Let’s first talk about the BA.5 Omicron subvariant.
BA.5 is now dominant in the U.S. It is generating a lot of infections because it is wildly contagious—more so than past Omicron subvariants. But luckily so far, BA.5 doesn’t seem to be intrinsically more virulent than past variants. So far, hospitalization and death rates haven’t significantly spiked despite widespread infections. (So why are people still being hospitalized? Because non-immune and otherwise vulnerable individuals remain at higher risk for serious outcomes when infected, but this is not necessarily because BA.5 itself causes more severe disease.)
Also so far, BA.5 does not seem to have evaded the vaccine’s protection from death and serious COVID outcomes. (Then what the heck does “waning immunity” mean?? Waning immunity typically refers to the fact that our blood antibody levels naturally and gradually drop over the course of weeks or months, both after vaccination and after an infection. Why does this matter now more than it did pre-Omicron? Because in the face of a highly contagious variant like BA.5, we can expect to see people get reinfected as antibody levels fall.)
In other words, in the Omicron era, immunity—whether from past infection or from the vaccine—simply doesn’t protect us well against (re)infection, particularly 2-3 months after a last dose or bout of COVID. To reiterate: Waning immunity does NOT mean the vaccine no longer works.
Is the vaccine perfect? Hell no! (Is anything in life? Not that I am aware of.)
Do I still recommend getting vaccinated and boosted if eligible? Absolutely! But these decisions are increasingly complex given an individual’s age, underlying health conditions, past COVID infections, and underlying immunity.
Which is exactly why we must navigate risk with managed expectations, a clear-eyed view of the data, and trusted guides who understand the nuances of complex medical decision-making.
Enter pediatrician Dr. Jessica Hochman, a board-certified pediatrician outside of LA and a trusted voice of sane, rational, and data-driven advice. You can find her podcast, Ask Dr. Jessica, on YouTube or Instagram. It’s a wonderful resource for all things parenting and pediatrics! Here is her guest post today.
Why COVID Vaccination for Children Under Age 5 Isn’t a Slam Dunk Decision
By Jessica Hochman, MD
The CDC has finally approved the COVID vaccine for children as young as 6 months of age. The public health community has been giving a blanket recommendation: Get children vaccinated as quickly as possible. I believe the COVID vaccine is a miracle of modern science. However, particularly in the face of the highly contagious BA.5 variant, the decision to vaccinate young children is nuanced and should be individualized.
As a pediatrician, every day I hear questions from parents who want guidance: “I want to go to Disneyland—should we wait until after my child receives the COVID vaccine?” or “My child already had COVID, what benefit will the vaccine provide?” or “The vaccine seems too new, I want to wait a bit longer, but I’m worried that my child’s school will now require the vaccine for school.”
What to do? Let’s start with the available data thus far. Both the Moderna and Pfizer vaccines received emergency use authorization from the FDA for children under 5 years of age. The Moderna vaccine is given as 2 doses (a total of one-fourth of the recommended adult dose), while the Pfizer-BioNTech vaccine is a 3-dose series (a total of one-tenth of the recommended adult dose).
Studies of both vaccinations involved thousands of young children. Perhaps the most important finding from these analyses was that no major adverse effects were identified. This is critical because most children do very well with COVID itself, such that even a small risk of a severe side effect would make the vaccines not worth the risk. Nevertheless, as we learned with the adult vaccines, sometimes adverse effects become apparent only after vaccine approval when more data are available. (For example, blood clots were only recognized as a complication of Johnson & Johnson after its approval. Similarly, we learned about the rare but real risk for vaccine-related myocarditis in teenage boys from the 2nd Moderna vaccine—but only after its approval.)
In sum: While we can now say confidently that the risks of major vaccine side effects are extremely low, it would be naive to tell parents that the vaccines are unequivocally safe.
In terms of preventing infections in young children, both the Pfizer and Moderna vaccines appeared to be modestly effective. But beyond this, based on the available data we have at this time, much information is still wanting.
Severe outcomes from COVID are so rare in children that, despite thousands of vaccine trial participants, any benefit of preventing severe illness wasn’t shown. A pediatric COVID vaccine trial would need to include hundreds of thousands – if not millions – of participants to identify a significant impact of vaccination on outcomes such as hospitalization or serious COVID complications.
