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The notion is out there that public school students should not return to in-person learning until they’ve been vaccinated. That proposition worries me. Here are five reasons why schools can and should open at 100% capacity before a vaccine for those under age 16 is available.

For kids, the risk of missing school dwarfs the risk of Covid-19. Kids are less likely to acquire SARS-CoV-2, the virus that causes Covid-19, than adults. Several meta-analyses confirm that in contract tracing studies, kids are approximately half as likely to acquire the virus as other household contacts with the same exposure.

In addition, the risk of death or other bad outcomes is low for children. Between March and October of 2020, among those between the ages of five and 14, the risk of dying of Covid-19 in the United States was 1 in 1,000,000. To put that in perspective, in that same age group during non-Covid times, the risk of suicide is 10 times higher. For young adults ages 15 to 24, the risk of dying from Covid19 was 9.9 in 1,000,000, and they are also generally 10 times more likely to commit suicide.

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A study in Sweden, where 1.95 million kids younger than age 16 attended schools without masks between March 2020 and June 2020, 15 (or 1 in 130,000) developed severe Covid-19 and none died.

Contrast these outcomes with those of adults. For the sake of comparison, imagine 100,000 infected people at different ages, using data from a meta-analysis conducted by an international team: two of those age 10 might die compared to 1,400 adults aged 65 and 15,000 adults aged 85. In other words, the risk of an 85-year-old dying from Covid-19 is 7,500 times greater than that of a 10-year-old.

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Meanwhile, school closure is associated with considerable harms to children. Mental health problems are on the rise. Abuse has gone undetected, and children with disabilities are no longer benefitting from educational and other programs. With proper use of precautions, such as masks, the chance of spread is very low even without vaccines, as shown in a recent analysis by three Centers for Disease Control and Prevention researchers.

When I put it all together, it is clear to me: Adult interests have been prioritized over children’s well-being by closing schools. For kids to return to school, I support teachers being vaccinated (though this is not essential), the use of indoor masks, capping classroom size at 20, quarantining students if symptomatic cases occur, and distancing between classes. These were the precautions used in the CDC analysis.

Vaccine data will take a while. Current emergency use authorization for the Pfizer vaccine permits adults as young as 16 to receive the vaccine, and ongoing trials are recruiting kids as young as 12, which may yield results later this year. If these are successful, future trials will extend to 9-year-olds. Trials including even younger individuals may not yield results until 2022.

Kids can’t wait for the results of these trials before returning to their lives.

Do kids in school drive Covid-19 spread? In the CDC analysis, when precautions were used, 0 of 654 staff members acquired Covid-19 in school. One well-done study from Germany took advantage of the staggered summer break to explore the impact of school closure and reopening on Covid-19 cases, and found no association between closing or opening schools and overall cases. These data further erode the claim that kids need to be vaccinated to slow the spread of the virus.

An emergency use authorization may not be appropriate. The entire premise of an emergency use authorization is that, when faced with an emergent biological, chemical, radiological, or nuclear threat, the Food and Drug Admininstration can allow products to be used based on lower levels of evidence than traditional approvals. A key provision is that “there are no adequate, approved, and available alternatives.”

There’s no question that Covid-19 is an emergency for adults, a catastrophic disease that becomes more deadly with advancing age. But it isn’t that for children. For them it is a respiratory pathogen with a rate of harm that is comparable to other, annual respiratory pathogens like influenza.

I hold that an emergency use authorization is not appropriate for a SARS-CoV-2 vaccine for children, which should instead proceed via traditional FDA approval pathways.

Vaccinating kids to slow the spread of the pandemic cannot be justified if adults are choosing not to be vaccinated. The risk-benefit calculus suggests that adults will derive more benefit from the vaccine than children, because the virus is more lethal in adults. If parents are reluctant to send their kids to school before children are vaccinated, they should be educated in a way that puts those risks in perspective.

Although a formal approval process will further slow any pediatric vaccine, I believe this is justified to ensure a favorable risk-benefit profile. In the meantime, schools can reopen.

The vaccines’ harm-benefit profile may be suboptimal in kids. The last consideration I offer is that we do not know if a vaccine will have a favorable risk-benefit profile, gain FDA approval, and be palatable to parents. Consider what might happen to a million kids who receive a vaccine that works as well in kids as it does in adults with comparable side effects.

