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.
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.
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.
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).