The Next Childhood Immunization Hurdle Has Arrived

Pediatricians, health officials, and schools are eagerly awaiting the rollout of the COVID-19 vaccine for younger children after the Biden administration announced plans for distributing millions of doses of Pfizer’s vaccine, if authorized, for 5- to 11-year-olds. Pfizer’s vaccine is already fully approved for people ages 16 and older, authorized for youth 12 to 15 years of age, and hopefully soon will be authorized at a lower dose for younger kids ages 5 to 11.

This begs two critical questions: are COVID-19 vaccinations necessary for young kids and should they be mandated?

The Role of COVID-19 Vaccination in Kids

The answer to the question of whether children should be vaccinated against COVID-19 is a resounding yes. There are several reasons why. First, the COVID-19 pandemic and its complete disruption of children’s lives proves dangerous for children’s health. While childhood infections tend to be mild, the more than 600 pediatric deaths in the U.S., thousands of hospitalizations, and rising awareness of pediatric long COVID prove infections are not risk-free for our kids. Physical harm is perhaps the tip of the iceberg. Last week, leading pediatric organizations declared a national emergency in children’s mental health, citing the serious toll of the COVID-19 pandemic.

The second major reason for childhood vaccination is because children can and do transmit COVID-19. This has both personal and communal ramifications. As we head into the season of holiday gatherings, we will share space with those who are not or cannot be vaccinated, and with vaccinated immunocompromised persons for whom the vaccine is not 100% effective. It is devastating to hear personal stories from patients who brought the virus home to unvaccinated parents or from morally weary intensive care physicians who now are calling time of death on unvaccinated patients who did not need to die. Personal stories are the backdrop of the larger concern of U.S. community immunity. As a society, we will not return to normal until transmission of COVID-19 drops to a much lower level. Experts believe that with the more transmissible Delta variant, over 80% of our community must be vaccinated to prevent community transmission. With children ages 0 to 17 years comprising 22% of our population, our community immunity must include them.

Lastly, no matter how raucous school board meetings get, most schools will continue to adhere to at least some public health standards, namely isolation of cases and quarantine of the exposed. Per current CDC guidelines, vaccinated students are allowed to remain in school, while those exposed and not vaccinated must quarantine. Being unvaccinated will only continue to interrupt already disrupted children’s lives and limit their choices, which is something no parent, pediatrician, or school wants.

The Pfizer mRNA vaccine certainly is the Rolls-Royce of vaccines for kids ages 12 and up in terms of ingredients, side effects, safety, and effectiveness. Out of all the vaccines I have given in my career as a pediatrician, the Pfizer vaccine is perhaps the most “pure,” by that I mean it is not live, contains no thimerosal, mercury, aluminum, fetal cells, egg products, gelatin, latex preservatives, or pork products. The volume of the shot is tiny and it hardly stings at all.

While collectively we each share our vaccination side effect stories, real-world data finds fewer common side effects than in clinical trial reports (13.5% after first Pfizer dose, 22% after second). At the time of this writing, over 240 million doses of Pfizer have been given in the U.S. with over 14 million doses given to those under 18 — certainly enough doses to detect even the rarest of side effect signal. Impressively, anaphylaxis to polyethylene glycol and myocarditis remain the only serious, but transient, side effects from Pfizer vaccination. And most importantly, vaccination effectiveness in 12- to 18-year-olds is overwhelmingly protective against hospitalization and ICU admissions. The FDA shared its briefing document on Pfizer data for 5- to 11-year-olds just last Friday highlighting the lower 10 μg dose in 3,109 participants was 90% effective against symptomatic COVID-19 at 7 days after the second dose. Rates of local and systemic side effects were generally similar to children 12 years and older, with no reported cases of myocarditis in this group.

Getting Shots Into Kids’ Arms

Given positive news about the Pfizer vaccines in kids, many ask if school mandates will be needed to achieve community immunity against COVID-19. Indeed, major school districts like Los Angeles Unified have already mandated the vaccine for children ages 12 to 18 years. It is critical that school vaccine requirements be considered carefully and judiciously. Historically, vaccines required for school were for diseases with serious morbidity or mortality in children. And most mandated vaccines, such as measles or polio, have full licensure, stable, coordinated vaccine delivery and payment systems, and high parental acceptance that reduces compliance burden on schools. The pediatric COVID-19 vaccines do not currently stand up to these important historical parameters. While school vaccine requirements are historically effective and constitutionally supported, it is state laws that establish vaccination requirements. If recent school vaccine requirement legislation debates in Maine, New York, or Connecticut provide any prognostication, it will be a long road to widely mandating COVID-19 vaccines for school children.

So, until then, it’s up to us as providers to educate hesitant parents about safety and benefits of COVID-19 vaccination.

In a recent poll, 25% percent of parents with kids ages 5 to 11 years old said they will “definitely not” get their child vaccinated once a vaccine is authorized for their child’s age group. The reasons for vaccine hesitation prior to the pandemic were not monolith, and the political resistance movements have only complicated its etiologies. Healthcare providers are consistently identified as the most trusted sources of information for vaccination, putting us in a unique position to urge childhood vaccination among parents. Providers need to arm themselves with effective and understandable answers to the myths about infertility (e.g., “these are rumors with no biologically plausible etiology”); long-term side effects (e.g., “‘long term’ side effects are seen within 2 months in vaccines — not years”); and concerns about newness (e.g., “after millions of doses, the vaccine’s safety and efficacy are not new”). The CHOP Vaccine Education Center is an excellent source of information for providers and families alike. Sensitivity in responding to well-founded caution among Black, Indigenous, and other people of color is also paramount. When all else is said and done, sharing a personal story about your vaccination decision and, if applicable, why you believe it was safe for your children/nephews/nieces/grandchildren to be vaccinated can go a long way.

Winston Churchill is quoted as saying, “Success is the ability to go from one failure to another with no loss of enthusiasm.” We can stop at nothing to lay the foundation for a successful and healthy future for our children. So, keep calm and carry on.

Laura Blaisdell, MD, MPH, is a pediatrician, consultant, researcher, and advocate. She currently practices at the Pediatric Clinic at Maine Medical Center and is the vice president of Maine American Academy of Pediatrics.