Assume the same 95% relative risk reduction seen in studies of the Pfizer/BioNTech and Moderna vaccines in adults. The vaccine might save one life for every 1 million kids who get it.

At the same time, assume the vaccine has side effects comparable to adults for the second Moderna dose in adults. In that scenario, 45,000 kids will develop severe headaches requiring analgesics and interfering with daily living, 14,000 will have a fever higher than 104 degrees F for less than a day, and 880 will have this fever last for more than a day. This happens not because these side effects are common — they are rare — but because you have to vaccinate 1 million kids to save one life.

My point is that the vaccine side effects, which are absolutely justified in adults — full disclosure, I have been vaccinated — may be a tough sell to children and parents simply because the absolute benefit to kids is very small given the low absolute risk of developing severe Covid-19 or dying from it.

Closing thoughts

The Covid-19 pandemic has harmed children — not because they have fallen ill from the virus, for the most part, but by the choices societies have made to protect adults who are vastly more likely to suffer from the disease. In many places, kids have already lost a year of school, development, and life. A vaccine for kids will not happen in the short term, and emergency regulatory pathways for one or more of them may not be appropriate. The risk and benefit will need scrutiny.

We must not keep the lives of children on hold waiting for what might never come. As Vladimir Kogan and I argue elsewhere, schools should open now after the impacts to teachers, parents, society, and schools are taken into consideration.

Vinay Prasad is a hematologist-oncologist, associate professor of medicine at the University of California, San Francisco, and author of “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer” (Johns Hopkins University Press, April 2020).

  • This author is incorrect and false info is not what we need right now.
    Stop spreading false info!

  • You say” there’s no question that Covid-19 is an emergency for adults, a catastrophic disease that becomes more deadly with advancing age.”
    So why then is it ok to send unvaccinated teachers (many of whom are older) back into the classroom in old, unequipped public schools?
    In many states teachers are forced to go back unvaccinated while kids, who are at low risk, have the option of continuing virtual classes.
    Now the CDC is saying school is safe. Well if it’s safe enough for higher risk people ( teachers) then it’s certainly safe for kids.
    Many teachers must now teach in a circus with some kids online at the same time kids are in the room.

  • I totally disagree with the author. It has been proven that children are asymptomatic carriers of SARS-CoV-2 (even situations with 60% diagnosed in a school population yet zero symptoms). Luckily for Germany it does far better than that, but the US la-de-dah behaviour towards Covid is a very far cry from solidly rules-respecting German behaviour. In the unruly US, kids for sure are spreaders – to those older and more health-challenged that then may get severely ill and even die. It’s not just about the kids. The author also fails to state the need for HEPA filters in the air vents & circulation systems in the schools – most of which are old and would need to be drastically retro-fitted – for which Trump allocated zero funding and Biden is still fighting hard for. Eventually, to curb a contagious disease with detrimental outcomes like over 3000 US deaths per day (my God, and do not under-estimate the work-force debilitation by “long covid”) : vaccinating active innocently spreading kids for Covid ought to be normal – just like for measles, mumps, rubella, rabies, typhoid, tetanus, polio etc. We need far more creativity, space, different methods of teaching – as a solid preparation for when (not if) the next Pandemic arrives.

  • Dr. Prasad has supported vaccinated adults remaining unmasked in each other’s private company. Does he support adult vaccinated teachers remaining unmasked in the presence of their unvaccinated students? If you argue transmission among children doesn’t matter because it’s altogether less severe in kids than adults, how would you respond to teachers who don’t want to wear masks? How would you respond to children who refuse to wear masks indoors, and therefore not adhere to these guidelines?

  • It’s no good being the most intelligent child in the graveyard! Saying the risks of missing school dwarfs the risk of COVID-19 is despicable. Tell that to the young sufferers of long COVID or the parents of the 7 year old who lost their life today to COVID.
    Also, “Between March and October of 2020, among those between the ages of five and 14, the risk of dying of Covid-19 in the United States was 1 in 1,000,000.” Why pick those dates? Let’s see the figures in the UK since the new more transmissible strains have taken hold over the last 4 months

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