. Centers for Disease Control and Prevention has more on RSV. JAMA 2022;327:63951. Side Effects of COVID-19 Pfizer-BioNTech mRNA Vaccine in Children Aged 12-18 Years in Saudi Arabia. The documents were first released in November last year reporting vaccine adverse events. Reactions were reported to v-safe with equal or slightly higher frequency after receipt of a booster dose than after dose 2, were primarily mild to moderate in severity, and were most frequently reported the day after vaccination. Hause AM, Baggs J, Marquez P, et al. All information these cookies collect is aggregated and therefore anonymous. An absolute SMD 0.20 indicates a nonnegligible difference in variable distributions between medical events for vaccinated versus unvaccinated patients; single SMD calculated by averaging pair-wise comparisons of each vaccinated category versus unvaccinated and separately for patients with SARS-CoV-2positive versus SARS-CoV-2negative test results. Those include vaccines from Moderna and Bavarian Nordic. Hospitalization in the week after booster dose vaccination was reported for one adolescent with new onset migraine; whether hospitalization was the result of COVID-19 vaccination could not be determined. Adults aged 18 years reported adverse reactions less frequently after receipt of a homologous Pfizer-BioNTech COVID-19 booster dose than after the second primary dose. Preliminary safety findings for booster doses among adolescents are generally similar to those reported after a primary series in this age group. 552a; 44 U.S.C. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. All information these cookies collect is aggregated and therefore anonymous. Centers for Disease Control and Prevention. Among adolescents aged 1215 and 1617 years, VE 14149 days after dose 2 was 83% and 76%, respectively; VE 150 days after dose 2 was 38% and 46%, respectively. For adolescents aged 1617 years, the study period began when COVID-19 vaccines became available to all those aged 16 years at each study site. eCollection 2022. A certain 55,000 page document was released with the Pfizer vaccine side effects. Additional data are needed to better understand duration of protection against COVID-19associated hospitalization in adolescents aged 1217 years, the protection from 3 doses, and the level of protection among children aged 511 years. URL addresses listed in MMWR were current as of FDA authorized the EUA for the Pfizer-BioNTech vaccine for children aged 511 years on October 29, 2021 (https://www.fda.gov/news-events/press-announcements/fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use-children-5-through-11-years-ageexternal icon), and CDC recommended the Pfizer-BioNTech vaccine for this age group on November 2, 2021 (https://www.cdc.gov/media/releases/2021/s1102-PediatricCOVID-19Vaccine.html). Resulting in various adverse effects that may emerge after vaccination. 2023 Jan 15;11(1):182. doi: 10.3390/vaccines11010182. provided as a service to MMWR readers and do not constitute or imply The phase IV clinical study analyses which people get Pfizer BioNTech Covid vaccine and have kidney stones. VE was not calculated for exposure categories with fewer than 20 encounters or with no SARS-CoV-2 testpositive cases. Saving Lives, Protecting People, https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19, https://www.cdc.gov/media/releases/2020/s1213-covid-vaccine.html, https://www.cdc.gov/media/releases/2021/s1208-16-17-booster.html, https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use, https://www.cdc.gov/media/releases/2021/s0512-advisory-committee-signing.html, https://www.fda.gov/news-events/press-announcements/fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use-children-5-through-11-years-age, https://www.cdc.gov/media/releases/2021/s1102-PediatricCOVID-19Vaccine.html, https://www.cdc.gov/media/releases/2022/s0105-Booster-Shot.html, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html, Centers for Disease Control and Prevention, U.S. Department of Health & Human Services. | Please enable it to take advantage of the complete set of features! In addition, the age SMD calculation comparing negative SARS-CoV-2 test result and positive SARS-CoV-2 test result was generated by directly calculating the SMD for negative SARS-CoV-2 test result and positive SARS-CoV-2 test result. A 35-year-old woman developed an acute hepatitis with autoimmune features one to two weeks after receiving a first dose of the Pfizer COVID-19 vaccine. Effectiveness of COVID-19 Pfizer-BioNTech BNT162b2 mRNA Vaccination in Preventing COVID-19Associated Emergency Department and Urgent Care Encounters and Hospitalizations Among Nonimmunocompromised Children and Adolescents Aged 517 Years VISION Network, 10 States, April 2021January 2022. For example, the age SMD calculation comparing unvaccinated versus different vaccinated categories was generated by averaging the pairwise SMD calculations for unvaccinated and 2 doses (14149 days earlier), unvaccinated and 2 doses (150 days earlier), and unvaccinated and 3 doses (7 days earlier). SAS software (version 9.4; SAS Institute) was used to conduct all analyses. 