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A Pro-Con Debate: Should doctors encourage healthy kids 11 and under be vaccinated against COVID-19?
One of the most popular types of sessions at medical meetings is the pro-con debate. Its popularity stems the fact that the topic is relevant and that the debaters are skilled appraisers and presenters of the evidence.
Today on Sensible Medicine we present such a debate. The topic could not be more relevant:
Should doctors encourage healthy kids 11 and under be vaccinated against COVID-19?
Dr Adam Cifu argues yes; Dr. Vinay Prasad argues no.
We recognize that some will object to a general internist and an oncologist having this debate.
Yet, here at Sensible Medicine, the focus is *always* on content, not credentials. We believe that content expertise is not necessary to appraise data. For instance, we trust guidance from the US Preventive Services Task Force (USPSTF) largely because they are considered neutral judges of the evidence.
What is more, we all have biases. A doctor’s views are surely influenced by the patients they see as well as their a priori beliefs about medical care. This would be true if we had hospital epidemiologists, pediatric infectious disease clinicians or immunology researchers arguing in this debate.
Consider the biases and arguments of Drs. Cifu and Prasad and feel free to weigh-in (politely) in the comments. — John Mandrola
Yes: Adam Cifu
It is a pleasure to argue the side supported by science and common sense in this debate. My argument should fit nicely on a Substack called Sensible Medicine. (For the sake of brevity, I am going to focus on children between the ages of 5 and 11 since that is where much of the argument and much of the data has been but my arguments extend to children from 6 months to 11 years old.)
Children, with and without comorbidities, should be vaccinated against COVID-19.
Let’s start with some facts to convince people who need little convincing.
If you are comfortable deferring to experts, the decision is clear:
2. Every pediatrician I know recommends the COVID-19 vaccine and every physician I know vaccinated their children as soon as the vaccine was approved and available.
If you were comfortable with our vaccine strategy before COVID-19, there is no reason to hesitate.
1. For almost every disease that we vaccinate kids against, the risk of any one child dying of that disease (be it measles, chicken pox, or COVID-19) is low. BUT, nearly every death that does occur is preventable.
2. Vaccinating children against these diseases helps to protect the entire population by assuring that fewer people are infected (or efficiently spreading) the illness.
3. COVID-19 is not harmless in children. As I write this, the CDC reports that 422 children in the 5-11 age group have died of COVID-19. COVID-19 is as dangerous in kids as the other diseases against which we routinely vaccinate. There have been about 1.45 deaths/100,000 kids aged 5-11 (CDC data). For reference, measles killed about 12 per 100,000 population in 1912 and approximately 0.2 per 100,000 in 1960 (around the time we started vaccinating). Varicella (chicken pox) kills about 1/100,000.
For those who need a little more convincing.
If you have chosen not to vaccinate your child, I’m guessing that three factors underlie your hesitancy.
1. Concern for side effects.
2. Belief that COVID-19 is harmless in kids
3. Belief that the vaccines do not work.
First, in any age group, but especially this one, the vaccines are terrifically safe. Other than mild soreness or achiness, we are seeing no important side effects. The myocarditis issue (which you may have heard about) has been overstated, in this population especially. The highest (and probably least reliable) estimate of vaccine-related myocarditis rate is 1/400,000 (VAERS) – 1/4th the death rate in this group.
Second. You might believe that COVID-19 is not that dangerous in kids. Well, here you are right and wrong. Since the start, a remarkable fact about COVID-19 is how much more dangerous it is in older patients. The ratio for COVID-19 hospitalizations, comparing the oldest patients to the youngest, is about 15:1; for death, the ratio is a staggering (approximately) 550/1. But this does not mean the disease is harmless in kids. Kids rarely die of anything. Looking at the data for 2020, about 685 kids in this age group died of all causes! When you consider this, 422 deaths in this age group over the last couple of years is astonishing. At the current rate, COVID-19 will clock in as the 5th leading cause of death in this age group (behind unintentional injuries, cancer, congenital malformations/chromosomal abnormalities, and homicide). So yes, COVID-19 is RELATIVELY benign in kids when you compare its danger to 80-year-olds, but in absolute terms, COVID-19 is serious business in kids.
And third, you might believe that the shots are ineffective. Here you are wrong. The initial data on the vaccine showed it to be shockingly effective with efficacies in the 90-95% range. Yes, the efficacy has waned as the population has gained more immunity to the disease and as the virus has mutated. Our most recent data in this age group gives efficacies of about 83% for preventing hospitalization. As I write this, there are 386 kids, 5-11 years old, hospitalized in the US with COVID-19. If every child was vaccinated, this number could be as low as 104. Anyone who have ever had a child in the hospital knows how much avoiding 282 hospitalizations is worth.
