Bioethics Forum Essay

Covid is Surging. Most Young Children Are Still Unvaccinated

Children are returning to classrooms amid another wave of Covid cases, but some public health leaders have leaned into the message that “most of us” can ignore the continued presence of Covid by taking just “a few basic steps,” such as staying up to date with vaccinations and promptly seeking antiviral treatment if infected. “Most of us,” however, does not include families with young babies, among other groups for whom these steps are unavailable or insufficient.

As the world has moved on from pandemic precautions, newborn babies are especially vulnerable. Infants under 6 months old are hospitalized with Covid at rates comparable to those of adults aged 65 to 74, and hundreds of children from birth to 4 years old have died. While rare, when severe disease occurs in older toddlers and preschoolers it is generally preventable. Yet we are not preventing it:  about 90% of children from birth to age 4 in the U.S. remain unvaccinated (meaning that they have not started the primary series of vaccines). Fewer than 1% have received a bivalent booster.

Headlines have attributed this low uptake to parents’ distrust of the vaccines, but focusing only on hesitancy overlooks other forces related to access, awareness, and motivation. Our own experiences vaccinating our young children, though not representative, illustrate that obstacles persist even for parents with the motivation and resources, raising ethical questions for future childhood vaccination efforts such as rollout of updated Covid vaccines and a newly approved RSV shot for infants this fall.

Access Barriers

As one of us (Elizabeth) found out when her second child turned 6 months old this year, it can be challenging to get a baby vaccinated. Though pharmacies are central to Covid vaccination in the U.S.,  few vaccinate children under 3 years old. Pediatricians’ offices may not stock up on Covid vaccines out of fear of wasting multidose vials amid low demand, or they may only offer the vaccines on a limited schedule. Elizabeth’s pediatrician’s office did not stock the vaccine; it is part of a health system that was offering appointments at only one of its seven facilities once a week for three hours.

Elizabeth’s baby aged into eligibility just as the public health emergency declaration ended, prompting many local health departments to close vaccination sites. In addition to having fewer places to go for Covid vaccines, many people will now face a financial hurdle: Covid vaccines must be paid for either by insurance or out of pocket. Uninsured people will face delays obtaining a fall Covid vaccine in major U.S. pharmacies.

For parents who would only vaccinate their children if little effort was required,  or who lack time to follow eligibility updates and attend multiple appointments during limited business hours, vaccinating a baby may be close to impossible in some areas of the U.S. Medicaid disenrollment affecting hundreds of thousands of children and cuts to Centers for Disease Control and Prevention’s child vaccination programs will further impede access as Covid vaccines enter the private market.

Perceived Risk and “Moral Calm”

Sociologist Jessica Calarco coined the term “moral calm” to describe the popular–but false–narrative promoted through public policy and media rhetoric that SARS-Cov2 was less likely to infect children than adults and posed little risk when it did, giving parents “almost no incentive at all” to vaccinate. Known, preventable harms of pediatric Covid infection were sidelined by this relative framing even as absolute cases, hospitalizations, and deaths mounted.

The CDC’s decision to relax Covid protections by making masks optional in public spaces, for example, increased children’s exposure amid surging pediatric hospitalizations and a stalled vaccine authorization process. Over a six-week period in January and February 2022, more than a thousand children under the age of 5 were hospitalized. High Covid transmission exacerbated risk to young children, for whom “the tools” of vaccination and antiviral treatment were out of reach.

Regulators who had repeatedly delayed authorization of vaccines for children since summer 2021 did so again in February 2022–during this record-setting wave of preventable pediatric hospitalizations–to request additional trial data. By this point, more data was unlikely to match the constant viral evolution and stream of evidence-resistant disinformation, and the potential to improve the quality of evidence was limited. The vaccines had already demonstrated a strong safety profile that the trials were not powered to augment.

Meanwhile, off-label use of approved vaccines was denied; and “one-way masking” was inaccessible to those too young to wear a mask. By the end of 2022, nearly all children ages 6 months to 17 years had Covid antibodies. Current estimates show that the youngest age group is unique in having acquired antibodies almost universally through infection alone, not vaccination or “hybrid” immunity.

The Race between Vaccination and Infection

During the peak of pediatric infections during the Omicron surge, two of us enrolled our kids in Covid vaccine trials for the 70% chance that they would get the vaccine instead of a placebo. Parents similarly eager to vaccinate their children organized online communities and traveled long distances to find trials. Sophia viewed trial enrollment as posing less risk to her children than infection without vaccination, and Ami was one of those parents willing to drive three hours each way to enroll her 3-year-old in a trial.

With the help of a grassroots parent network, Ami narrowly reached the goal of vaccination before infection. Her whole family was infected with Covid the week after finding out her child had received the vaccine. But such opportunities were largely restricted to those able to enroll in a trial, and with means to limit their children’s Covid exposure for more than two years. By the time vaccines were authorized for kids under 5, in June 2022, an estimated 74% of them had been infected at least once – a share that could have been substantially lower had authorization been given a few months earlier.

Despite conferring limited protection relative to vaccination, and carrying additional long Covid risk, immunity built up through prior infection is touted as a “tool” for protection against future Covid  infection. For the majority of parents whose young children lost the race to vaccination before first infection, previous encounters with the virus may reduce urgency to stay up to date with vaccinations.

Who Has the Tools?

At least two vaccine manufacturers, Moderna and Pfizer, are preparing to ship updated formulations for children ages 6 months and up this fall, though questions remain about whether the Food and Drug Administration will authorize, and the CDC  will recommend, the vaccine for all ages. They should, particularly if vaccines are to be the primary ongoing defense against Covid.

Projections suggest that in the best case scenario Covid hospitalizations and deaths will be on par with other viral illnesses this fall, but it is more likely Covid will remain a leading cause of death in the U.S. The best case entails nearly all people eligible for a fall vaccine getting vaccinated, a scenario that recent uptake and prior polling suggests is virtually impossible.

The moral calm around kids and Covid must be met with better communication about the risks of repeated infection. Journalists covering Covid can help by reinforcing the message that there are high-risk groups, including infants, for whom the “tools” are insufficient. Existing preventive options, including vaccination during pregnancy to protect babies in their first six months, should be promoted by public health organizations and clinicians. Finally, clinical trials studying vaccines for babies younger than 6 months old may yield important benefits and should command public attention.

Getting shots into arms (or legs) this fall requires a true paradigm shift for our health agencies and policymakers: urgency for authorizations and approvals, continuous funding for and access to vaccination programs, and communication about severe outcomes in children that are fortunately rare but deserve all the tools of prevention.

Sophia Bessias, MPH, MSA, is a bioinformatician at the Duke University School of Medicine. @sophiacbess

Ami Harbin, PhD, is an associate professor in the departments of philosophy and women and gender studies at Oakland University.

Elizabeth Lanphier, PhD, MS, is an assistant professor in the Ethics Center at Cincinnati Children’s Hospital Medical Center and in the departments of pediatrics and philosophy at the University of Cincinnati, as well as a nonresident research fellow in the Institute for Philosophy and Public Policy. @EthicsElizabeth