Should children ages 5 to 11 receive the COVID-19 vaccine? This is a difficult question without an easy answer, something you wouldn’t know from the strident opinions of politicians and health experts.
On one side are the Centers for Disease Control and Prevention, the American Academy of Pediatrics and Pfizer, which makes the only approved vaccine for children. They have all recommended vaccination for children ages 5 and older.
On the other side is the state of Florida. Florida’s Department of Health, at odds with most public health officials, does not recommend the shots for children. That agency said focus should be on youngsters with existing health conditions as “the best candidates for the COVID-19 vaccine” and that some healthy children “may not benefit from receiving the currently available COVID-19 vaccine.” Florida Surgeon General Joseph Ladapo said the decision should be made on an individual basis, rather than mandated. Ladapo did not specify what qualifies a child as “healthy” nor did he note the specific age group to which agency guidelines pertain.
In Washington by contrast, White House press secretary Jen Psaki, who recently contracted COVID-19 despite being vaccinated, articulated the Biden administration’s position: “We know the science. We know the data and what works and what the most effective steps are in protecting people of a range of ages from hospitalization and even death.”
This is a nuanced issue, and context matters. Children are certainly at risk from COVID-19 — at the beginning of the pandemic in 2020, children accounted for fewer than 3% of cases; today, they account for about 25%. More than 6 million U.S. children have contracted COVID-19, including 2 million ages 5 to 11. Any COVID-19 infection, no matter how trivial, creates the possibility of disruption of home and school activity.
But there are several important distinctions because children and adults show fundamentally different immune responses to COVID-19 in their airways and blood. Even with a surge caused by the omicron variant (currently declining in the U.S.), severe illness among infected children is rare: the death rate for Americans under age 18 is roughly 1 in 10,000 infections, primarily in those with comorbidities including obesity, diabetes, cancer and other chronic conditions.
For healthy children, the balance is different. The CDC has documented tens of thousands of hospitalizations in children with COVID-19. Although about one-third did not have existing health conditions, hospitalizations were less frequent in children 5 to 11 than in those under 5 or in teenagers. Each age group shows different outcomes. (If the new Moderna vaccine is approved, the vaccination question will extend to children 6 months to 5 years old.)
The data from the United Kingdom for children 5 to 11 is infrequently cited in the U.S. but is telling: Vaccination would be estimated to prevent 113 admissions to intensive care units per million vaccinated high-risk children in a future severe COVID-19 wave, but only three ICU admissions per million in low-risk children. In a less severe COVID-19 wave, the number of prevented ICU admissions for healthy children might be as low as 0.5 per million.
Extrapolating from the math, 5- to 11-year-olds are not the same as those younger or older. In addition, the distinction between healthy children and those with chronic conditions is significant.
High-risk children ages 5 to 11 should unquestionably be vaccinated for the same reason adults should be vaccinated — to minimize the serious outcomes of COVID-19 infection. In healthy 5- to 11-year-olds, the incidence of complications is extremely low, so the issue is whether the vaccine prevents children from acquiring and transmitting the virus. The most recent Pfizer data for children 5 to 11 in New York shows that the effectiveness of vaccination in preventing infection decreased during the omicron surge, to a mere 12% from a previous 68%. That finding raises new questions about whether to vaccinate healthy kids in this age group.
None of this means that 5- to 11-year-olds should not be vaccinated; merely, that scientists aren’t sure about the level of protection provided by the vaccine. Maybe the dose of Pfizer vaccine tested for children was too low. There is also uncertainty as to whether the vaccine dose for 5- to 11-year-olds should be based on age, weight or an evaluation of the maturity of the child’s immunity. Initial data indicates the vaccine is safe in children — the complication rate is extremely low. But because the complication rate of COVID-19 in healthy 5- to 11-year-olds is also low, it is difficult to compare both and draw a definitive conclusion, especially with different school mask mandates across the country confounding the question. A minority of children 5 to 11 in Europe have currently been vaccinated.
The typical risk-benefit of vaccination for COVID-19 is different for the diseases we were immunized for as children. There has been little genetic evolution and few variants for diseases like chickenpox. The vaccines for those diseases have proved safe and effective for decades. We have not reached that point with the COVID-19 vaccine for 5- to 11-year-olds. We need more data collection, more scientific debate and less inflamed political rhetoric.
For now, the decision remains with the parents. One of us has recommended that his grandchildren be vaccinated. The other is waiting for more information.
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ABOUT THE WRITER
Dr. Cory Franklin is a retired intensive care physician. Dr. Robert A. Weinstein is an infectious disease specialist at Rush University Medical Center.