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. official website and that any information you provide is encrypted To characterize the safety of Pfizer-BioNTech booster doses among persons aged 1217 years (adolescents), CDC reviewed adverse events and health impact assessments during the week after receipt of a homologous Pfizer-BioNTech booster dose reported to v-safe, a voluntary smartphonebased safety surveillance system for adverse events after COVID-19 vaccination, and adverse events reported to the Vaccine Adverse Event Reporting System (VAERS), a passive vaccine safety surveillance system managed by CDC and FDA. Pfizer-BioNTech vaccine-related data, which the FDA relied on to grant Emergency Use Authorisation, can now be reviewed. In addition, the age SMD calculation comparing negative SARS-CoV-2 test result and positive SARS-CoV-2 test result was generated by directly calculating the SMD for negative SARS-CoV-2 test result and positive SARS-CoV-2 test result. On January 3, 2022, authorization was expanded to include persons aged 1215 years, and for all persons aged 12 years, the interval between dose 2 and booster dose was shortened to 5 months (1). No potential conflicts of interest were disclosed. Reports of myocarditis and pericarditis, rare adverse events that have been associated with mRNA-based COVID-19 vaccines (3), after receipt of a booster vaccine were identified by a search for selected MedDRA preferred terms; CDC staff members attempted to collect information about clinical course and determined whether the CDC myocarditis case definition was met., This report assessed local and systemic reactions and health impacts reported during the week after vaccination among adolescent v-safe registrants who received a homologous Pfizer-BioNTech booster dose 5 months after completion of their primary series during December 9, 2021February 20, 2022. 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. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Pfizer-BioNTech VE data are not available for children aged 511 years. *** 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. endorsement of these organizations or their programs by CDC or the U.S. Estimated date of Delta and Omicron predominance at contributing sites: California (Delta: June 23, 2021; Omicron: December 21, 2021); Colorado (Delta: June 3, 2021; Omicron: December 19, 2021); Indiana (Delta: June 23, 2021; Omicron: December 26, 2021); Minnesota and Wisconsin (Delta: June 28, 2021; Omicron: December 25, 2021); New York (Delta: June 30, 2021; Omicron: December 18, 2021); Oregon and Washington (Delta: June 30, 2021; Omicron: December 24, 2021); Texas (Delta: July 3, 2021; Omicron: December 16, 2021); Utah (Delta: June 1, 2021; Omicron December 24, 2021). El-Shitany NA, Bagher AM, Binmahfouz LS, Eid BG, Almukadi H, Badr-Eldin SM, El-Hamamsy M, Mohammedsaleh ZM, Saleh FM, Almuhayawi MS, Alghamdi SA, Arab RA, Ali SS, Harakeh S, Alghamdi BS. In a multistate analysis of 39,217 ED and UC encounters with COVID-19like illness among nonimmunocompromised patients aged 517 years through January 29, 2022, estimates of Pfizer-BioNTech VE against COVID-19associated ED and UC encounters varied by time since vaccination and by predominant circulating SARS-CoV-2 variant. 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-19like illness diagnoses including cause-unspecified gastroenteritis, thrombosis, and acute myocarditis; 3) respiratory signs and symptoms consistent with COVID-19like illness, including hemoptysis, cough, dyspnea, painful respiration, or hypoxemia; 4) signs and symptoms of acute febrile illness. ** VE during the period of Delta predominance was not calculated for children aged 511 years because of the short eligibility interval in this age group during that time. We hope that our results will reassure the public that the benefits of vaccination far exceed the dangers. On 1 March 2022 Pfizers documents were made publicly available due to a judicial ruling. During December 9, 2021February 20, 2022, v-safe recorded a total of 3,418 Pfizer-BioNTech booster doses administered to adolescents, including 1,952 administered to persons aged 1215 years and 1,466 to those aged 1617 years. This model adjusted for demographic variables and accounted for repeated measures among doses reported by each registrant (needed medical care was not adjusted due to small numbers); p <0.05 was considered statistically significant. 2020;382:727733. Average of the most frequent side effects of 14 studies were injection site pain 77.34%, fatigue 43%, muscle pain 39.67%, local swelling 33.57%, headache 33.27%, joint pain 25.75%, chills 18.34%, fever 18%, itching 9.38%, lymph nodes swelling 7.86%, nausea 7.58%, dyspnea 7.86%,and diarrhea 6.36%. Safety, immunogenicity, and efficacy of the BNT162b2 Covid-19 vaccine in adolescents. For adolescents aged 1617 years, the study period began when COVID-19 vaccines became available to all those aged 16 years at each study site. Frenck RW Jr, Klein NP, Kitchin N, et al. Cookies used to make website functionality more relevant to you. -. