Why Aren’t We Better Protecting Our Youngest Children Against Infections?

ContagionContagion, December 2022 (Vol. 07, No. 6)
Volume 7
Issue 6

Vaccinations and mitigations for COVID-19 and other respiratory viruses have not been made a priority for young children. Let’s change this before the next big surge hits.

The United States is experiencing a diligent push to return to a “pre-COVID” version of normalcy. President Biden declared the pandemic over,1 and the Centers for Disease Control and Prevention (CDC) changed its COVID-19 metrics to report less severe–looking “community levels”2 of disease (largely based on hospitalization rates and not disease transmission3). In school settings the CDC greenlit the easing of COVID-19 screening tests, social distancing in classrooms, and masking.4 This is all taking a toll on the youngest group of children in the country and seems to be a very low priority.

US children have returned to school or daycare centers in greater numbers this year, and largely without mitigation measures. Despite published evidence that prevention methods such as masks5-11 and increased ventilation6,12-15 reduce the transmission of COVID-19 in classrooms, and that the COVID-19 vaccine prevents severe disease in children,16-19 there are no longer any states20 or schools21 requiring face masks and only a few school districts requiring COVID-19 vaccines for students.22 Findings from a recent CDC study also demonstrated that only 30% of K-12 schools are using high-efficiency particulate air filtration systems in their classrooms to clean the air.23 The lack of preventive measures at schools has resulted in high absenteeism this year due to unseasonal onslaughts of various respiratory viruses.24-28

The youngest children in the United States are the least vaccinated group in the country.29 COVID-19 vaccines were authorized for children 6 months to 4 years old in June 2022,30 but subsequent vaccine uptake in this age group has been extremely poor.31 Four months after vaccine availability, only 9% of children under 5 years have had their first COVID-19 shot, leaving 15.6 million children in this age group potentially at risk for severe illness.29,32 Pediatric COVID-19 vaccine uptake increases by age, as the percentage of children who have received at least 1 dose increases to 38% in the 5 to 11 age group, and to 67% among 12- to 17-year-olds. According to national survey data, about half (53%) of parents of children ages 6 months through 4 years say they will “definitely not” get their child vaccinated for COVID-19, a percentage that has increased from earlier surveys this year.33

Regarding recent public health data and results from parent opinion surveys, 3 themes emerge: 1) rates dropped for all vaccinations overall during the COVID-19 pandemic and have not yet returned to 2019 levels; 2) parents do not believe that COVID-19 poses a significant risk to children under 5 years; and 3) misinformation has fueled high levels of parental concern about COVID-19 vaccine safety and efficacy, especially for this youngest age group.

The CDC reported that vaccination rates for 2020 to 2021 were a full percentage point lower overall than the year before the pandemic, and this decline varied widely by state.34 Data from several other US studies validate this trend in dropping vaccination rates after the beginning of the COVID-19 pandemic.34-38 The problem of vaccination rates dropping during the COVID-19 pandemic is not confined to the United States. The World Health Organization (WHO) and United Nations International Children’s Emergency Fund report that global childhood vaccine coverage dropped 5% overall between 2019 and 2021, increasing the number of completely unvaccinated children by 5 million worldwide since 2019.39 WHO has deemed this as the largest backslide in vaccinations in 3 decades.40,41 The worldwide decrease in vaccinations was likely due to both negative opinions about vaccines that stemmed from recent politics and misinformation, and parents being too afraid or unable to take their children to well child pediatric visits during the pandemic.

Public health data show that almost 93% of US children are vaccinated against polio, and 90% against measles, mumps, and rubella by 24 months of age.42 But fewer than 10% of the youngest children are vaccinated against COVID-19,29 a virus currently in wide circulation.