To be clear: This is not to say that the vaccine does not or cannot prevent rare serious COVID outcomes in kids; it’s just that this benefit hasn’t yet been proven. For this answer to emerge, it will take the passage of time, looking at outcomes of a larger number of vaccinated children, compared to matched outcomes of unvaccinated children. That said, for my high-risk patients (for example, children with obesity, heart defects, diabetes or neurologic impairment), I encourage vaccination — even without studies powered to show this benefit — given the expected risk-benefit ratio.
Another major shortcoming of the Moderna and Pfizer studies is that follow-up was very short – just over one month. If there’s one thing we should have learned by now, from our experience with the COVID vaccine in adults, it is this: Immunity against infection lasts only a brief period of time, while protection against severe disease and death remains strong. Initial trial results for adults suggested benefits of over 90% protection against infection from the first round of vaccination, but over time – and with the emergence of new variants – booster doses were needed to maintain the benefits. As we are seeing with this summer surge, due to the highly contagious BA.5 and other variants, boosters are of modest benefit against infection. (Booster protection against serious disease remains strong and is most important for high-risk and older adults). Because the vaccine dose in children is so much lower than it is in adults, it is possible that over time we will find the vaccine will be no more beneficial than placebo.
From an individual child’s perspective, especially with regard to children who have already had the virus, the risk-benefit ratio of vaccination is uncertain at best. The Moderna and Pfizer trials largely consisted of children who had never had COVID, yet we know that having cleared an infection does provide strong — albeit imperfect — immunity against reinfection. In February 2022, the CDC reported that at least 75% of children have already had COVID, and this number is most certainly now much higher given the ongoing Omicron BA.4/5 subvariant surge.
So what about the public health benefit of vaccination? Even if the overall effects of vaccinating healthy young children are uncertain, shouldn’t vaccination reduce community transmission, thereby protecting the rest of us through herd immunity?
Perhaps. But again, especially with the highly transmissible BA.2, BA.4, and BA.5 Omicron subvariants, we are seeing a tremendous amount of breakthrough infections. So unless young children receive repeated vaccinations, constantly updated to new variants, the public health benefits of childhood COVID vaccination will likely remain small.
In my medical opinion, the best way to protect society as a whole is not to focus on vaccinating healthy children, but rather to direct our attention to the vulnerable members of the population, frail adults and those with immunodeficiencies. We can do this through vaccination and boosters, the use of medications, ventilating public spaces, one-way masking to protect the wearer in crowded indoor spaces, and by managing underlying health conditions that put people at high risk for serious outcomes. (Dr. McBride has written extensively about all of this!) Let’s devote our resources to ensure vulnerable members of society receive all recommended booster doses and that vaccines are being updated to cover newer strains.
In conclusion, I believe strongly in childhood vaccinations. Talking to parents about the importance of vaccines, and administering vaccines, is an integral part of my everyday work. My own kids are up-to-date with all of their routine immunizations. As a pediatrician, I favor a nuanced discussion about the COVID vaccine, where parents ultimately make the decision about whether or not to vaccinate. There is no right or wrong answer because again, based on current data, the vaccines appear to be extraordinarily safe. But in order to maintain trust in public health recommendations, it is important for the medical community to remain humble and open to the prospect that, at this time, the risk-benefit ratio of COVID vaccination for young children is not fully understood.
— Now for this week’s podcast episode!
Is it safe for pregnant women to drink a glass of wine? Should your child get a booster if they’ve already had COVID? What is the cost-benefit analysis on traveling to see grandparents during a COVID surge?
These are some of the vexing questions I have fielded from patients, social media followers, and my newsletter subscribers since March 2020. Alongside my medical colleagues, one of my favorite thought partners—and voices of reason—during the pandemic has been my friend, Dr. Emily Oster.
In my latest episode of Beyond the Prescription, I talk with Emily, renowned economist, Brown University professor, and bestselling author, about the answers to these questions (spoiler alert: it depends)—and about the importance of appropriately framing the quandaries in the first place.
As one of the leading voices in health economics—and recently named one of Time Magazine’s Most Influential People of 2022—Emily takes a data-driven approach to answer the difficult questions on everyone’s mind, especially for parents, in her wildly popular newsletter, ParentData. Her nuanced approach to evidence-based decision making has provided a lifeline for the worried and uncertain, especially during the pandemic.
No stranger to uncertainty herself, Emily was forced to overhaul her life plan after unexpectedly being denied tenure. Together, we unpack this challenging moment and explore the ways in which data can help us anchor our emotions, more appropriately manage risk, and face the unknown with confidence.
Give it a listen on Apple, Spotify or wherever you find podcasts!
I will see you next week. Until then, be well.