COVID-19 shows that infectious diseases don’t have to be extraordinarily deadly to be devastating to public health. Fortunately, with a few exceptions, in any given child, the most likely outcome of COVID-19 is a full and uncomplicated recovery. But the risk assessment changes dramatically when viewed through a public health lens, especially with considerations unique to children. Ethical considerations, for example, are more complex because children typically lack decision-making capacity, making paternalism in their care unavoidable (informed consent). This situation generally advocates conservative approaches to their risk so that they can grow to the stage of life where they do have capabilities.
Deaths in childhood represent an extremely premature loss of life and therefore have greater effects on public health figures, such as disability-adjusted life years. Ensuring children’s health is also critical to health equity. These are anodyne claims: they boil down to the simple truth that children deserve protection.
Let’s use influenza – another respiratory RNA virus of eminent public health importance, which has a spreading mechanism similar to SARS-CoV-2 – as a point of comparison. From 1999 to 2019, flu was the eighth cause of death in children, but one pediatric flu death has been documented this season. This is likely due to aggressive non-pharmaceutical interventions (NPIs). But in the same 2020-2021 season, the American Academy of Pediatrics (as of early June) reports 327 U.S. child deaths and the CDC reports 452 from COVID-19 (both are underestimates, as these data are incomplete). COVID-19 has killed twice as many children in about 1 year as flu in most years, and hundreds more in the same time interval, despite painstaking efforts to prevent infection. This easily makes COVID-19 a leading cause of death in children.
Some have differentiated between hospitalization with and hospitalization from COVID-19, which has merit: Childhood cases tend to be milder or asymptomatic, and they are screened within the hospital, so some cases certainly reflect incidental findings. Two such studies found that nearly half of these pediatric hospital admissions were unrelated to COVID-19; we must be careful about accepting the generalizability of these reports. But for the sake of the argument, applied to the entire US, that still amounts to about 100,000 pediatric hospitalizations caused by COVID-19 over a period of just over a year, based on statistics generalized to the CDC estimates. , or at least a minimum of 20,000, based on COVID-NET data. All estimates exceed the number of hospitalizations during the pre-vaccination period for several vaccine-preventable diseases on the childhood vaccination schedule.
We also need to consider the childhood multisystem inflammatory syndrome (MIS-C), a pediatric population’s post-COVID-19 syndrome, with a much greater risk of morbidity and mortality, including – perhaps most ominously – heart dysfunction. Worryingly, the previous infections leading to MIS-C are often asymptomatic and the condition presents suddenly 4 to 6 weeks later. Of the documented cases in the US, about 1% were fatal.
Post-acute impact of COVID-19 (PASC), commonly known as “long-term COVID”, is also a risk. There is wide variation in the estimated frequency of PASC in children, with some studies noting as much as 42% of cases (although this figure is likely an overestimate). We can use the conservative value of 1.8%: if we use the CDC estimates of infections, this would correspond to 480,000 American children with symptoms that last longer than 56 days. Further epidemiological data will clarify the importance of PASC as a pediatric health concern, but we note that clinics have been opened specifically to treat the condition, suggesting the burden is significant.
With the staggering deaths reported during the pandemic, 400 infant deaths may seem paltry compared to the catastrophic deaths in nursing homes and ICUs. But consider: If COVID-19 only affected children with these statistics—400 deaths, 20,000 to 100,000 hospitalizations, an insidious hyperinflammatory syndrome with significant potential for death and disability, and lingering symptoms after apparent recovery—would we ever have pediatric COVID-19? 19 with our present indifference?
Indeed, as we said at the outset, COVID-19 is much worse for many groups than children – but the impact on the pediatric population is significant not only for their social and emotional well-being, but also for their physical health. Today, children are not supposed to die, and the loss of a child can be especially shocking, in part because it’s not supposed to happen. What does it say about us that when faced with one of the greatest modern threats to their security, we are so willing to be complacent?
Children will benefit from adult vaccination through herd effects, and to the extent that adults are the main demographic group most at risk for COVID-19, vaccination should be prioritized accordingly. However, as vaccine uptake increases, the disease burden shifts to those who have not been vaccinated. While vaccination will reduce the overall number of cases, the shift from cases to children raises some complex questions. The viral load in children, even asymptomatic, can be quite significant, and therefore it is likely that as vaccine uptake in adults increases, children may become the major vectors. Children should be vaccinated for their own protection, but there are likely broader public health benefits as well, as they make up 23.6% of the US population.
When we talk about vaccinating our children, we cannot ignore health equality – but it is a false dichotomy that we have to choose between children or the devastated world. We can do both. Furthermore, there is no evidence that restricting vaccination in the US will increase vaccination elsewhere, given distribution hurdles beyond the reach of US policy (although this should not be taken to undermine international aid, which is imperative ).
The risks are adjustable. A seasonal decrease in COVID-19 during the summer is likely and we can take advantage of this to ensure a safe return to school. The FDA Emergency Use (EUA) authorization is a rigorous and appropriate avenue for administering vaccination to children to suppress this threat. All adolescents aged 12 years and older without a medical contraindication should receive the COVID-19 vaccine as soon as possible. It is virtually unheard of for a vaccine side effect to occur more than 2 months after vaccination, and especially unlikely with current vaccine technologies. The known and potential benefits of vaccinating children far outweigh the known risks. As we await the completion of the age de-escalation, we would like to emphasize that it is our duty to protect children with NPIs and cocooning when circumstances require it. We all want a return to normalcy, but it’s not fair to do this at the expense of child safety. We can avoid immeasurable suffering if we treat pediatric COVID-19 only with commensurate severity.
Edward Nirenberg is a blogger about COVID-19 and medicine. Risa Hoshino, MD, is a board-certified pediatrician working in public health with a focus on school health, vaccine education, and immigrant health in New York City.