Shifting Guidelines for COVID-19 Vaccines in Children


Tina Tan, MD, and Sean O’Leary, MD, comment on the importance of vaccinating children against COVID-19, as well as how vaccine recommendations are changing.

Tina Tan, MD: I know you touched on this briefly, but people still think that children with COVID-19 are at much lower risk for hospitalization and complications. I think this brings up the question of why it is important to vaccinate children against COVID-19? You and I both know why, but how do you explain to someone who has it in their head that, “So, my kid gets COVID-19, it’s no big deal?”

Sean O’Leary, MD: I mentioned that there is still some uncertainty about how things are going to look moving forward. I will tell you, to set the context, what is being discussed at the Advisory Committee on Immunization Practices right now, which is the body that makes vaccine recommendations for the US public in collaboration with AAP [American Academy of Pediatrics]. What is being discussed right now is potentially moving away from the primary series of vaccination for certain parts of the US population, including certain children. They are considering that because of the seroprevalence, meaning how many people have been infected with COVID-19, then in addition of course, those who have been vaccinated is so high, like 95% at this point. And we know that infection does provide some immunity. So, there is consideration going forward of potentially just having annual boosters for everyone, regardless of their vaccination history.

For example, right now, the recommendation is if there is a child who is 10 years old, who may have had a couple of COVID-19 infections in the past, none very recently, and has never been vaccinated, they are recommended to get a primary series of either the Pfizer or the Moderna product. Going forward, that may change, meaning it may be recommended that they get an annual dose of the bivalent vaccine, the one that has both the Omicron subvariant as well as the original ancestral strain. Then, considering that newborns and young children are still at significant risk, that is the highest age group in pediatrics for hospitalization, they would still be recommended for a primary series of vaccines, and probably going forward that would be bivalent, possibly as soon as the fall.

At what age do you stop doing the primary series? That is being discussed. Is it age 2, or age 4? In terms of your original question, why would we bother? Because kids are still being hospitalized, kids are still dying of COVID-19. I can tell you, you probably have the same clinical experience, just about every single child we see—where I am at Children’s Hospital Colorado—who is in our ICU [intensive care unit] is completely unvaccinated. As I mentioned before, we know that this hybrid immunity, infection plus vaccination, offers better protection across age groups. To me, those are just tragedies, when I see those kids who are so sick, and I know it could have been prevented. To me, yes, there is still some uncertainty out there. But I think it is much better safe than sorry. We know these are very safe vaccines. In my mind, there is not really a downside to vaccinating kids who have not been vaccinated at this point.

Tina Tan, MD: I completely agree. Especially given the fact that, yes, you may have had a COVID-19 infection before. But we know that these new subvariants are not going to give you any immunity protection against those past COVID-19 infections that you may have had, so you do not get protection.

Sean O’Leary, MD: I want to add one piece to that. This is where there is still a lot of uncertainty out there as well and that is long COVID, or PASC, post-acute sequelae of COVID. That is something I think we still have an early understanding of what is going on there. We know it affects a lot of people. The epidemiology is a bit better described in adults than in kids. Though, certainly, I think anyone in pediatric infectious disease knows that we have some kids who are suffering from this condition. A lot of those kids are ones who may have not come to the attention of an outpatient provider, much less an inpatient provider. We are not systematically tracking that. It is a very debilitating condition for many people, and we’ve also seen that some people can get long COVID, even though they’ve had COVID-19 before, they can get it with a second or third infection. We’ve also seen that vaccination appears to be protective in most studies against symptoms of long COVID. So, I think that’s another important thing to consider in all of this, the uncertainty around long COVID, even though it’s not something that rises to the level of hospitalization typically, it’s a very important public health issue.

Tina Tan, MD: You bring up a great point. Many of the kids who have long COVID did not have severe COVID-19 infections. Many of them had mild COVID-19 infections to start, and then symptoms just persisted for very long periods of time.

Transcript edited for clarity

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