Let’s Hold-off The COVID-19 Needle On Children: Experts

In a nutshell, while there is certainly evidence of potential transmission in secondary school ages, children do not appear to be major spreaders of coronavirus

By Dr. Vinod Balasubramaniam and Prof. Sunil Lal

At a time when communities around the world are still struggling to access COVID-19 vaccines, medical experts and regulators are split when it comes to expediting children’s vaccinations.

The scientific question that followed was – will vaccinating children save lives? – which is complex as the answer may vary from country to country. On the flipside, moral and ethical quandaries have been raised over the opportunity cost of vaccinating children over health workers and vulnerable adults in less well-off countries.

Eighteen months into the COVID-19 pandemic, several countries that have achieved high vaccination coverage in adults such as Canada and the United States have started vaccinating adolescents aged 12-15.

Over the past month, Australia’s COVID-19 vaccination rollout has taken another step forward with the Therapeutic Goods Administration (TGA) approving the use of Pfizer COVID-19 vaccine for young teenagers aged 12 to 15 years but stated that the vaccine will not be used in that age group just yet as it is now up to the Australian Technical Advisory Group on Immunisation (ATAGI), to decide how and when younger people should be prepared to roll up their sleeves. Up until now, the Pfizer vaccine had only been approved for use in Australia for people aged 16 years and over.

On the home front, the Malaysian Health Ministry has recently signed a letter recommending the dispensation of COVID-19 vaccines for the adolescent age groups starting from September 15.

The circular from the Health director-general came following laudable efforts by the government to vastly improve vaccination rates in which about 50.1 per cent of the country’s adult population had received the first vaccine dose.

No doubt vaccinating large numbers of adults will allow us to prevent deaths and serious illness, and therefore reduce the burden on health systems. Which is the primary goal of “herd immunity”. Studies have shown that high coverage in adults will go a long way to achieving this, but the incremental benefit from vaccinating children 15 and under is still unclear as there is not enough information on the safety of this approach.

Amid all the noise, claim and counterclaim, what are the ethics, benefits and most importantly, the safety and usefulness of inoculating children as we try to quell the pandemic?

Benefits of vaccinating children and is it necessary?

Since the early days of the pandemic, parents have been taking some comfort from the fact that SARS-CoV-2 is much less likely to cause serious illness in children than it is in adults. Although there are rare cases of Long COVID and multisystem inflammatory syndrome in children, these events are rare. Infections in children are nearly always mild or asymptomatic, which is in sharp contrast to older age groups who have been prioritised by vaccination campaigns. A study across seven countries, published in the Lancet, estimated that fewer than two out of every million children died with Covid during the pandemic.

Generally, Pfizer has reported that side effects of the shots appear to be similar in children and adults. Your child might notice pain at the injection site (upper arm) and could feel more fatigued than usual. Headache, achy muscles, or joints, and even fever and chills are also possible side effects. These side effects are usually temporary and generally clear up within 48 hours.

Therefore, unless they are part of a group at higher risk of severe COVID-19, it is less urgent to vaccinate this age group compared to older people, those with chronic health conditions and health workers.
Another potential benefit to vaccinating children is it could save other people’s lives through “herd immunity”, which is a common approach that is already used for flu, measles and many more. Previously, it seemed possible to control Covid while avoiding vaccination of teenagers and children, however with the cyclical upsurge of Coronavirus infections particularly the Delta variant, individuals at highest risk are those who are unvaccinated.

Additionally, the Delta variant has shown maximum infectivity between the age group of 5-50 years old, this observation depicts a significant change in SARS-coronaviral infection dynamics from its earlier variants. With researchers not completely ruling out the possibility that more-transmissible variants will develop a way to push through whatever it is in a young person’s immune response that makes them more resistant to infection, hence making for a solid argument for expediting the vaccination of teenagers between the age of 12-15 yrs.

Once this cohort is vaccinated, it makes a lot of sense to protect the children below 12 years of age. Although efficacy data is not yet available for these age groups, however, fully vaccinated individuals that have had a double dose of the Pfizer vaccination have shown symptoms of mild disease only and no death, in the United States. This becomes very reassuring at this time and hence it is better to administer the vaccine as a prophylactic means of prevention in young adults, rather than staying unprotected.

In a nutshell, while there is certainly evidence of potential transmission in secondary school ages, children do not appear to be major spreaders of coronavirus, but older teenagers may still play a role. Against overwhelming evidence that children get very mild symptoms, it is laudable that the move to vaccinate children against Covid-19 will be important for protecting the community against the Delta variant, but vaccination of high-risk populations must take precedence as the vaccine offers less benefit for healthy adolescents, who tend to have a relatively mild illness.

Let’s keep the focus on adults for now

The World Health Organization has expressed major concern over higher-income countries beginning to vaccinate children while much lower- and middle-income countries have insufficient supply to vaccinate high-priority groups. This concern echoes the WHO published advice on June 21, 2021, clarifying which populations should receive COVID-19 vaccines – to which it states, ‘Children should not be vaccinated for the moment.’ Furthermore, the WHO says, “There is not yet enough evidence on the use of vaccines against COVID-19 in children to make recommendations for children to be vaccinated against COVID-19. However, children should continue to have the recommended childhood vaccines.”

One thing to bear in mind is who doesn’t get a vaccine if a child is given one instead. In this context, WHO academics and researchers alike have urged wealthy countries to postpone their plans to immunise children and donate them to the rest of the world as it was “morally wrong” to prioritise children. Another reason to hold off with adolescents is the fact the global COVID-19 vaccine rollout has been slow and highly inequitable. The more we let unvaccinated people get infected, the more time we allow the virus to evolve and to come up with newer variants.

Echoing the call by the WHO, it is worrisome that if countries like Nepal, where the vaccination program had to be temporarily suspended in April because of a lack of supplies, got left behind the rest of the world would be endangered as well. In some countries with adult vaccination rates above 50%, such as Israel, infections have declined overall, suggesting adults play a key role in the transmission and prevention of infections in children. In fact, one study in Israel found vaccinating adults did prevent infections in unvaccinated children.

At this stage, the focus of a vaccination program should remain on attaining high coverage in adults, especially the elderly and those with other medical conditions. We should aim for above 90% coverage in these groups to maximise individual protection and prevent transmission to younger age groups.
Recommendations for vaccination will evolve and vaccination of children will play a key role in achieving herd immunity. That being said, the top priority right now must be maximising vaccination in adults — both in countries that may have the capacity to vaccinate children and around the world. As increasing age is the biggest risk factor for severe diseases such as the COVID-19 influenza, vaccinating older people should remain the priority.

In totality, what we certainly should not be doing is ignoring the issue of vaccinating children altogether and solely focus on opening vaccination for children only once we’ve got a certain proportion of adults vaccinated – because then we’ll have turned this into a pediatric epidemic.

Dr. Vinod Balasubramaniam, Molecular Virologist and Senior Lecturer, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia and Prof. Sunil Lal, Professor of Microbiology, School of Science, Monash University Malaysia

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