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations, including a booster dose for those aged 1217 years. For adolescents aged 1617 years, the study period began when COVID-19 vaccines were recommended and became available to persons aged 16 years at each study site (AprilMay 2021). The vaccine, known as RENOIR, was developed by pharmaceutical giant Pfizer Inc. Local injection site reactions were more commonly reported after booster dose (82.0%) than dose 2 (77.8%) (p<0.001), and systemic reactions were similarly reported after booster dose (77.8%) and dose 2 (77.2%) (p = 0.48) (Figure). This study was reviewed and approved by the institutional review boards at participating sites or under a reliance agreement with the Westat, Inc. institutional review board.. Frenck RW Jr, Klein NP, Kitchin N, et al. allergic reaction; biontech covid-19 vaccine; bnt162b2 vaccine. The Pfizer-BioNTech vaccine is the first mRNA-based vaccination that enhances immunity. Serious reports to VAERS were reviewed by CDC physicians to form a clinical impression. Pre-Delta refers to the period before Delta predominance. For children aged 511 and persons aged 1215 years, the study period began 5 weeks after the Pfizer-BioNTech vaccine was authorized for each age group (November 2, 2021, and May 12, 2021, respectively). COVID-19 Vaccine Safety in Children Aged 5-11 Years - United States, November 3-December 19, 2021. Vaccines (Basel). Among 39,217 eligible encounters at 306 ED and UC facilities, 23.4%, 46.2%, and 30.3% were among persons aged 511, 1215, and 1617 years, respectively (Table 1). Views equals page views plus PDF downloads. Anaphylactic shock or severe reactions are rare. CDC is not responsible for the content This. The Food and Drug Administration (FDA) amended the Emergency Use Authorization (EUA) for Pfizer-BioNTech vaccine on December 9, 2021, to authorize a homologous* booster dose for persons aged 1617 years 6 months after receipt of dose 2 (1). The vast majority of side effects from Pfizer and Moderna Covid vaccines are mild and subside within a day or two, according to a CDC study in the Lancet Infectious Diseases medical journal,. No deaths were reported to VAERS. Estimated date of Delta and Omicron predominance at contributing sites: California (Delta: June 23, 2021; Omicron: December 21, 2021); Colorado (Delta: June 3, 2021; Omicron: December 19, 2021); Indiana (Delta: June 23, 2021; Omicron: December 26, 2021); Minnesota and Wisconsin (Delta: June 28, 2021; Omicron: December 25, 2021); New York (Delta: June 30, 2021; Omicron: December 18, 2021); Oregon and Washington (Delta: June 30, 2021; Omicron: December 24, 2021); Texas (Delta: July 3, 2021; Omicron: December 16, 2021); Utah (Delta: June 1, 2021; Omicron December 24, 2021). 2023 Jan 5;23(1):5. doi: 10.1186/s12879-022-07974-3. Most hospitalizations of adolescents aged 1215 years (613 [82.7%]) and 1617 years (476 [70.7%]) occurred during Delta predominance, whereas two thirds of hospitalizations among children aged 511 years (190 [66.7%]) occurred during Omicron predominance. One code in any of the four categories was sufficient for inclusion. 3501 et seq. Pfizer has also taken a multiple actionsto help alleviate the large increase of adverse eventreports. Percentage of registrants who reported a reaction or health impact at least once during days 07 after vaccination. and Terms of Use. CDC twenty four seven. Guan WJ, Ni ZY, Hu Y, et al. This release contains forward-looking information about Pfizer's Clostridioides difficile (C. difficile) vaccine candidate that involves substantial risks and uncertainties that could cause actual results to differ materially from those expressed or implied by such statements. ; C4591001 Clinical Trial Group. Social Support Mediates the Relationship between COVID-19-Related Burnout and Booster Vaccination Willingness among Fully Vaccinated Nurses. N Engl J Med 2021;385:23950. The Adverse Reactions of Pfizer BioNTech COVID-19 Vaccine Booster Dose are Mild and Similar to the Second Dose Responses: A Retrospective Cross-Sectional Study. 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. First, v-safe is a voluntary program; therefore, data might not be representative of the vaccinated population. Fatigue has been reported by roughly 63 . Galanis P, Katsiroumpa A, Sourtzi P, Siskou O, Konstantakopoulou O, Katsoulas T, Kaitelidou D. Vaccines (Basel). N Engl J Med. During Omicron predominance, VE of a second dose received 14149 days earlier was 45% and 34% for adolescents aged 1215 and 1617 years, respectively, suggesting that the lower VE observed among children aged 511 years was likely driven by the predominant variant rather than differences in VE across age groups. However, in adolescents aged 1617 years, VE during the Omicron predominant period increased to 81% 7 days after a third booster dose. Abukhalil AD, Shatat SS, Abushehadeh RR, Al-Shami N, Naseef HA, Rabba A. BMC Infect Dis. