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COVID-19 vaccination in children – the next dilemma

All COVID-19 vaccines currently approved or authorized for emergency use have demonstrated the ability to protect against moderate to severe COVID illness in people above 18 years of age. The mRNA-based vaccine by Pfizer (BioNTech) has been given emergency use authorization in USA for children above 5 years of age. Covaxin, the inactivated virus-based vaccine and the DNA-based ZyCoV-D vaccine have been tested in children in India. Covaxin is tested in children between two to 18 years of age, while ZyCoV-D is tested in and has received emergency use authorization in children aged 12 to 18 years. The Subject Expert Committee (SEC) of the Central Drugs Standards Control Organization (CDSCO) recommended Covaxin for use in children aged two to 18 years in October. However, it is awaiting approval from the drug regulator.

Now that the vaccines have been tested and approved for use in children, there is an ongoing dialogue and debate on the use of these vaccines in children. The COVID-19 pandemic can be controlled only when a critical proportion of the population has immune protection, triggered either from natural infection or from vaccination. This ranges from 65 to 85 percent of the population according to the reproduction rate (R0) of the viral variant. Children aged 18 years and less constitute nearly 40 percent of the population in India. Hence, it is critical that enough children also have immune protection for the country to reach herd immunity to stop the pandemic.

In the face of vaccine supplies not being commensurate to the needs, governments across the world are adopting a policy of prioritizing vaccination for people at higher risk of hospitalization and death. Global bodies are also urging nations to consider priority setting in the global context and not just in national or subnational context as the world is not safe until an adequate proportion of the world population has immune protection. These factors pose an ethical dilemma to policymakers in every country. The same ethical dilemma is playing out in the context of vaccination for children. We have to ensure that the most vulnerable people ( such as the elderly, people with multiple morbidities, and people with compromised immunity) receive mandated doses of vaccines before we consider Covid vaccines for children. The same ethical dilemma is faced while giving booster doses.  

Children should be vaccinated if supplies are available after vaccinating eligible adults. Though children are at a very low risk of developing moderate to severe illness from COVID-19, infected children can continue the viral transmission to unvaccinated, vulnerable adults. In addition, it will enable children to attend their schools as before. Long term physical, mental and scholastic effects of prolonged absence from schools on child development will be known only in the years to come.

The issue of booster doses also has a direct bearing on the policy related to vaccinating children. It is now apparent that the immunity conferred by vaccines wane over time. Booster doses are already being recommended to vulnerable people in many countries. Some countries are starting to give booster doses to everyone. Evidence is gradually mounting that points to a need for annual boosters against the Covid illness, akin to flu vaccines. Booster doses to adults may take priority over vaccines for children in the near future.

Studies are demonstrating the safety of vaccines in children. However, post vaccination surveillance has to be more robust in children to identify potential safety issues in future. The risk to benefit ratio will be different in children compared to adults given the very low risk of developing moderate to severe illness in children. A concern was raised on the potential risk of developing myocarditis in young males with mRNA vaccines. However, it was concluded that the benefit of vaccines outweighs the rare complication of self-limiting myocarditis. Given the weak surveillance systems in India, it is highly critical that a good surveillance system is in place before rolling out the policy on COVID-19 vaccination in children. 

In summary, children should be vaccinated if supplies are sufficient. A robust surveillance system is critical to address safety concerns. National policies on vaccinating children have to address global inequities and priority setting in the context of a demand-supply mismatch.

Dr Krishna Reddy Nallamalla
President, InOrder
South Asia Regional Director, ACCESS Health International

Photo Credit: The Weather Channel

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