Don’t wait to vaccinate your grade-school kids against Covid-19.
CDC approves Pfizer-BioNTech for ages 5-11. Here’s why I wouldn't delay.
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Children ages 5-11 are finally eligible to receive the Pfizer-BioNTech Covid-19 vaccine. I choose to deploy the word finally because the march to this moment has felt like a comparative slog, with both the Pfizer-BioNTech and Moderna clinical trials having been expanded this summer before results were released and a somewhat pokey schedule over at the CDC and the FDA regulatory and safety committees. But all of that was to ensure that scientists could determine the right dose to recommend and to give them time to share data on how safe and beneficial the vaccines are. If they had not done it right, parents would have balked.
Now, for many parents, the anticipated moment has arrived. We know that the Pfizer-BioNTech vaccine is safe and we know that it works. (Moderna has not yet applied for authorization for this age group). We also know that while Covid-19 is statistically far less likely to cause serious illness or death in children, around 750 children in the United States have died so far and over 70,000 have been hospitalized. When you compare Covid-19 to other diseases that we routinely protect children against by way of vaccinations—from hepatitis A to meningococcus to Rubella to chickenpox—many if not most of those diseases killed fewer children per year prior to the vaccines becoming available than Covid-19 has.
That right there is the #1 reason to not wait to vaccinate your 5- to 11-year old children. As an emergency physician, I can tell you that the grief around the death of any child is just as awful as you can probably imagine, if not worse. But if I were to attempt to describe the feeling that parents feel around any death that is understood as preventable, I would fail. The words don’t exist.
Thankfully, deaths from Covid-19 among children ages 5-11 are mercifully rare. But death is not the only metric.
Hospitalizations are unusual, but they can no longer said to be “exceedingly rare.” In areas of major outbreaks during the Delta variant era, like Georgia this summer, pediatric hospitalization rates from Covid-19 can dwarf the usual rates associated with flu. So far, around 7,000 children ages 5-11 have been hospitalized due to Covid-19, which is around 1 in 250 children known to have been infected, and around 1 in 4,000 of all children in this age group in the United States. That’s simply not rare. Yes, hospitalization of a child with Covid-19 is still not likely on average, and I find myself reassuring parents worried about their infected children on an individual basis. But, again, we vaccinate against diseases that harmed far fewer kids in the past.
Precisely because pediatric deaths and hospitalizations are not the most likely Covid-19 outcomes, a “wait and see” approach seems to have an appeal for parents. But it’s a bad idea masquerading as prudence. We already know the vaccines are safe. So refining our understanding of just how safe they are with respect to actually “exceedingly rare” adverse events (which we will indeed learn about once hundreds of thousands or millions of children ages 5-11 have been vaccinated) adds almost no actionable information. Currently, around 33% of parents of children 5-11 plan to “wait and see” on Covid-19 vaccines. But waiting will cause many other harms, beyond deaths and hospitalizations. Let’s go through some of them and see if we can’t get that number lower, while increasing the “right away” group.
•Waiting means kids will be walking around unprotected for longer. Every day more kids get infected, especially as we let our guard down—be it due to pandemic fatigue or policy changes. Even mild infections will prove highly disruptive to kids. Haven’t they missed enough school? We also know that other complications like “multi-system inflammatory syndrome in children” (which can be very serious), and Long Covid are likely to be reduced by vaccines.
•Waiting means that infections are more likely to be brought home to younger children who are not yet eligible for vaccination. In particular, there have been a substantial number of deaths in infants.
•Waiting means that worse variants may emerge. We now understand that vaccination likely decreases the odds of new mutations emerging, both by temporarily decreasing infections and likely by decreasing the window of maximal contagiousness. The last thing we need is kids being the source of a variant that undoes the progress we’ve made across all age groups.
•Waiting might mean that a child might not become eligible for a booster next year, should that become necessary. (I remain skeptical of universal boosters for most younger adults, but if a particularly nasty variant emerges that requires a whole new round of vaccinations, we’ll want to be able to vaccinate as many people as possible; more time between doses is likely to be an important factor in terms of safety and side effects.)
•What about those 11-year-olds “on the bubble”? Should they wait to turn 12 so that they can get the adult dose which is 3-times stronger? My vote is no. By the time kids are in school, immune systems are up and running. School-aged kids don’t need a bigger dose because, unlike with medications where the distribution of a substance through the body’s bloodstream and tissues hinges on adequate amounts being present, vaccines work by attracting an immune response to the site of the injection. If anything, given that the clinical trials showed that kids 5-11 mounted similar antibody responses as teens and young adults did, it’s theoretically possible that some teens and young adults would have done just fine with the pediatric dose, and with fewer adverse effects. In fact, that’s why researchers ultimately settled on the lower dose for the 5-11 age group: the antibody response was seen as likely to be adequate, but bothersome side effects would be far less frequent. That’s exactly how it played out. Interestingly the CDC spent some time on this exact question in their public deliberations, specifically homing in on what to do with kids approaching their 12th birthdays. The short version is that if kids “age up” between the 1st and 2nd doses, it does not matter which dose they get the 2nd time. If it were my child, barring unusual circumstances, I’d probably have them get the pediatric dose twice. If anything, I’m confident based on the data that 2 doses will protect both 11- and 12-year-olds. But since we do not yet know about the rates of rare side effects like myocarditis (the trials were not large enough to detect any cases, but we expect some will occur once hundreds of thousands of kids are vaccinated), a lower dose might turn out to be just a tiny bit safer.
Speaking of myocarditis, an inflammatory condition of the heart that ranges from mild and ultimately meaningless to serious, the data are now abundantly clear. Not only do the vaccines rarely cause this condition (mostly among males), but Covid-19 itself causes it both more frequently and more severely. In fact, even if the only symptoms that Covid-19 caused in any child were myocarditis and we ignored all of the lung and other systemic effects, vaccinations would be the most effective strategy to reduce myocarditis incidence, even though, ironically, they occasionally do cause a case.
Adults have been eligible for Covid-19 vaccinations for almost a full year. We had no choice but to wait before vaccinating children if we wanted to proceed with the confidence that well-done science and an open process provides. We’ve waited long enough. The time to protect children ages 5-11 with Covid-19 vaccines is now.
Will you vaccinate your children against Covid-19? If you remain unsure, what questions do you have? Chime in below.
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