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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. Partners contributing data on medical events were in California (vaccine availability: April 30, 2021), Colorado (May 22, 2021), Indiana (April 27, 2021), Minnesota and Wisconsin (April 21, 2021), New York (April 27, 2021), Oregon and Washington (April 28, 2021), Texas (March 29, 2021), Utah (April 9, 2021). Unauthorized use of these marks is strictly prohibited. The FDA licensed the Pfizer vaccine on Aug. 23, 2021, just 108 days after Pfizer started producing the records to the agency. Kanizsai A, Zavori L, Molnar T, Tks-Fzesi M, Szalai Z, Berecz J, Varnai R, Peterfi Z, Schwarcz A, Csecsei P. Vaccines (Basel). FDA amended the EUA for the Pfizer-BioNTech vaccine to include adolescents aged 1215 years on May 10, 2021 (https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-useexternal icon), and CDC recommended the Pfizer-BioNTech vaccine in this age group on May 12, 2021 (https://www.cdc.gov/media/releases/2021/s0512-advisory-committee-signing.html). The list notes 1,291 different adverse events following the Pfizer Covid vaccine. government site. Lutrick K, Rivers P, Yoo YM, et al. VE against COVID-19associated ED and UC encounters was substantially lower during the Omicron predominant period than the B.1.617.2 (Delta) predominant period among adolescents aged 1217 years, with no significant protection 150 days after dose 2 during Omicron predominance. ; C4591001 Clinical Trial Group. Daily science news on research developments and the latest scientific innovations, The latest engineering, electronics and technology advances, The most comprehensive sci-tech news coverage on the web. https://vaers.hhs.gov/faq.htmlexternal icon. -, Characterization of spike glycoprotein of SARS-CoV-2 on virus entry and its immune cross-reactivity with SARS-CoV. Interim estimate of vaccine effectiveness of BNT162b2 (Pfizer-BioNTech) vaccine in preventing SARS-CoV-2 infection among adolescents aged 1217 yearsArizona, JulyDecember 2021. VAERS received 914 reports of adverse events after Pfizer-BioNTech booster dose vaccination of adolescents; 837 (91.6%) were nonserious and 77 (8.4%) were serious. AFP To date, there have been 17-million people vaccinated in South Africa. As of February 20, 2022, only BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine has been authorized for use in persons aged 1217 years in the United States (1). 2020;92:14841490. This systematic review was undertaken to assess the Pfizer-BioNTech vaccine side effects by reviewing the previous studies. What are the implications for public health practice? On 1 March 2022 Pfizer . Reports to v-safe after receipt of a booster dose in an adolescent were generally similar to those previously described for persons aged 18 years who received a homologous booster dose of Pfizer-BioNTech vaccine (6,7); however, reactions among adolescents were reported to v-safe with equal or slightly higher frequency after receipt of a booster dose than after dose 2. March 8, 2022 - Side effects from the Pfizer and Moderna vaccines in the United States have largely been mild and short-lived, a large new study of the first 6 months of vaccinations shows . JAMA 2022;327:33140. Two doses of Pfizer-BioNTech vaccine provided protection against COVID-19 in persons aged 1217 years during Delta predominance, but data during Omicron predominance and among children aged 511 years are lacking. COVID-19-Related Burnout and Intention of Fully Vaccinated Individuals to Get a Booster Dose: The Mediating Role of Resilience. Indicates the reference group used for SMD calculations for dichotomous variables. Nicola P. Klein reports institutional support from Pfizer, Merck, GlaxoSmithKline (GSK), Sanofi Pasteur, and Protein Scient (now Sanofi Pasteur) for unrelated studies, and institutional support from Pfizer for COVID-19 vaccine clinical trials. Producing the records to the second dose Responses: a Retrospective Cross-Sectional Study form a impression... 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And Human Services, CDC ; 2021 t necessarily caused by the.! The U.S. Centers for Disease Control and Prevention has more on RSV the accuracy a! ( 1 ):182. doi: 10.1186/s12879-022-07974-3 safety in Children aged 5-11 -! Fully vaccinated Individuals to Get a booster dose are Mild and similar to those reported after a series... Reactions less frequently after receipt of an incorrect dose vaccinations, including booster! It to take advantage of the BNT162b2 COVID-19 vaccine ; BNT162b2 vaccine problems! Complete set of features Pfizer COVID-19 vaccine safety in Children aged 511 years COVID-19-Related Burnout and booster Willingness. Enable it to take advantage of the four categories was sufficient for inclusion understanding!
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