Why Florida’s New COVID-19 Vaccination Guidance Could Hurt Kids

Florida Surgeon General Dr. Joseph Ladapo sparked controversy this week by recommending against COVID-19 vaccination for healthy children—contrary to the advice of health organizations and plenty of data that suggest the shots are safe and effective.

Florida “is going to be the first state to officially recommend against the COVID-19 vaccines for healthy children,” Ladapo said at a roundtable on March 7.

Official guidance released the next day softened that stance somewhat, saying that “healthy children aged 5 to 17 may not benefit from receiving the currently available COVID-19 vaccine” due to their low risk of severe disease and the possibility of rare side effects. Parents of kids with underlying medical conditions should consult their pediatricians, the guidance says.

While the guidance does not prevent parents in Florida from vaccinating their children if they wish, some doctors fear it could have a chilling effect on a pediatric vaccine campaign that has already moved more slowly than experts had hoped.

“The Florida Surgeon General’s decision to recommend against COVID-19 vaccination for healthy children flies in the face of the best medical guidance and only serves to further sow distrust in vaccines that have proven to be the safest, most effective defense against severe COVID-19 disease, hospitalization, and death,” said Dr. Daniel McQuillen, president of the Infectious Diseases Society of America, in a statement.

Dr. Mobeen Rathore, past president of the Florida Chapter of the American Academy of Pediatrics and associate chair of the University of Florida Health Jacksonville’s department of pediatrics, calls Ladapo’s remarks dangerous. “Any time people in power…make a statement, some people will believe that,” he says. “This could result in some children dying.”

He recommends that pediatricians in Florida and elsewhere encourage vaccination among all patients who are eligible. “All children should be vaccinated,” he says. “This is the only way we’re going to get out of this morass of the pandemic.”

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Following the U.S. Food and Drug Administration (FDA)’s authorization of Pfizer-BioNTech’s COVID-19 vaccine for 5- to 11-year-old children last fall, the CDC recommended COVID-19 vaccination for everyone in the U.S. ages 5 and older, as did the American Academy of Pediatrics. However, just 26% of children ages 5 to 11 are now fully vaccinated. The vaccination rate for 12- to 17-year-old children is higher, at 58%, but that’s still well below the adult rate of 75%.

Reports from the Kaiser Family Foundation (KFF), which has tracked attitudes toward vaccination throughout the pandemic, suggest that many parents fear side effects and unknown, hypothetical harms of COVID-19 vaccines, despite numerous studies that have found both the two-dose series and the boosters to be safe and effective. “The younger the age group, the more cautious [parents] are in terms of proceeding with vaccination,” says Liz Hamel, KFF’s vice president and director for public opinion and survey research.

In February, KFF asked U.S. parents if they felt they had enough information about the safety and effectiveness of COVID-19 vaccines. Of parents with kids ages 12 to 17, 66% said they did, compared to 61% of parents with kids ages 5 to 11 and 43% of parents with kids younger than 5.

The hesitation is understandable among parents of very young children, given that vaccines have not yet been authorized for kids under 5 and the FDA recently delayed its review of Pfizer’s shot while waiting for more data. (Early indications suggest it is safe for young children, but there are outstanding questions about its efficacy.) Among older age groups, though, COVID-19 shots have proven safe “not only in research, but also in the real world,” Rathore says.

Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia and a member of the FDA’s vaccine advisory committee, says that much of the reluctance among parents stems from the belief that children—especially those without preexisting medical conditions—do not need to be inoculated because they are very unlikely to get severely ill or die from COVID-19.

That rationale came up during the roundtable at which Ladapo recommended against COVID-19 vaccination for healthy kids. Ladapo also mentioned a recent preprint study from New York, which found that, during the Omicron wave, vaccine protection waned more quickly among 5- to 11-year-old children than it did among older kids—perhaps because of the smaller dose given to the younger age group.

However, a CDC report based on data from 10 states (and published shortly after the New York study) concluded that differences between age groups could be explained by timing. Omicron, which is extra-contagious and better at outsmarting vaccines than previous variants, emerged shortly after vaccines became available for 5- to 11-year-old kids. While both papers found that vaccines get worse at blocking infections over time, particularly against the highly transmissible Omicron variant, the CDC report estimated that they were between 73% and 94% effective at preventing COVID-19 hospitalization.

That benefit alone makes vaccination worthwhile, Offit says. It’s true that kids develop severe disease much less often than adults, but exceptions happen. More than 100,000 kids have been hospitalized with COVID-19 since the pandemic began, according to CDC data, while others have developed complications including Long COVID and the inflammatory disorder MIS-C.

“When I was working in the hospital in the middle of December, we admitted 18 children that week,” Offit says. “Five of them went to the intensive care unit. If you can avoid that safely [through vaccination], then avoid it.”

Offit, however, doubts that Florida’s guidance will have a major effect on pediatric vaccination rates in the state or more broadly. It’s “a political statement” more than a public-health policy, he says, and most people have by now made up their minds about whether they plan to vaccinate their children. “I don’t know what people are waiting for, at this point,” he says.

But data show that at least some parents are still undecided. As of February, 10% of parents with 5- to 11-year-old kids said they were going to “wait and see” about vaccination, according to a recent KFF report. That suggests there is still some wiggle room—and anything that further confuses or concerns parents could sway them against vaccination, Rathore says.

One-on-one conversations with loved ones and trusted sources—which, for parents, often means their child’s pediatrician—can make the biggest difference in vaccine intentions, Hamel says. “One big question is, how do pediatricians interpret [Florida’s] advice and filter that to their patients?” she says.

On Twitter, several Florida pediatricians voiced support for vaccination. “As a Florida pediatrician I could not recommend the covid vaccine for eligible children more,” tweeted Dr. Chelsea Torres. “I am beyond myself as a pediatrician in Florida,” tweeted Dr. Lindsay Thompson. “This will have ripple effects on all vaccines and children will end up suffering and dying.”

Rathore says he hopes his colleagues ignore the guidance. “Anyone who cares for children, advocates for them, and stands for them,” he says, “would want them to get vaccinated and get protected.”