It’s official: Teens are getting the shot. Today, the US Food and Drug Administration decided that Pfizer’s Covid-19 vaccine could be used in children as young as 12, following a clinical trial that found the vaccine was safe and effective. The decision means roughly 17 million children younger than 16—the previous cutoff for the Pfizer shot—are newly eligible for vaccinations, which could begin as soon as Wednesday, following a separate recommendation from a CDC panel.
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By Eve Sneider
When she first heard about the trial results, Monica Gandhi, an infectious disease expert at UC San Francisco, was relieved. The opportunity to vaccinate teens had come sooner than expected—and, as she saw it, in the nick of time: It meant plenty of breathing room to start vaccinations before the fall. More than half of California students are learning remotely, according to an analysis by the education nonprofit EdSource, and the next semester remains uncertain. But with vaccines available, the process of getting everyone back on campus was looking smoother—for reasons that, in her view, had more to do with psychology than with epidemiology. “It’s been such a barrier for middle and high school students, not because schools aren’t safe but because of the perception that they aren’t,” she says.
Across the US, the return to school has been complicated by a twist-filled pandemic spring. First there was the problem of high case rates—too much virus was moving around during the winter surge, just as district officials from New York to Los Angeles were debating how to return more students to in-person instruction. Then came the unknowns of new, more transmissible variants. But even in places where case rates are now far below those winter peaks, and where teachers have been vaccine-eligible for weeks, the prospect of returning has remained fraught. Some parents are reluctant to send their kids, who may now be the only unprotected people in their families, to mix with other unvaccinated people. And some teachers are wary of receiving those students in their classrooms.
In San Francisco, where Gandhi lives, some students have returned to campus—but often only to open their laptops again when they arrive: so-called “Zoom in a room,” as disgruntled parents have put it. Schools are constrained by CDC recommendations of 3- to 6-foot distancing in buildings and by limited staffing due to teachers with medical exemptions. This summer, state legislators will decide whether to continue a waiver that has allowed remote instruction. Laura Dudnick, a spokesperson for the San Francisco Unified School District, notes that the district’s agreement with employees covers only the remainder of the spring semester, and she says the district will follow public health guidance as it develops plans for the fall.
Meanwhile, public health experts like Gandhi have maintained that schools can be fully opened safely, even prior to widespread vaccination. The benefits of doing so would be enormous, she says, given the toll of closures on mental health and learning. It’s a tricky needle to thread: As more schools have opened, we’ve learned that kids do transmit the virus—perhaps more than scientists initially thought—and some studies have linked the reopening of schools to more household infections. But we’ve also learned how to manage those risks better with precautions like good ventilation, masks, and testing. A recent preprint by Johns Hopkins University researchers, which has not yet been peer-reviewed, found that the risk that kids attending in-person school would seed infections in their households disappeared in places that adopted careful protection measures. (The research was conducted prior to widespread adult vaccinations, which should further reduce household spread.) A January review by CDC scientists came to a similar conclusion, based on data from a number of countries where schools had by then reopened. School outbreaks did occur, they found, but they were easier to control than outbreaks in places like nursing homes.
Returning with precautions isn’t returning without risk. About 100 children under age 15 died in the US from Covid-19 in 2020. And there are still unknowns, such as the long-term effects of the disease on kids, including the inflammatory illness known as MIS-C, says Ashleigh Tuite, an epidemiologist at the University of Toronto. Plus, while deaths and hospitalization rates are comparatively low among kids, the impact is uneven: Those rates are higher among Black and Latinx students, immunocompromised children, and those with other health problems.
The newer variants have also highlighted the need for stronger layers of protection, like masks and ventilation, in reopened schools, Tuite says. In Ontario, schools reopened this winter just as the province was gripped by a wave of infections driven by the more transmissible B.1.1.7 variant that has sickened a higher proportion of younger people than before, in part due to lower rates of vaccination. The timing meant students became “the unwitting recipients of an experiment when you reopen and have an unprotected population,” Tuite says. The province decided to end in-person learning in April as part of a wider lockdown. (Canada authorized the Pfizer vaccine for teenagers on May 5.)
The vaccine authorizations for teens arrived faster than many experts expected. Last summer, pediatrics researchers sounded the alarm that including younger people in clinical trials was moving too slowly. But that process sped up in December after the FDA’s emergency use authorization of the Pfizer and Moderna mRNA vaccines, both of which were shown to be remarkably effective at preventing disease in adults. The first children were enrolled in small trials of both vaccines later that month. In late March, Pfizer reported good news about the vaccine’s efficacy among younger users: No teens in the test group contracted Covid-19, compared with 18 cases in the placebo group, and the shot induced similar immune responses to those seen in young adults. But the primary aim of the trial was to demonstrate that the shot would be as safe for teens as for adults; the results showed they indeed experienced similar rates of side effects.
The prospect of a return to relative normalcy in the US while the virus rages elsewhere has also raised some confounding ethical questions. The US is poised to begin vaccinating teens with minimal chances of severe illness, while in India, where 6 percent of people have been vaccinated so far, health officials have been reporting a staggering 400,000 new infections per day. “Would you vaccinate a small child here before a 65-year-old in India? I think global vaccine equity should be achieved first,” Gandhi says.
But that shouldn’t discourage teens from getting vaccinated, she adds. Last month, researchers at Duke University predicted the US could have 300 million excess doses by the end of July, given the slowing vaccination rates among adults. Starting today, there will be about 17 million newly eligible teens in the US. Even with a significant charitable pivot by the US government, drugstores and doctor’s offices are unlikely to go short.
Over time, protecting kids is important for protecting everybody, says Marm Kilpatrick, a population biologist at UC Santa Cruz. That’s true even as experts express doubts about the ability for society to reach a herd immunity threshold, where enough immunity is built up in the community that the cycle of viral transmission is effectively halted. “Any herd immunity calculations rely on well-mixed populations, where everyone is having equal contact with everyone,” he says. But in real life, “that’s not how it works. Social networks segregate by age.” Having certain pools of people who aren’t protected but spend time together—say at school or at basketball practice—is a recipe for outbreaks that can spread quickly and potentially to unvaccinated people in the community beyond.
As for adults, uptake is a question for teens. A survey this month by the Kaiser Family Foundation indicated that roughly a quarter of parents would definitely not vaccinate their children, while a fifth would do so only if their school required it, following the examples of some workplaces and universities. Doing so would be unusual, says Gandhi, based on current vaccine rules for public schools. Schools typically require vaccines for diseases that pose a high risk to school-age people—diseases like measles and hepatitis B—while simply recommending shots to prevent lower-risk diseases like the flu. That said, policies will likely vary by district.
On May 4, Pfizer CEO Albert Bourla told investors that the company plans to complete its trials of the vaccine in children as young as 2 by the fall. Gandhi was happy to hear parents would have the option, but the timing left her a little worried. Would some elementary schools and preschools decide to hold off on in-person classes until the youngest children could get inoculated? She hoped they would see that there were other ways to keep everyone safe. “That’s my biggest fear, that people believe we need children to be vaccinated for normalcy,” she says.