COVID-19: What about the kids too young to receive a vaccine?

In the midst of the firestorm over the CDC’s “guidance” (sarcastic quotes deliberately inserted) about unvaccinated persons being safe without masks in most situations, the most common question I’ve received is, “What do I do with my kids who are too young to get vaccinated?”

Today my goal is to discuss how parents can mitigate the risk of COVID-19 for their children without going insane and end with some information on the mRNA vaccines in kids.

My kids are too young to receive a COVID-19 vaccine. What do I do now?

There are three parallel tracks to thinking about COVID-19 in children: understanding the actual risk of severe disease if they get infected, assessing the likelihood of infection in particular situations, and how to mitigate the risk of infection as much as reasonably possible.

How likely is severe disease in children younger than 12 years?

The American Academy of Pediatrics (AAP) reports that there have been almost four million cases of COVID-19 in children. That has to be a huge undercount because of:

1. The high rate of asymptomatic or mildly symptomatic disease in children that looks like every other common respiratory virus and is never tested (especially early in the pandemic), and
2. The vagaries of the data and how it is reported differently by each state and within the same state over time.

The AAP also reports about 16,000 COVID-19 hospitalizations in children, which is likely an accurate number. (Hospitalizations are more easily tracked than simply all infections.) But even if you assume that the four million case count is accurate, that means a hospitalization rate of about 0.4%

Even lower risks are found when you look at deaths and cases of multi-system inflammatory syndrome (MIS-C). The percent of all known child cases resulting in MIS-C was 0.09% and a mortality rate of 0.01%.

Again, those percentages are likely to be huge overestimates because the numerator (deaths or cases of MIS-C) is probably accurate but the true denominator (total number of cases) is likely much higher than is known. These numbers are a classic case of listening to your mind and not your heart as a parent. 

I’m a dad, I understand worry, and your worry is human, normal, and ok. As I have said multiple times, just try and have the cold, hard numbers inform your perspective. This is what my wife and I have had to do lately, as our children are 17, 15 and 11.

How likely is it that my under 12 child becomes infected with COVID-19?

As I stated in this post, there’s no way we can give a precise estimate of risk. We’ve all been trained to assume that everyone is potentially infected with COVID-19. And such an assumption may have been reasonable for much of the pandemic. But we are no longer in that position. 

We have nearly 50% of the population 12 years and older fully vaccinated. Chances are we’ll have 60% of that group fully vaccinated by the end of June. Those percentages are already driving case counts down, and vaccination effects will only grow larger. Oh, and if there is some seasonality to COVID-19 infection, then we would expect the summer months to have lower disease activity as well. All this to point out that the risk of infection is getting lower and lower. And as the risk of infection gets lower and lower, the risk of severe disease in children will drop as well.

Perhaps the most important thing to keep in mind as parents, therefore, is that the mathematical risk of infection is nowhere near what it was a year ago, or likely at any other previous time in the pandemic. 

What can I do to lower my child’s risk of infection?

Here is a list of the things that effectively reduce your child’s risk of infection:

1. Vaccinate everyone in your household who is eligible for a vaccine.
2. When socializing, hang out with families where everyone in the household who is eligible for a vaccine is vaccinated.
3. Maximize time spent playing outdoors instead of indoors.
4. Have your child, and the unvaccinated children they’re playing with, wear a mask when playing indoors, especially if the area is not well ventilated.

What’s the deal with outdoor vs. indoor settings?

The risk of infection in outdoor settings is very low. Yes, I know, kids are gross and easily swap respiratory droplets, but remember that droplets dissipate quickly outside. Masks aren’t necessary if playing outside, unless the children’s faces are very close for an extended period of time. Remember, if the rule of thumb is 3 to 6 feet of separation indoors, the necessary distance for dispersion of droplets is even lower outside. Ultimately each parent has to figure out what is the right balance between risk reduction and sanity.

How long will I have to wait to vaccinate my kids younger than 12 years old?

I am confident we will have good data supporting vaccinating kids 5-11 years old by year end, and there’s a good chance we’ll have it in the Fall. Remember, we don’t have to run a randomized clinical trial of 40,000 kids to get the data we need. We need sufficient data to show that we can bridge the huge data set we have in all people 12 and up to younger children. This is standard operating procedure for vaccinations and is no different than what is done for other vaccines that are first used in adolescents or adults and are later used in younger children.

Vaccination data for the youngest children down to infants may be available by the end of the year. Here’s when you’ll know vaccination availability for this age group is close: The first news you’ll hear will be a press release announcing “top-line” results. Pfizer will have their data first (they started studies first) followed by Moderna. Once you read about those press releases, look specifically for information that the manufacturer has submitted the request to the FDA for expansion of the Emergency Use Authorization (EUA) down to the younger age groups. Usually it only takes four to six weeks after that submission to receive the EUA age expansion. 

You never told us what you think of the mRNA vaccines in adolescents 12-15 years of age. What’s your opinion?

Good question. The short answer is I think the mRNA vaccines are an absolute wonder of modern science and human innovation. I find the evidence so compelling that my 15-year-old son got his first dose of vaccine 25 hours after the Advisory Committee on Immunization Practices (ACIP) voted to recommend the Pfizer vaccine in his age group.

The longer answer is that all of the data in the small randomized clinical trial looked very similar to that seen in older adolescents and adults. Although the vaccine was 100% efficacious in preventing symptomatic infection, I don’t actually think that number is the true number. I think the vaccine effectiveness in real-world scenarios in younger adolescents will probably be closer to that seen in adults. It is utterly remarkable, however, to see a 100% efficacy rate in any vaccine clinical trial, even one with a small sample size.

If anything, the mRNA vaccines “might” be even better in younger adolescents and children. For example, the immunogenicity data (ability to generate the right antibodies and cell-mediated immunity) looked even better in the 12- to 15-year-olds than in older age groups. We’ll see if that data pans out, but I find the data promising and quite plausible (the younger you are, typically the better your immune system).

Stay safe, and go make some lemonade.

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