The Kids Are Alright - Then, Now and Always

Recently, I have received the same question from friends or store cashiers, when checking out - should they vaccinate their kids or grandkids? I tell them each the same, “Go ahead if you want. The vaccine appears to be very safe in this age group. If you feel more comfortable with having your kids vaccinated, please go ahead, But, if they don’t have any underlying health problems, I don’t know that it will help them a lot individually. But if it gives them more freedom or gives you reassurance, that’s something.”

Below is a version of a post I sent into a forum for Infectious Diseases physicians (this version was modified for non-ID docs). The forum doesn't use a website approach, but rather uses email to distribute questions and replies. The questions and answers go through a moderator, whom I have gotten to know. The earliest version of this post was simply held up and without anyone explaining to me why. I eventually received a phone call from an older ID doc, charged with discussing the issue with me. The phone call, while civil, was strange, because I never learned what was controversial about this post or why it was held up. A few days later, a slightly edited version of my submission was "posted", meaning it was emailed to everyone on this listserv. Maybe more on that later, maybe not, because who really cares about censorship these days? When someone tells you that they are for Free Speech, well, that's pretty scary thing to be told.

As a result, I actually planned not to post this, because there is no upside for me personally. I really don't need a fight with the CDC right now.

But more and more are asking me this same question in person, through texts and through emails. So, what the heck? (Notice how I didn't swear)

Obviously, we vaccinate for two broad reasons:

1. To help the individual;

2. To help the community.

Smallpox and polio vaccines were used initially for both reasons, but later on, for communal protection.

Pneumococcal vaccination of children was given to benefit the child. The pneumococcal conjugate vaccine of kids was so good it reduced the incidence of pneumonia in their grandparents, an unexpected communal benefit. Pneumococcal vaccination for adults is given only for the individual’s benefit.

Regarding issue #1, will the Covid vaccine benefit children ages 6-11 yo?

That’s going to be tough to ever demonstrate. The mortality rate for Covid in this age group is very low by case and by total population. The rate of MIS-C (Multisystem Inflammatory Syndrome in Children), a weird reaction to Covid, is also very low. (See below)

The rates of Covid in all age groups have dropped throughout the USA. Accordingly, the rates of Covid in 5-11 yo kids have dropped considerably. It is going to be very difficult to show that vaccination of this group results in fewer deaths or fewer cases of MIS-C.

No matter how safe the vaccine is in this population, it is going to be tough to show a significant benefit for individual children without risk of severe disease, which again are primarily obesity and DM. Vaccinating children, 5-11, who have a risk factor for severe Covid makes sense, but for those kids, 5-11, who are healthy, well, the benefit is not clear.

Regarding issue #2, will vaccinating 5-11 yo’s decrease communal spread and help eliminate the virus from the human or US population?

Certainly, vaccinating 5-11 yo’s could have an impact on spread of Covid, but if the adults around them are fully and adequately vaccinated, presumably the impact would be minimal. Further, young children infected with Covid are less likely to spread it than adults. The vaccines, while potent initially, do not provide long-lasting immunity. As best I can tell, the Covid vaccines have the highest 3 month:12 months protection rate ratios of any vaccine. For the best vaccines, this ratio is close to one, meaning the protection rates, at 3 months after and 1 year after receiving the vaccine, are the same. For the Covid vaccines, it is close to 3 in some studies. Of course, a sizeable percentage of US adults is refusing to get the vaccine. As a result, vaccinating children 5-11 is not going to lead to eliminating SARS-CoV-2 from the US population.

So, should kids 5-11 be vaccinated with Covid? This question isn’t the no-brainer we thought it would be back in December 2020, when the vaccine data first came out. In all likelihood, vaccinating kids this age won’t protect the kids much and won’t reduce spread much.

It will, however, lead to more disturbing advertisements with those unfortunate few kids who develop adverse effects from the vaccine.

Will vaccination of 5-11 yo’s lead to end of masks in schools? I have no idea because those decisions haven’t been based on science. Mask mandates in schools have varied not only from state to state, but within some states, from district to district. There has not been a consistent approach and, obviously, these decisions haven't been science based.

Some are considering using masks as "the stick". Kids who get vaccinated won't have to wear masks, so the carrot-stick approach goes. Those who don't get vaccinated will. This mask the unvaccinated policy is already used by hospitals with employees who refuse to get the flu vaccine.

https://www.kmbc.com/article/school-mask-mandates-are-starting-to-disappear-in-some-areas-is-it-too-soon/38197967#

I am not against 5-11 yo’s getting the vaccine. I am also not for it. I am against mandatory vaccination of this age group. It reminds me of the OPV, oral polio vaccine, in the early 1990’s. Polio had long been eliminated from the USA (polio was eliminated from the US in 1979). The risk of vaccine induced paralytic polio was small (~4 per million babies). The risk of polio infection was zero. Parents of those kids, who did develop paralysis from the vaccine, rightfully complained. I too hesitated vaccinating my oldest child, who was born in 1995 (at least I thought about hesitating). By the late 1990s, a better version of the IPV, inactivated polio vaccine, came out and this point became moot. Now, the OPV is not even available in the USA.