This represents a distinction in parents’ minds between the perception of risks from other vaccine-preventable illnesses and the risks from COVID-19. Results from a recent survey showed that, among parents of children aged 6 months to 4 years who were not opposed to vaccination, 14% said they want to “wait and see” before vaccinating their child for COVID-19, and another 8% will get them vaccinated “only if required” for school or other activities.33 These results further suggest a lack of urgency about protecting young children from COVID-19. Contrary to perceptions, this age group has a large burden of illness. As of October 2022, there have been over 3 million cases of COVID-19 officially reported in children under 5 years, comprising 3.6% of all reported US cases.43 As this age group makes up 6% of the US population, this means that over half the country’s youngest age group have received an official COVID-19 diagnosis at some point.

Findings from seroprevalence surveys, however, suggest the real number is closer to 70% having been infected.44 According to data from a recent meta-analysis, the prevalence of long COVID in children was 25%,45 which translates to at least 750,000 US children aged 0 to 4 years experiencing prolonged symptoms. Although severe COVID-19 is not as prevalent in young children as it is in adults, its occurrence is not always predictable. The CDC reported in June 2022 that over 46% of children aged 0 to 4 years who were hospitalized with COVID-19 had no underlying conditions.46 The vaccination rate is the lowest for this younger age group despite the fact that hospitalization and intensive care unit admission rates for the 0 to 4 year age group has been consistently higher than the 5 to 11 or 12 to 17 years age groups since the beginning of the Omicron period.46 Of these hospitalizations, over 86% were admissions specifically due to COVID-19.46 There have been 585 COVID-19 deaths in the 0 to 4 years age group,47 and COVID-19 was listed among the top 10 causes of death for children in the United States in 2021.48 Omicron and its subvariants have presented a challenge to neutralizing antibodies derived from both the vaccine and the virus. So any risk of severe COVID-19 disease in children would not be balanced by the benefit of lasting immunity. Antibodies from COVID-19 infection also wane, and immunity acquired through previous infection is less effective against Omicron49 than against other previous variants.49 In fact, the most durable immunity occurs when a person with a previous COVID-19 infection is also vaccinated.50

Misinformation on social media about the safety of COVID-19 vaccines has led many parents of young children to believe the benefits do not outweigh the risk of the vaccine, especially if their children previously had COVID-19. There seems to be a misconception that the COVID-19 vaccine is a less safe way for their child to build immunity than the disease itself. Pfizer and Moderna both reported earlier this year that their respective COVID-19 vaccines were effective for children aged 6 months to 4 years when Omicron variants were circulating.51,52 Most adverse events in both trials were mild or moderate, with safety profiles similar between vaccine and placebo groups.51-53 The major worry for parents has been related to vaccine-induced myocarditis. In addition to its already being extremely rare in teenaged and young adult males,54-56 myocarditis has not been seen at all in the younger age groups.53 The American College of Cardiology has published a recent consensus statement that states that the COVID-19 vaccines have a “favorable risk-to-benefit ratio for all age and sex groups.”56 Also, data from a recently published systematic review and meta-analysis showed that the overall risk of myocarditis is 7 times higher after a COVID-19 illness than after the vaccination.57

Preschools, churches, daycare centers, and other community settings not requiring mitigation measures would not be as concerning if COVID-19 vaccination rates among the youngest children were higher. In the absence of nonpharmaceutical interventions, over 90% of United States children aged 0 to 4 years are currently not protected in any way.29 The COVID-19 vaccine predictably prevents severe SARS-CoV-2 outcomes, with minimal short-term immunogenicity reactions and very rare complications. COVID-19 disease, on the other hand, can unpredictably cause severe infection, hospitalization, multisystem inflammatory syndrome, long-term chronic health problems, and death.

Although immunity from both infection and vaccines will wane over time, it is not worth taking a chance with severe outcomes for transient immunity from infection. Thus, the vaccine is a safer way to shift pediatric COVID-19 illness to the milder end of the spectrum. Understanding the gap between fear and vaccine choice brings us back to the complicated perceptions of risk and benefit on which parents base their vaccine decisions. Views on the COVID-19 pandemic and sentiments around the COVID-19 vaccine could spill over to other vaccines for children. We are already seeing vaccine-preventable illnesses reemerging where vaccination rates in general are low.58,59

Continued levels of undervaccination will lead to additional public health crises. Strategies including community education, social media campaigns, immunization tracking, and vaccination reminders from health care providers will all be vital to get the youngest children up to date with their regular vaccines and will also increase their COVID-19 vaccination coverage.


