By Dato' Dr Amar-Singh HSS

The recent statements by the minister and the director general of health regarding COVID-19 infections and severity in children have worried many parents.

It was reported that 82,341 children had been infected with COVID-19 from 25th January 2020 till 30th May 2021; the vast majority happening in 2021.

Infections have happened to children of all ages, including 19,851 in those under the age of five years.

The director general of the Ministry of Health (MOH) also reported that three children under the age of five years had died in the first five months of 2021.

In addition, 27 children had been admitted to pediatric intensive care units (PICUs) this year, with 19 of them aged under five years.

While we take every protective measure to prevent children from getting infected, we need to ask ourselves if we should consider vaccinating children against COVID-19. Some issues to consider the risk and the benefit are discussed below:

How severe is COVID-19 in children? Will vaccines benefit children?

A key determinant to vaccination is the severity of any illness. From available data it does appear that most children infected with COVID-19 get a mild or asymptomatic illness and that severe illness is rare.

One rare, severe complication of COVID-19 in children is multi-system inflammatory syndrome.

A comparison of mortality in seven countries estimated that 1.7 out of every million children died when infected with COVID-19.

Adolescents appeared to have a higher mortality rate than younger children.

A local evaluation of our deaths was published in Code Blue and showed that death rates among children aged 0-4 years and 13-17 years were both higher than that of primary school children (analysis is limited by the small number of deaths).

It however must be remembered, that in this pandemic, parents may have been shielding children as much as possible from COVID-19 infections and this may underestimate infections and mortality.

There are emerging reports that COVID-19 is causing severe illness in young children in Brazil with more than 2,200 deaths under the age of 10 years. This is unlike any other nation and may reflect emerging variants of concern which cause more severe illness.

There is growing evidence that children can suffer from Long COVID and be unwell for months after the infection. More data and work is required to clarify the size and severity of this problem in children.

Are COVID-19 vaccines safe to use in children?

The Pfizer-BioNTech vaccine has shown good efficacy against COVID-19 in children aged 12-15 years of age in preliminary phase 3 trial results. Sinovac has announced that its vaccine is safe in children ages 3-17 years. AstraZeneca and other vaccine companies are doing trials in children aged 6-17 years. Before the use of any such vaccines in children, our National Pharmaceutical Regulatory Agency will have to approve their use based on available data.

At all times we must have a vigilant surveillance on vaccine safety signals and act early if any appear.

Although clinical trial data is appearing about the safety and efficacy of some COVID-19 vaccines in children, we need to recognize that we will not see very rare side-effects until we use the vaccines in large populations.

The rare side effects of Oxford/AstraZeneca (blood clots) and Pfizer/BioNTech (myocarditis) in younger people were only recognized when populations were vaccinated.

Are there benefits to the family and society?

While children rarely have severe illness, we see the devastation COVID-19 has on adults, especially those who are elderly or have chronic illnesses. We also recognize that children can and do spread COVID-19 to adults.

Although no one is certain of the percentage of the population required to be vaccinated before we can hinder the spread of COVID-19 (herd immunity) in the community, we do know that this will be difficult without vaccinating children.

I recently wrote about whether we can achieve herd immunity. Approximately 30% of our population is under the age of 18 years; some Malaysians will choose not to vaccinate; others will be too ill or have a contraindication to vaccination; our large economic migrant and refugee populations are another factor. Hence we will not be able to reach sufficient rates of COVID-19 vaccination in the population without vaccinating children aged 12-18 years of age.

Remember that children cannot be a priority for vaccination until we first vaccinate all adults that are keen. This includes the elderly, those with chronic illness, younger adults who comprise our workforce and our migrant workers.

What are other nations doing?

The table below summarizes the response of selected countries on the issue of vaccinating children. A number of nations have approved its use, predominantly in those aged 12 years and older.

There are however global ethical issues in using COVID-19 vaccines in children.

There is a limited supply of vaccines and using them for children in wealthier nations (where a high proportion of adults have already been vaccinated) limits their access to poorer nations.

The World Health Organization (WHO) does not currently recommend that children be vaccinated against COVID-19. WHO has urged affluent nations to reconsider vaccinating children/adolescents and donate vaccines to low and lower-middle income countries where supply has been insufficient to immunize even healthcare staff.

Summary

The pandemic impacts all of us, even those not infected. We will have to grapple with these issues as parents and a society as we decide about COVID-19 vaccination for children.

How effectively we control the outbreak locally and the spread and impact of variants (mutations) will also determine our response and decision regarding this issue.

In Malaysia, we have yet to make a serious impact on vaccination rates for those at high risk of severe illness and death (the elderly and those with chronic illnesses).

No matter how much we want to support children, it is imperative that we push for those at highest risk to be vaccinated before we vaccinate children.

In addition, it is vital to vaccinate young adults who are working and mobile as they are important drivers of the pandemic. However we should consider selectively vaccinating children with severe disabilities in residential care, especially if at high risk of exposure to COVID-19.

My personal preference would be not to subject our children to mass vaccination against COVID-19, however to control COVID-19 in the community we may have to vaccinate children aged 12-17 years.

The recovery of our nation from COVID-19 means the recovery of our children from the severe mental strain that currently impacts them daily.

Lives are currently being lived on a 'pause button' and vaccination is an important measure to return our society to a semblance of normality.

(Dato' Dr Amar-Singh HSS is a Senior Consultant Pediatrician.)