Children should be vaccinated against COVID-19, experts agree, the treatment is in line with accepted medical therapy of the last 60 years, and the data supports it.
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No: Vinay Prasad
Encouraging a vaccine makes sense if vaccination benefits the recipient and/or others, and is the best use of limited time. COVID-19 vaccines in healthy kids (who have largely been infected) do not meet these criteria.
→First, the vaccine doesn’t benefit others. A JAMA study shows, with time, vaccine effectiveness against symptomatic COVID-19 goes to zero.
That means all kids, like all adults, will eventually get COVID-19. And when they do, vaccination is not associated with a shorter duration of viral spread. BA.5 is so contagious, vaccines are so poor at halting infections, and they wear off so quickly, that vaccinating a kid does not help Grandma.
→Second, we don’t know if kids benefit from vaccination. COVID-19 is not a serious threat to kids, and we can estimate the upper bound benefit of vaccination. Consider these facts.
Most kids already had COVID-19. CDC estimates 75% as of February, but this number is an underestimate, as millions have been infected since.
If you have and recover from COVID-19, reinfection is, on average, milder.
MIS-C rates have fallen precipitously, not due to vaccination, but omicron itself.
All COVID-19 vaccines target the Wuhan ancestral strain.
The current prevailing strain is BA.5, which has immune escape from the vaccine.
Kids vaccines were authorized based on antibody titers, a surrogate that becomes less reliable by the day, and is not evidence they can lower rates of symptomatic Omicron, and its’ sequelae.
Trials for kids aged 6 mo-4 years contained very few kids who already had COVID-19.
In these studies, conducted during Omicron, Moderna vaccine efficacy was 28% (when home tests were included). (p117), and this is the best case scenario. As months pass, vaccine efficacy will drift downward.
Pfizer data was so deeply limited in kids < 5, the FDA said only, “An additional analysis pertaining to the occurrence of COVID-19 cases was determined not to be reliable due to the low number of COVID-19 cases that occurred in study participants.”
There is no evidence vaccination lowers long covid in kids, a poorly defined entity.
In short, the case for kids’ vaccine for personal benefit is weak. The vaccine offers modest & transient protection against symptomatic disease, and that is uncertain in kids with prior COVID-19.
Observational data has been used to support vaccines, but is plagued by confounding. That is because parents who vaccinate their kids are different from those who don’t. The same studies could show that driving a baby home from hospital in a Mercedes is better than a Ford.
Consider a recent study from Singapore. This study excluded kids who already had COVID-19. Whether vaccinated or not, 0 kids died. This is lower than an earlier German study where 3/1000000 kids died, but that occurred when Alpha and Delta were prevailing strains.
The risk an unvaccinated kid ended up in the hospital on oxygen was 0.002% (likely upper bound estimate for the study, but will rise with time). The risk of a vaccinated kid having a serious adverse event from the vaccine was 0.005%. The risk of any child ending up in the hospital on oxygen was 0.002%. The risk of requiring O2 in the hospital if you had COVID was 0.009% (vax’d and unvax’d).
These risks are low, in all directions, and not directly comparable because covid risks rise with time, while vaccine risks are one time. On the other hand, given high seroprevalence in the US, the benefits will be smaller.
The study authors’ claim reduction in hospitalization, but we do not know how many were for or with COVID-19. Moreover, vaccination was not random, and confounding is at play. Falsification testing may help.
The bottom line: risks are low either way, and no one knows with confidence that kids benefit, especially those who had COVID-19. Vaccines are supposed to be much safer than the disease, but that is uncertain here. Likely, kids vaccination should have been approved by traditional pathways, and not via the emergency use authorization (EUA).
Parents are smart and get this. They vote with their feet. Just one in three kids 5-11 have gotten the shot and <5% of kids less than 5.
→Third, and finally, doctors’ time is limited. Routine childhood vaccine rates are slipping. Contrary to COVID-19 shots, the measles vaccine is sterilizing and high rates are needed to halt spread. Doctors must realize that pro-vax does not mean zealotry, but evidence first.
Focus on what matters. No need to push COVID-19 vaccination in kids who already had COVID-19. Tying vaccination to school attendance would be counter productive.
To the proposition: Should doctors encourage healthy kids (11 and under) to be vaccinated against COVID-19?
I say, “No, Save your breath for routine vaccination”