1. Biden on ‘60 Minutes’: ‘The pandemic is over’. Updated September 18,2022 Accessed October 25, 2022. https://www.politico.com/news/2022/09/18/joe-biden-pandemic-60-minutes-00057423

2. CDC COVID data tracker. Updated October 25,2022 Accessed October 25, 2022. https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=CommunityLevels

3. CDC COVID-19 Integrated County View. CDC.Updated October 25, 2022 Accessed October 25, 2022. https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=Risk&null=Risk

4. CDC streamlines COVID-19 guidance to help the public better protect themselves and understand their risk. August 8, 2022, October 25,2022. https://www.cdc.gov/media/releases/2022/p0811-covid-guidance.html

5. Talic S, Shah S, Wild H, et al. Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality: systematic review and meta-analysis. Bmj. Nov 17 2021;375:e068302. doi:10.1136/bmj-2021-068302

6. Gettings J, Czarnik M, Morris E, et al. Mask Use and Ventilation Improvements to Reduce COVID-19 Incidence in Elementary Schools-Georgia, November 16-December 11, 2020. MMWR Morb Mortal Wkly Rep. May 28 2021;70(21):779-784. doi:10.15585/mmwr.mm7021e1

7. Hekmati A, Luhar M, Krishnamachari B, Matarić M. Simulating COVID-19 classroom transmission on a university campus. Proc Natl Acad Sci U S A. May 31 2022;119(22):e2116165119. doi:10.1073/pnas.2116165119

8. Dawson P, Worrell MC, Malone S, et al. Pilot Investigation of SARS-CoV-2 Secondary Transmission in Kindergarten Through Grade 12 Schools Implementing Mitigation Strategies - St. Louis County and City of Springfield, Missouri, December 2020. MMWR Morb Mortal Wkly Rep. Mar 26 2021;70(12):449-455. doi:10.15585/mmwr.mm7012e4

9. Falk A, Benda A, Falk P, Steffen S, Wallace Z, Høeg TB. COVID-19 Cases and Transmission in 17 K-12 Schools - Wood County, Wisconsin, August 31-November 29, 2020. MMWR Morb Mortal Wkly Rep. Jan 29 2021;70(4):136-140. doi:10.15585/mmwr.mm7004e3

10. Volpp KG, Kraut BH, Ghosh S, Neatherlin J. Minimal SARS-CoV-2 Transmission After Implementation of a Comprehensive Mitigation Strategy at a School - New Jersey, August 20-November 27, 2020. MMWR Morb Mortal Wkly Rep. Mar 19 2021;70(11):377-381. doi:10.15585/mmwr.mm7011a2

11. Cowger TL, Clarke J, Murray EJ, et al. Impact of Lifting School Masking Requirements on Incidence of COVID-19 among Staff and Students in Greater-Boston Area School Districts: A Difference-in-Differences Analysis. medRxiv. 2022:2022.08.09.22278385. doi:10.1101/2022.08.09.22278385

12. Burgmann S, Janoske U. Transmission and reduction of aerosols in classrooms using air purifier systems. Phys Fluids (1994). Mar 2021;33(3):033321. doi:10.1063/5.0044046

13. Curtius J, Granzin M, Schrod J. Testing mobile air purifiers in a school classroom: Reducing the airborne transmission risk for SARS-CoV-2. Aerosol Science and Technology. 2021/05/04 2021;55(5):586-599. doi:10.1080/02786826.2021.1877257

