Ideas
November 3, 2021 12:37 PM EDT
Dr. Jeff Vergales, MD, MS is an Associate Professor of Pediatrics at the University of Virginia
Gandhi MD, MPH is Professor of Medicine; Associate Division Chief of the Division of HIV, Infectious Diseases, and Global Medicine; Director of the Ward 86 HIV Clinic at San Francisco General Hospital; and Director of the Center for AIDS Research at UCSF

With emergency use authorization for the Pfizer-BioNTech COVID vaccine newly approved for children 5-11, many parents are asking the question—should we vaccinate our kids? To be fair, many parents may have already made up their mind on this topic with the majority not rushing to get their kids vaccinated.

Much of the argument against vaccinating this younger age group is that COVID-19 just doesn’t seem to cause a high likelihood of significant illness among immunocompetent children. Thankfully, purely as a percentage of total cases, this does hold true. To date, over six million children in the U.S. have contracted this coronavirus which has led to 64,000 hospitalizations and 650 deaths. These numbers pale in comparison to the over 3,000,000 hospitalizations seen during the pandemic in adults that has led to a staggering 718,000 deaths.

The low rates of complications and severe illness from COVID-19 in children is the exact data needed to justify a swift return to normalcy for many kids. It underscores the fact that schools should be open, recreational activities can continue as scheduled, children should be allowed to socialize with each other in a normal fashion, mask-mandates need an end date, and we should minimize learning loss from exposures. Yet, the argument that kids are, for the most part, unaffected medically by COVID-19 ignores a simple, yet essential, premise.

Children are not supposed to die.

The denominator of how many kids have contracted COVID is so vast that it makes it easy to ignore the very small numerator. While the low likelihood of severe illness in children should continue to drive our public policy, the fact that there are children that succumb to this illness, needs to drive our vaccination guidelines. In pediatrics, children recovering from disease is the expectation—the norm—yet we must always remember that it does not always happen.

To put this in perspective, COVID would currently rank 6th in the list of reasons that children die every year in the United States. Trauma (including motor vehicle accidents, drownings, firearm incidents, suffocation and other injuries) dominate the majority of childhood death and drives advancement of seatbelt laws, car seat laws, firearm laws, and swimming pool laws to reduce this number. Cancer, mental health disorders, and heart disease come next which are massive focuses of research spending and medical advances aimed towards improving survival from these conditions. While all of these events are rare, just like deaths of children from COVID, they absolutely do occur and are devastating for the families that go through them.

Yet, none of these conditions have a preventative strategy as profoundly effective as immunity to COVID-19. We vaccinate children to prevent severe illness and death, not to prevent mild disease. It is the same reason that pediatricians emphasize influenza vaccination—not to prevent all kids from getting the flu—but to protect children who should not be hospitalized and die. This remains true for the other 16 pediatric immunizations the CDC recommends and nearly every state requires. The goal is to prevent severe disease in children, keeping children alive and healthy.

If a medication existed today that would prevent children from ever developing and dying of cancer, we would never be discussing whether we should use it—parents would be lined up. If we had a shot that ensured your child would never suffer from mental illness or commit suicide, families would be all in. If a treatment existed to ensure a child would never die from a congenital anomaly or heart disease, it would be criminal to not incorporate it as the standard of care.

Most American parents have never been in a serious car accident, yet they don’t think twice about insisting their children ride in car seats and use seat belts. Why is this? The rate of fatal car crashes as a factor of how often we drive is thankfully low—and similar to fatal rates from COVID. Yet, if a car crash were to occur, the seatbelt may be the only true protection from harm. Simply put, kids buckle up to ensure if on the rare chance a serious car accident occurs, it will have a low likelihood of leading to death.

The COVID vaccination program in children keeps this same premise. Just like in riding in a car, the chance of a fatal or near-fatal event is very low, yet with COVID we use vaccination as our protective tool to prevent severe outcomes. Parents choosing to double down on masking and social distancing maneuvers for the foreseeable future may reduce exposure for a time, but these tools are not sustainable and have no effect on altering the course of the disease in a child.

The vaccine must also be safe to be effective. COVID-19 vaccines have now been given out to more than 6.6 billion people worldwide, with the safety data clear. Furthermore, the vaccine prevented 90.7% of COVID-19 infections in children. The episodes of myocarditis seen more commonly with the mRNA vaccine after the second dose in males are rare, mild and easily treated. We tend to forget that this is the same demographic that has developed myocarditis associated with the actual viral infection, oftentimes developing profound illness requiring intensive care. Yet, minimizing the risk of this rare adverse effect is the exact reason for the lower 10 microgram dose deliberately decided upon by Pfizer in June of 2021.

In pediatrics, we are used to prescribing medications “off label”, meaning not for their initial intended purpose or age range. We do this because we frequently lack clinical trial data in children and have to base medical decision making on assumptions, logic and very small studies. With the conclusion of the current trial, pediatricians will be prescribing this vaccine with more data, knowledge and science behind it than virtually any other medicine we routinely administer. We will base this on billions of real-world examples in adults and thousands of children in a clinical trial. While that might not be enough for many parents, that is vastly more data than other medications we usually give children.

So where did we lose our way? Parents that have fully vaccinated their children up to this point remain hesitant to give this vaccine despite the rationale, safety profile and approval process being identical. We need to return to our usual approach to childhood vaccination by recognizing that a “one size fits all” strategy is impractical and ineffective. Conversations and medical decision-making surrounding childhood vaccine needs to leave the public space and return to the doctor’s office. We should not be discussing the necessity of vaccinating children against COVID; instead we should be determining the best way to do it.

Doing this will allow us to meet the needs of the individual patient in the exact same way we do for all other childhood vaccines. We should be reviewing data that longer intervals (6-8 weeks) between doses increases immune responses, effectiveness and safety and may be a better approach for many children. Providers can discuss with parents how to manage children with natural immunity (none of the cases of COVID in the child trial occurred among those with prior infection) and whether a single dose of the vaccine following natural infection is the best approach in that situation. This is the framework for other immunizations and needs to be for this one as well.

We need ongoing safety monitoring which is exactly what pediatric providers do every day with other vaccines and continues to be the framework for this one. Spending time debating if instead of how children should get the vaccine ignores every parent’s goal: keeping their children alive and healthy.

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