Should children be vaccinated against COVID-19?

A new Pediatric Respiratory Reviews study conducted in Israel examines issues surrounding children between the ages of five and 11 who are eligible for vaccinated against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Herein, the researchers offer a detailed overview of factors that could influence the decision to take or abstain from vaccination.

In many developed countries, most adults have been vaccinated against the coronavirus disease 2019 (COVID-19), leaving children as the largest group of susceptible individuals in the population. Thus, children not only are at risk of infection with SARS-CoV-2 but are also often obliged to wear masks, cannot travel freely, must be tested regularly, and might be isolated after exposure to the virus.

The Pfizer/BioNTech COVID-19 vaccine was given emergency use authorization (EUA) by the United States Food and Drug Administration (FDA) at the end of October 2021 for use in children between the ages of five and 11. The company’s clinical trial results showed an impressive 91% efficacy against symptomatic infection in children who were administered a third of the adult dose.

The trial group did not report any cases of severe COVID-19 in the study or placebo groups. Furthermore, the number of participants was not large enough to detect uncommon events such as myocarditis, which is a major adverse event associated with the adult vaccine. Nevertheless, over eight million children have already received the vaccine, including over 25% of the U.S. population. Almost the same proportion of Israeli children have also been vaccinated with one or more doses.

The U.S. Centers for Disease Control and Prevention (CDC) estimate that pediatric vaccination for children aged five to 11 years can avert 80-226 hospitalizations during a peak transmission situation, as well as prevent COVID-19 deaths and long-term sequelae. In general, children are at low risk for serious or fatal disease following SARS-CoV-2 infection. Moreover, the U.S. CDC estimates a case fatality ratio (CFR) of less than one in ten thousand in the children between the ages of five and 11 years.

However, since this is based only on the known pediatric cases, the true CFR is likely much lower. In fact, Israel’s Ministry of Health (MOH) has stated that between 50-70% of children who tested positive for COVID-19 experienced asymptomatic disease, thus confirming this supposition. The population-wise mortality rate among children ranges from 0.8 to five per million in different parts of the world, which is comparable to that of the seasonal flu. In contrast, adults have a mortality rate of 1,000 to 3,000 per million.

Hospitalization rates from COVID-19 are also low in this patient population as compared to adults, at less than eight in a thousand. Over 40% of these children had comorbidities, such as obesity, lung disease, or preterm birth. Such children should be prioritized for the vaccine. Israeli data show only 11 deaths among children up to 19 years of age out of almost 550,000 cases. Thus, the population mortality risk is less than 0.0004%, with a CFR of 0.002%. Importantly, two of these deaths were of newborns born to mothers with severe COVID-19. Overall, 460 hospitalizations were among children between the ages of five and 11 years, with 72 being for moderate to critical disease, and three deaths.

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