14. Lindsley WG, Derk RC, Coyle JP, et al. Efficacy of Portable Air Cleaners and Masking for Reducing Indoor Exposure to Simulated Exhaled SARS-CoV-2 Aerosols - United States, 2021. MMWR Morb Mortal Wkly Rep. Jul 9 2021;70(27):972-976. doi:10.15585/mmwr.mm7027e1

15. Fisk WJ. The ventilation problem in schools: literature review. Indoor Air. Nov 2017;27(6):1039-1051. doi:10.1111/ina.12403

16. Sacco C, Del Manso M, Mateo-Urdiales A, et al. Effectiveness of BNT162b2 vaccine against SARS-CoV-2 infection and severe COVID-19 in children aged 5-11 years in Italy: a retrospective analysis of January-April, 2022. Lancet. Jul 9 2022;400(10346):97-103. doi:10.1016/s0140-6736(22)01185-0

17. Price AM, Olson SM, Newhams MM, et al. BNT162b2 Protection against the Omicron Variant in Children and Adolescents. N Engl J Med. May 19 2022;386(20):1899-1909. doi:10.1056/NEJMoa2202826

18. Tan SHX, Cook AR, Heng D, Ong B, Lye DC, Tan KB. Effectiveness of BNT162b2 Vaccine against Omicron in Children 5 to 11 Years of Age. N Engl J Med. Aug 11 2022;387(6):525-532. doi:10.1056/NEJMoa2203209

19. Klein NP, Stockwell MS, Demarco M, et al. Effectiveness of COVID-19 Pfizer-BioNTech BNT162b2 mRNA Vaccination in Preventing COVID-19-Associated Emergency Department and Urgent Care Encounters and Hospitalizations Among Nonimmunocompromised Children and Adolescents Aged 5-17 Years - VISION Network, 10 States, April 2021-January 2022. MMWR Morb Mortal Wkly Rep. Mar 4 2022;71(9):352-358. doi:10.15585/mmwr.mm7109e3

20. State-by-State Guide to Face Mask Requirements. Accessed October 25, 2022. https://www.aarp.org/health/healthy-living/info-2020/states-mask-mandates-coronavirus.html

21. Mask tracker: Last batch of K-12 mandates have come to an end. Accessed October 25, 2022. https://districtadministration.com/school-mask-tracker-who-is-and-isnt-loosening-the-rules/

22. Beard M. Just a few school districts are imposing coronavirus vaccine mandates. The Washington Post. Accessed October 25, 2022. https://www.washingtonpost.com/politics/2022/08/25/just-few-school-districts-are-imposing-coronavirus-vaccine-mandates/

23. Pampati S, Rasberry CN, McConnell L, et al. Ventilation Improvement Strategies Among K-12 Public Schools - The National School COVID-19 Prevention Study, United States, February 14-March 27, 2022. MMWR Morb Mortal Wkly Rep. Jun 10 2022;71(23):770-775. doi:10.15585/mmwr.mm7123e2

24. US schools are back in person, but many children aren’t back to full time. New York Times.Accessed October 25, 2022. https://www.nytimes.com/2022/02/28/world/school-is-back-in-person-but-many-children-arent-back-to-full-time.html

25. CDC FLU View. 2022; Accessed October 25, 2022. Updated October 21, 2022. https://www.cdc.gov/flu/weekly/usmap.htm

26.CDC RSV Numerator Data. Accessed October 25, 2022. Updated October 21, 2022. https://www.cdc.gov/surveillance/nrevss/images/trend_images/RSV14Num_Nat.htm

27. Gleeson S. After over 1,000 students report flu-like symptoms, Virginia high school investigates cause. USA Today. October 24, 2022. https://www.usatoday.com/story/news/education/2022/10/24/virginia-school-flu-thousands-students-sick/10586818002/

28. Dendinger J. Absenteeism is chronic at Belen Consolidated Schools. Valencia County News Bulletin. October 22, 2022. https://news-bulletin.com/absenteeism-is-chronic-at-belen-consolidated-schools/

29. CDC. COVID-19 Vaccinations in the United States. Accessed October 24, 2022. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total

30. CDC Recommends COVID-19 Vaccines for Young Children. June 18, 2022. Accessed October 24, 2022. https://www.cdc.gov/media/releases/2022/s0618-children-vaccine.html#:~:text=Today%2C%20CDC%20Director%20Rochelle%20P,receive%20a%20COVID%2D19%20vaccine.

