Martin Makary MD, MPH,
Editor-in-chief MedPage today
June 10, 2021
The case of vaccinating children is there, but at the moment it is not mandatory. The delta variant (B.1.617.2) could change the calculation, depending on upcoming data from Great Britain, Singapore and India, where the variant may show more contagious and virulent properties in younger people. By now we should all know that it is important to be humble when dealing with this virus. An increase in cases in the UK in the last few days is worrying and should be followed closely by us.
To return to the current discussion on the risk of COVID-19 for children (ages 0-12), it is worthwhile summarize the best data available so far. Reading through medical literature and news reports, and speaking to pediatricians across the country, I am not yet aware of a single healthy child in the United States who has died of COVID-19. To conduct further research, my research team at Johns Hopkins partnered with FAIR health to study pediatric COVID-19 deaths, using around half of the country’s health insurance data. We found that 100% of pediatric COVID-19 deaths occurred in children with a pre-existing medical condition, which solidifies the case to vaccinate any child with a comorbidity.
Given that the risk of death of a healthy child is between zero and negligible, it is understandable that many parents rightly ask why healthy children should vaccinate in the first place.
For these parents, I would say that the main reason for giving the vaccine to a healthy child is not to save their lives, but to prevent Multisystem Inflammatory Syndrome (MIS-C), which can be painful and have long-term health consequences. There have been 4,018 cases of MIS-C after COVID-19, with a mean age of 9 years, according to the CDC. A total of 36 children died. Cases of MIS-C were largely shifted to minority children (62% were Hispanic / Latino or Black), likely due to the disproportionate rates of obesity and chronic illness among children in these populations. This finding again supports COVID-19 vaccination in every child with a disease, including obesity.
It is also important to note that the risk of exposure to COVID-19 in children is not linear over time. With the number of new COVID-19 cases rapidly declining in May, the weekly rate of new cases of MIS-C related to COVID-19 has dropped to zero. And this week, a CDC report on child hospital stays for COVID-19 in March and April 2021 found no deaths in the entire cohort of children studied.
There is an argument in favor of vaccinating children for a community benefit for children to accomplish. Vaccinating healthy children can help reduce virus transmission to children at risk who choose not to be vaccinated or others who cannot receive the vaccine. On the other hand, data from Israel suggest that high vaccination rates in adults significantly reduce transmission among children – a trend that is now being seen in the United States. We also know that compared to adults, children are inefficient carriers of COVID-19. That could possibly change with new information about the current Delta variant, but so far it has not.
The extremely low chance of benefit for healthy children is exactly why pediatricians like Richard Malley, MD, from Harvard, and Adam Finn, MD, PhD, from the University of Bristol have written passionately, « Not Using Valuable Coronavirus Vaccines In Healthy Children ». . « A recent editorial in the BMJ reiterated that opinion – an argument also eloquently articulated by MedPage’s own Vinay Prasad, MD, MPH. From a global perspective, two doses of a globally scarce, life-saving vaccine could be more equitably used to save a 65 – Immunize a year old couple in India or Brazil (one dose for each person) instead of giving both doses to a single one year old healthy child. Accordingly, California’s announcement that it will spend $ 116 million to pay people for the vaccine is when much of the world begs for it in the midst of angry epidemics, a sad commentary on excess, injustice and ethnocentrism in our country.
Children can also experience unique side effects from the second dose of COVID-19 vaccine onwards. Seven teenage children have been reported myocarditis within 4 days of receiving the second dose of Pfizer vaccine, all were Ju age between 16 and 19 years. Both mRNA vaccines were shown to be 100% effective in preventing COVID-19 in children. But every time a drug is found to be 100% effective, the question should be raised of whether the dose is too high, the interval too short, or whether the second dose is needed at all. Pfizer is now considering lower vaccine doses for children, as they mentioned on Tuesday in their announcement that they were starting their vaccine study in children under the age of 12.
Important, and confirmed 2 weeks ago by a Washington University study, immunity is not is only conferred by antibodies, but also a function of the B and T memory cells, which the study researchers believe can confer long-lasting immunity. Given the near zero risk of COVID-19 death in healthy children and the recent discovery of rare myocarditis complications immediately after the second dose, this should spark a discussion of whether a single dose is the more appropriate approach for healthy children.
In my residency training, I was taught an old dictum that many of you may be familiar with: « When you donate blood to someone, always give at least two units. » It took decades for the medical community to reverse this dogma. We now understand that a second unit of blood causes rare but real harm. We have come to the realization that when a second unit is not required, one unit is actually safer than two. We should also give up the idea that the vaccine must always be given in two doses. For transplant patients, for example, there can be three. In children with a natural immunity to previous infection, it cannot be.
What about children who have been confirmed to have COVID-19 infection in the past? I would recommend avoiding a COVID-19 vaccination. Using adult natural immunity as a benchmark, the observational and empirical data is overwhelming: natural immunity is real and it works. Researchers at the Cleveland Clinic published a study this week that found that « none of the 1,359 previously infected subjects who remained unvaccinated had SARS-CoV-2 infection for the duration of the study. » This is one of many studies that show that natural immunity is strong. While the long-term stability of natural immunity is unknown, it is also unknown for vaccinated immunity. We can positively postulate with compelling arguments, but to be true to science we don’t have any data beyond 18 months for either. In fact, there is more follow-up data on natural immunity than on vaccinated immunity. Based on the data collected, children who have had COVID-19 should not be vaccinated unless they are immunosuppressed.
A final and minor consideration should be fear of needles, which will have no or minimal effects in most children but can be traumatic for some. In children who should receive the vaccine and who are also afraid of needles, cold therapy and vibration devices, such as the « Buzzy » device, can be applied to the skin puncture site before the injection and cause little to no pain.
In my opinion According to, the COVID-19 vaccination makes sense for every child who is overweight or who has a previous illness. It can also make sense for a teenage boy as they have a greater physiological resemblance to adults and that vaccines that are safe in adults were safe in children when properly dosed. But given the rarity of a healthy child dying from COVID-19, I wouldn’t recommend a two-dose vaccination to a healthy child aged 0-12 until we have more data. Each parent needs to assess the individual risk of their own child, but in my opinion vaccination of young healthy children is not mandatory right now.
Marty Makary, MD, MPH, is Editor-in-Chief of MedPage Today and a professor at the Johns Hopkins School of Medicine , Bloomberg School of Public Health and Carey Business School. He is the author of The Price We Pay.
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