But is a very small risk of a vaccine worth it, when the benefit is small or none? 100% of vaccinated kids will face the risk of the vaccine. However, only a small percentage of unvaccinated kids will become infected and only they will face the small risks of Covid. To date, less than 10% of kids, 5-11, have tested positive for Covid. Presumably, another 5-20% were infected and didn't know. But for healthy children who don't have a risk factor for severe disease, the rate of severe Covid is already very small.

How safe is the vaccine for 5-11 yo's?

We don't know yet. The clinical trials only vaccinated a few thousand kids. So, it takes a while to see adverse effects, which have a low, but real rate. The vaccine appears to be very safe for kids, 5-11 yo. But how safe is safe enough? That's a decision for parents...or school boards.

Data –

The CDC published data on children ages 0-18 years old, who were seen in the ER or as an inpatient for Covid.(1)

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780706

· The total number of pts or encounters = 43,465 kids.

· 6-11 yo kids made up 17.4% of this cohort (N= 7,552 children 6-11 years old).

· Of these 7,552 kids, 190 or 2.52% had severe illness.

· A total of 38 of the 43,465 children died. The study did not break down mortality rate by age group. If one assumes the mortality rate of severe Covid was consistent across age groups, then the mortality rate for children with ages 6-11 yo and who were seen in the ER or admitted with Covid = 0.074% or 74 deaths/100,000 children with ages 6-11 yo and who were seen in the ER or admitted with Covid.

The study identified pre-existing conditions associated with severe illness and mortality. The study was not clear on how many children without a pre-existing condition died but the aRR for DM and obesity and congenital circulatory anomalies = 4.6, 3.1 and 2.1 respectively.

CDC estimated 2020-2021 USA population with Puerto Rico = 335 million

According to the CDC, 5-11 yo’s make up 8.7% of US population = 29 million children.

Through 11/3/2021, total Covid cases in 5-11 yo children = 2,050,340.

Total deaths in 5-11 yo children = 173.

Mortality rate per infection = 0.084% or 8.4 per 10,000 children ages 5-11.

Mortality rate for all 5-11 yo children = 0.00059% or 5.9 per million.

It is unclear why the mortality rate (0.084%) for all Covid cases in children 5-11 yo is higher than the rate (0.074%) for those children who were seen in the ER or admitted to the hospital.

As of 10/4/2021, the CDC reports that 5,217 cases of MIS-C have been diagnosed in 50 states plus Puerto Rico.

44.4% occurred in 5-11 yo children.

The rate of MIS-C in all 5-11 yo children = 0.008% or 8 per 100,000.

Using the above total cases in 5-11 yo kids, the rate of MIS-C per Covid case ~0.11%. (the total Covid cases includes October case; the total MIS-C case number does not).

https://covid.cdc.gov/covid-data-tracker/#demographics

https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance

Death from Covid by Age Group - according to the CDC

Asymptomatic Covid in children –

Varying rates of asymptomatic SARS-CoV-2 infection in children have been reported. Few, longitudinal screening studies have been performed on children. Therefore, the data on this topic are not strong. The asymptomatic rate appears to be above 30%. From three studies, the asymptomatic pediatric Covid rate = 38.5% (2), 42.9% (3) and 54.7% (4) from Singapore, China and Greece respectively.

1. Kompaniyets L, Agathis NT, Nelson JM, Preston LE, Ko JY, Belay B, et al. Underlying Medical Conditions Associated With Severe COVID-19 Illness Among Children. JAMA Netw Open. 2021 Jun 7;4(6):e2111182.

2. Li J, Thoon KC, Chong CY, Maiwald M, Kam KQ, Nadua K, et al. Comparative Analysis of Symptomatic and Asymptomatic SARS-CoV-2 Infection in Children. Ann Acad Med Singapore. 2020 Aug;49(8):530–7.

3. Cai J, Wang X, Zhao J, Ge Y, Xu J, Tian H, et al. Comparison of Clinical and Epidemiological Characteristics of Asymptomatic and Symptomatic SARS-CoV-2 Infection in Children. Virol Sin. 2020 Dec;35(6):803–10.

4. Maltezou HC, Magaziotou I, Dedoukou X, Eleftheriou E, Raftopoulos V, Michos A, et al. Children and Adolescents With SARS-CoV-2 Infection: Epidemiology, Clinical Course and Viral Loads. Pediatr Infect Dis J. 2020 Dec;39(12):e388–92.