The Pfizer vaccine may soon be available to New Zealand children aged 5 to 11, following approval for emergency use by the US Food and Drug Administration (FDA). The vaccine next has to be signed off for the US by the Centres of Disease Control, before going through regulator MedSafe here. Why is it being recommended for kids? And what issues might that raise? Dr Jin Russell answers four questions.
Why do children need to be vaccinated against Covid-19?
I think it would be sensible to vaccinate children, despite them being at much lower risk of severe illness compared to adults.
The majority of children experience a mild or asymptomatic infection with Covid-19, and it's important to differentiate children as a group within the population as at lower risk.
There are four main reasons, though, to try to minimise the spread of Covid-19 among children.
The first one is that, if we had a surge of pediatric cases similar to what's been seen in some US states where vaccination levels were low - or even in the UK, where schools were reopened with few mitigations in place – then we would expect to see a lot of children infected.
And that could potentially lead to even rare outcomes such as severe illness or the rare complication multi-inflammatory syndrome, becoming more frequently seen.
Children who have pre-existing conditions are also at higher risk of severe illness.
The second reason is that any hospitalisations and rare side-effects would almost certainly be inequitable. It would be very likely that Māori and Pacific children and children from low-socioeconomic households would be most impacted, as we see with other respiratory illnesses.
Covid-19 would become yet another illness that these children have to contend with, which would only increase inequity.
The third, and probably most important, reason is that, while children themselves tend to experience a mild or asymptomatic illness from Covid-19, they can still transmit it, particularly to their own household bubbles.
An infected child may bring home the virus and transmit it to family members who are unvaccinated, or still vulnerable despite being vaccinated.
This would particularly pose a risk to Māori families, given Māori vaccination levels are only now catching up.
The fourth reason is that, because SARS-CoV-2 is a relatively new pathogen, there is still ongoing research into possible complications, like persisting symptoms in children – sometimes referred to as Long Covid.
The research that's been done into Long Covid in children so far has been of generally poor quality; some of the studies have lacked comparison groups, for instance.
So it's been difficult to disentangle the effects of pandemic responses like lockdowns on children from the possible long-term effects of the virus, which might include fatigue or poor concentration.
While the evidence so far suggests that persisting symptoms in children tend to be less frequent and severe compared to Long Covid in adults, the precautionary principle – that is, protecting children from being infected, is a good principle to follow.
When can we expect the vaccine to be approved in children here, and how will we know it's safe?
I'm not sure that anyone knows at this stage, but there are two timeframes that need to be considered.
One is around the administrative process. Pfizer will need to put in an application to MedSafe, so MedSafe can undertake its own assessment.
Then, if approved for use in children, Cabinet needs to make decisions over who receives the vaccines and how.
We'd also need to have a supply of pediatric vials and it's not clear to me when we'd be able to access the pediatric formulation.
That second timeframe that's important has to do with Pfizer's trials.
The Pfizer 2/3 trial that was undertaken in 5-to-11-year-olds included just under 2300 children, so while the results are very promising in terms of safety and efficacy, the trial wasn't able to exclude rare vaccine side effects such as myocarditis.
From looking at the FDA documentation, it's expected that the risk of myocarditis in 5-to-11-year-olds would be lower than in 12-to-15-year-olds, where it is already very rare.
So, while I expect the risk-benefit ratio is going to be in favour of providing the vaccine to 5-to-11-year-olds, without extra safety data from real-world administration or data from Phase 4 trials, it would be difficult to precisely say what the likelihood of rare side effects were.
With the vaccine rollout starting this week in the US, more data will come in quickly.
When the vaccine was rolled out to 12-to-15-year-olds here, for instance, over nine million US adolescents had already received at least one dose.
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If we're going to roll out the vaccine to healthy children, it may be wise to wait for more data, just so we can be assured of any rare side effects there might be.
But I say this expecting that any vaccine side effects are going to be very rare and mild, given that the paediatric dose is one-third of that used for older age groups.
How can we discuss the vaccine and Covid-19 with young children?
We need to use a bit of risk-framing with our children.
What I say to my own children is that Covid-19 can be a serious illness for grown-ups, and particularly for grandparents, which means keeping our distance, wearing masks, and only seeing friends and family outdoors for now.
I also tell them that, just like with other viruses that go around, that we should take care to keep to the rules, as we don't want to pass any viruses on to other people in case it makes them sick.
A smaller number of people aren't yet vaccinated, and we need to be careful to help keep them safe too.
I tell them that, if they were to be infected with Covid-19, it would be a little like having a cold, given I have healthy boys. They might not even notice they have an infection, many kids don't.
But if I had a child who had a pre-existing condition, it might be more helpful to frame the risks around other common respiratory viruses that go around. We don't want to catch viruses in general, so it's a good idea to take care.
I'd talk about how most of the people around them who are eligible - like grown-ups and teachers and teenagers, are vaccinated and protected, and this helps protect them too.
When the time comes, we will need to encourage children to go to school and to know that schools will feel and look different with people wearing masks and staying in bubbles.
Should unvaccinated children be allowed to attend school?
Personally, I don't think that vaccination status should prevent children from attending schools. I've said before that schools are an essential service for children.
It's also very important to not stigmatise children whose parents have chosen for them not be vaccinated.
That can be quite harmful. It's worthwhile to think about how to include all children, no matter their vaccination status.
It obviously helps us, at a society level, to have very high levels of vaccination so that we provide a degree of community immunity for children in general, and for the slowly shrinking number of adolescents who may remain unvaccinated.
But the way to get through this is to try to have good relationships with everyone, no matter their vaccination status, so that we can be a source of good information and support.
Stigma and shame only drives people further away, making it even less likely they will want to be vaccinated.
When we reach out to families who are sceptical, we need to do so in a very respectful way, so that they can receive good information from people that they trust.
• Dr Jin Russell is a developmental pediatrician in Auckland and a PhD candidate at the University of Auckland's School of Population Health.