There is a general misconception that vaccination ought to be reserved against diseases that cause death in large numbers. COVID-19 is generally a mild disease in the large majority of healthy young children infected with SARS-CoV-2.
However, children living with diabetes, chronic heart/lung/kidney/neurological diseases, obesity, and with an immunocompromised state due to immunodeficiency syndromes or immunosuppressant therapies are at high risk of severe disease, need for hospitalisation and expensive treatments, even of mortality. Older children and adolescents have a higher risk of severe COVID-19, approximating adult risk levels. All such children deserve COVID-19 vaccination to preserve good quality of life.
MIS and diabetes
Four to six weeks after COVID-19, irrespective of severity, some among otherwise healthy children develop Multisystem Inflammatory Syndrome (MIS). Statistics available in India showed 5% mortality among 800 children hospitalised for MIS; more than half required intensive care and prolonged hospital stay. Without a national registry of MIS, we do not know its real burden. The U.S. Centers for Disease Control and Prevention (CDC) reported 91% protective effectiveness of two doses of Pfizer’s mRNA vaccine against MIS in children 12 to 18 years. COVID-19 vaccination prevents MIS.
Another post-COVID-19 disease in adults and children is diabetes, starting within weeks. In a report from the CDC on 80,893 children (below 18 years), the incidence of post-COVID-19 diabetes was 31 per 10,000 versus control, 11.8/10,000 after other respiratory infections. India already has a heavy burden of diabetes in children. COVID-19 vaccination will prevent post-COVID-19 diabetes.
The Brihanmumbai Municipal Corporation’s COVID dashboard (January 13, 2022), showed 16,426 total deaths, of which 19 were in children below 10, and 43 in children between 10 and 18 years (total of 62 or 0.38%). January data from UNICEF show that 0.4% of a total 3.5 million COVID-19 deaths were in children and adolescents. India’s reported deaths were 4.86 lakh till January 17, 2022 — child deaths at 0.4% rate would amount to 1,944. Independent analysis by expert epidemiologists (Science, January 6, 2022) estimated a six to seven-fold higher number of deaths, suggesting a far higher number of child deaths.
Other factors
It is estimated that 2,00,000 children are born with congenital heart defects every year in India. New cases of cancer in children are about 50,000 per year. A huge number of children have neurological disorders. As in a United Nations estimate, about 40 million in India are disabled due to various diseases, among whom over 7% are children. India has the second highest number of obese children in the world (~14.4 million). The burden of childhood nephrotic syndrome annually is about 1,40,000. Sickle cell disease is highly prevalent in the tribal populations in India. The Indian Society for Primary Immune Deficiency estimates that over a million children have primary immune deficiency disease. These are all conditions that are known as risk factors for severe COVID-19. Protecting them with COVID-19 vaccination is a humanitarian priority.
India’s third COVID-19 wave began from December 28, 2021. On January 3, 2022, children above 14 years are allowed vaccination, undoubtedly a step in the right direction. They become eligible for the second dose four weeks later — thus, children are not getting the benefit of protection during the present wave. Although we have not been able to protect children with vaccination so far, the Government of India must now plan for protection against the inevitable future endemic COVID-19. Paediatricians caring for children with the above listed conditions associated with high risk of COVID-19 and its complications, need approval to protect them with vaccination.
SARS-CoV-2 (except the Omicron variant) invades many body tissues and organs. Damage to the pancreas is the reason for new onset diabetes. COVID-19 is a new disease and the extent of damage to the health of children will be known only in due course. All facts considered, rolling out vaccination with vaccine(s) of assured safety is the right way forward.
Vaccine safety
Since the risks of severe COVID-19, its related complications and mortality are much higher in adults, a risk-benefit comparison has so far favoured vaccination, even with vaccines with some known serious adverse reactions. Globally, both mRNA vaccines and Adenovirus vectored vaccines are recognised to cause some specific and defined diseases that need to be immediately diagnosed and treated in order to prevent mortality
Since risk of COVID-19 severity is low in children, only vaccines with little or no risks of serious adverse reactions are justified in them. Thus, vaccine safety is the most crucial criterion for approval. Fortunately, the indigenous inactivated virus vaccine with adjuvant promoting cell-mediated and antibody arms of immunity had been investigated for safety in children at and above two years, and found to be safe without any serious adverse reaction. Obviously for this reason the Government has allowed it for exclusive use in children between 15 and 18 years. We argue for vaccinating younger children also with the same vaccine.
The urgency for vaccination is the continued high risk of disease, complications and death in children who, on account of their chronic diseases or prolonged treatments are vulnerable. Selective vaccination of high-risk groups will not be feasible under the emergency use approval (EUA) of vaccines in children. Once safe vaccines are licensed for general use, health-care givers can vaccinate selected children under their care.
Age of eligibility
As of now, the ethical, scientifically sound and wise decision ought to be step-wise lowering of age of eligibility: first to above 12 years, then to above five years and eventually to above two years, in rapid succession, ensuring safety in each age group. Expanding the age range for EUA of the vaccine does not necessarily mean that all families may opt for their otherwise healthy children to be vaccinated. However, without EUA, children who need prophylaxis against COVID-19 will continue to be denied the benefit of vaccination.
Dr. Dhanya Dharmapalan is a paediatric infectious diseases specialist in Navi Mumbai. Dr. T. Jacob John is a former (retired) Professor of Virology, Christian Medical College, Vellore, Tamil Nadu
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