COVID-19 vaccination for 5- to 11-year-olds is finally an attempt. But even as the emergency use authorization process unfolded, there were also arguments over whether children should be (or soon be) forced to take shots. School mandates for new vaccines tend to: lagging behind CDC recommendations by about half a decade, but COVID-19 shots appear to be in the express lane. The Los Angeles Unified School District— the second largest in the country — will require students aged 12 or older to be vaccinated by mid-December if they wish to continue taking in-person classes. The entire state of California plans to compulsory admissions for all its public and private students once the vaccines are fully approved for them, and the elected mayor of New York City has said he will the same idea.
The implementation of all K-12 school mandates statewide could take a while, given the expected delay before the FDA gives full approval for injections for children — for reference, the same process for the adult vaccines took eight months. In the meantime, parents, pediatricians and public health officials will have to think about the pros and cons. COVID-19 could be an unprecedented disease that gives rise to an unprecedented vaccination effort to match. But how exactly does the case for mandating COVID vaccines in schools compare to all the other injection requirements — such as those for polio, chickenpox and measles — already in place across the country?
When state regulators decide whether to mandate a particular vaccine, they generally consider the risks and benefits — just as the FDA and CDC do when deciding whether to green-light a vaccine — but also how. those risks and benefits compare to a school setting, says Mary Anne Jackson, an infectious disease pediatrician at the University of Missouri at Children’s Mercy Hospital in Kansas City. A vaccine must not only be safe and effective, but must also be easy to distribute and well accepted by the medical community and the public. Under these circumstances, vaccination mandates in schools can provide “a vaccine policy safety net,” said Jason Schwartz, a vaccine policy expert at the Yale School of Public Health. They help increase vaccination rates when other persuasion methods have failed.
The main benefit of mandatory COVID vaccination, as far as parents are concerned, would be the potential to prevent death. COVID-19 has so far caused relatively few deaths in children aged 5 to 1166 from October 2020 to October 2021. But we routinely vaccinate schoolchildren against diseases that were even less deadly before their respective vaccines were available. For example, chickenpox killed an average of 16 5- to 9-year-olds per year in the early 1990s; now all 50 states (as well as the District of Columbia) require primary school students to be vaccinated against it. Chickenpox, Jackson told me, used to kill “a certain subset of children” — mostly those who were immunocompromised. The same is true for COVID-19 today.
In addition to warding off death, childhood COVID vaccines also promise to prevent and reduce disease, whose long-term effects in children and adults remain unclear. In data Pfizer provided to the CDC, the company’s infant dose was: 90.9 percent effective in the prevention of symptomatic infections. (Note, however, that vaccine effectiveness can change over time, just as it does for adults.) This level of protection is similar to vaccines mandated for elementary schools in all 50 states: polio (99 percent), the measles (97 percent), chicken-pox (94 percent), and whooping cough (84 percent).
It’s also important to consider how likely children are to get the disease to begin with. The Delta variant appears to be less transmissible in children then chickenpox, measles, and whooping cough, and about as transferable as polio. But we have very little data on how quickly the Delta variant spreads among schoolchildren in particular, and how much faster it would do if precautions like masks and social distancing were removed in schools.
To sum up the benefits, the COVID vaccine for children fights a disease that is about as dangerous as others that require regular vaccinations for schools, and, at least for now, appears to be about as effective as these other vaccines, while the disease it prevents seems a little less transmissible.
Now for the risks. The main concern with the Pfizer pediatric vaccine is myocarditis, a condition in which the heart muscle becomes inflamed, leading to symptoms such as chest pain and shortness of breath in children. Non-Vaccine-Induced Myocarditis tends to be rarer in young children than in teens and young adults, and the Pfizer small children trial did not result in registered cases among the approximately 3,000 vaccine recipients. But in older boys and young men who received a second dose of an mRNA vaccine, myocarditis has been observed in about one in 10,000.
How does this percentage compare to the percentage of the most troubling side effects of school-mandated vaccines? COVID vaccine-induced myocarditis is less common than febrile seizures do after the measles, mumps, and rubella vaccine (about one in 2,500 doses), but more often than a condition called bruising immune thrombocytopenia purpura (one in 30,000). The cases of myocarditis are also more common than cases of anaphylaxis after the hepatitis B vaccine (one in 1.1 million), which is required for elementary school students in all but a handful of states.
But the rate of COVID vaccine-induced myocarditis by itself doesn’t tell us much. “The question is, how serious is myocarditis?” says Daniel Salmon, who leads the Johns Hopkins Institute for Vaccine Safety. We still don’t really know. According to the CDC, most patients with myocarditis after vaccination “felt better quickly” and “usually can return to their normal daily activities after their symptoms improve.” But no one can say yet whether a bout of vaccine-induced myocarditis would harm a person’s health in a year, or 10, or 50. Salmon told me he wouldn’t support a children’s mandate until researchers are able to rigorously monitor children. who get myocarditis for a year or two and find no related serious health problems.
Waiting a year or two would also give regulators a chance to see how Americans are learning to live with SARS-CoV-2 as an endemic virus, which has its own implications for any mandates. Lainie Ross, a pediatrician and bioethicist at the University of Chicago, told me that “what makes this disease unique right now is that everyone is kind of a virgin” to the virus that causes it. If it doesn’t continue to evolve into new and more dangerous variants, and if the vaccines (or the natural immunity left by previous infections) continue to protect against it, then COVID-19 will probably start to resemble measles or chickenpox: it will be a childhood disease, because every living adult has already been exposed to it. That makes things much easier for children’s mandates.
But if, as some experts (and CEOs of pharmaceutical companies) have predicted, the virus changes to the point where we have to get a new shot once or twice a year, mandates for schoolchildren could suddenly become an issue. lot more complicated. Most schools routinely follow vaccinations at certain entry points, such as kindergarten or high school enrollment, says Seema Mohapatra, a visiting law professor at Southern Methodist University, and they have systems in place to do this.
Should the COVID vaccine become an annual injection, “that’s a whole different story,” she told me. The paperwork, she said, would be a nightmare.
Think of the flu vaccine. During the 2019-20 season, 112 children aged 5 to 17 died of flu, but no state mandates annual flu shots for K-12 students. (Massachusetts announced a mandate in August 2020, when dropped it in January after the flu season was found to be mild.) In contrast, an average of three children and teenagers per year died from hepatitis A in the five years before the two doses-and-that’s it vaccine for that disease had been approved. Still, hepatitis A vaccines are: compulsory in primary schools in a third of the states. It’s true that the hepatitis A vaccine is significantly more effective than the annual flu shot, but the flu arguably poses a much greater danger to children.
The prodigious speed with which the COVID vaccines were developed has only made these questions more difficult to work out. By the time the first emergency use authorization was issued for Pfizer’s adult injections last year, humanity had only had about 13 months of experience with the novel coronavirus. The first US polio epidemic occurred decades before Jonas Salk started his famous vaccine; measles existed for centuries before an effective inoculation was discovered. If we had had such a time with COVID-19 before vaccines were introduced, many more children would probably have gotten sick or died from the disease, but we would also know a lot more about how quickly the virus mutates over time. , the exact extent to which children spread and become infected, and the rate at which it causes chronic symptoms.
Likewise, any bits of information that can be gathered in the coming months will be helpful in deciding whether to mandate the vaccine for children. The approaches taken so far by mayors, governors and regulators suggest that most plan to wait for the FDA to give its full approval for the shots. We should have some more by then.