31. Kates J, Oum S. COVID-19 Vaccination Rates Among Children Under 5 Have Peaked and Are Decreasing Just Weeks Into Their Eligibility. KFF (Kaiser Family Foundation) Accessed Oct 18, 2022, https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-vaccination-rates-among-children-under-5-have-peaked-and-are-decreasing-just-weeks-into-their-eligibility/

32. AAP. Children and COVID-19 Vaccination Trends 2022. Accessed October 24, 2022. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-vaccination-trends/

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35. Ackerson BK, Sy LS, Glenn SC, et al. Pediatric Vaccination During the COVID-19 Pandemic. Pediatrics. Jul 2021;148(1)doi:10.1542/peds.2020-047092

36. Patel Murthy B, Zell E, Kirtland K, et al. Impact of the COVID-19 Pandemic on Administration of Selected Routine Childhood and Adolescent Vaccinations - 10 U.S. Jurisdictions, March-September 2020. MMWR Morb Mortal Wkly Rep. Jun 11 2021;70(23):840-845. doi:10.15585/mmwr.mm7023a2

37. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic - Michigan Care Improvement Registry, May 2016-May 2020. Am J Transplant. Jul 2020;20(7):1930-1931. doi:10.1111/ajt.16112

38. Services CfMaM. Service use among Medicaid & CHIP beneficiaries age 18 and under during COVID-19. CMS Accessed October 18, 2022, https://www.medicaid.gov/resources-for-states/downloads/medicaid-chip-beneficiaries-18-under-COVID-19-snapshot-data.pdf

39. WHO. Immunization coverage. July 14, 2022. October 24, 2022. https://www.who.int/news-room/fact-sheets/detail/immunization-coverage

40. WHO. COVID-19 pandemic fuels largest continued backslide in vaccinations in three decades. July 15, 2022. Accessed October 24, 2022. https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades

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42. CDC. Immunization Faststats Homepage. Accessed October 18, 2022, https://www.cdc.gov/nchs/fastats/immunize.htm

43. (AAP) AAoP. Children and COVID-19: State-Level Data Report, Oct 13, 2022. Accessed October 18, 2022.

44. Clarke K, Kim Y, Jones J, al. e. Pediatric Infection-Induced SARS-CoV-2 Seroprevalence Estimation Using Commercial Laboratory Specimens: How Representative Is It of the General U.S. Pediatric Population? SSRN. 2022

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46. Fleming-Dutra K. COVID-19 Epidemiology in Children 6 months - 4 Years 2022. ACIP meeting materials. June 17, 2022. Accessed October 18, 2022. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-06-17-18/02-covid-fleming-dutra-508.pdf

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51. Anderson EJ, Creech CB, Berthaud V, et al. Evaluation of mRNA-1273 Vaccine in Children 6 Months to 5 Years of Age. N Engl J Med. Oct 19 2022;doi:10.1056/NEJMoa2209367

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53. Fleming-Dutra KE, Wallace M, Moulia DL, et al. Interim Recommendations of the Advisory Committee on Immunization Practices for Use of Moderna and Pfizer-BioNTech COVID-19 Vaccines in Children Aged 6 Months-5 Years - United States, June 2022. MMWR Morb Mortal Wkly Rep. Jul 1 2022;71(26):859-868. doi:10.15585/mmwr.mm7126e2

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58. Polio vaccination rate for 2-year-olds is as low as 37% in parts of N.Y. county where paralysis case was found. Accessed October 19, 2022. https://www.nbcnews.com/health/health-news/polio-vaccine-coverage-low-37-ny-county-paralysis-case-was-found-rcna43279

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