Always on the little ones?
In the long run, no one will escape the virus who isn’t vaccinated. For children and teenagers, that’s a delicate situation. How we can protect them nevertheless.
By Harro Albrecht, Ulrich Bahnsen, Linda Fischer und Jan Schweitzer
21.07.2021, edited on the 24.07.2021
Translated by Grzmot
Source: https://www.zeit.de/2021/30/corona-infektion-kinder-impfung-schutz-delta

Infestation, that sounds dangerous. And it sounds like surrender: just stop resisting and let the coronavirus work, until it has infected all unvaccinated people. Prime minister Boris Johnson seems to be following such a strategy, he has lifted almost all restrictions related to corona this Monday. His idea: the old and vulnerable are protected by vaccinations, the rest of the population will not go through a severe infection. The United Kingdom is daring to go through a world-wide unique experiment with unknown results.
In Germany, more than 46 percent of the population has been completely vaccinated, it can be surmised that even with rising positive cases, fewer deaths can be expected. But what about the children and teenagers, who have not received a vaccination recommendation or for who there is no allowed vaccine? In Germany only 4 percent of vaccinated people are under 18. It can be expected that Sars-CoV-2 will spread between the younger ones at the end of the summer holidays. There are millions.

Can it be avoided, that all children will be infected eventually?

Sometimes one gets the impression from all the debates in this country, that between infection and vaccination there is a third option – evading the virus somehow. But in the long run, there are only two options: vaccination or infection. In both cases, special anti-bodies and immune cells appear in the blood of the individual. Research shows that only a minority of the children and teenagers have such anti-bodies. Reinhard Berner, director of the hospital for children- and adolescent medicine clinic at the university hospital in Dresden, estimates that 15 percent in that age group have an infection behind them. That leaves 85 percent, if they won’t be vaccinated.

How many children have a severe infection?

Apparently even with the Delta variant, children go through a severe infection extremely rarely. In mid July the Robert Koch institute (RKI) reported, for the duration of the entire pandemic, 23 deaths of people under 20, of which 16 had pre-existing illnesses. Sars-CoV-2 is almost never deadly for children, but still some fall ill so severely that they have to be hospitalized. Known is the paediatric inflammatory multi-organ syndrome (Pims) [Addendum: In English, the syndrome seems to be called multi-organ inflammatory syndrome, changing the acronym to PMIS], a persistent inflammation, which starts with stomach aches and fever and can end in severe cardiovascular and neurological problems. So far, 383 cases have been registered in Germany, and in most cases, the symptoms disappear after some time. Based on data from the German society for paediatric infectiology; from all children under 14 reported as infected, only 1600 had to be hospitalized, and in only half of those cases, a corona infection was the reason for hospitalization, 100 ended up in intensive care. In a lot of the cases, the children came into the hospital because of something else, and the corona infection was detected by chance.

Do children get long covid?

If all 13 million children and adolescents in Germany get infected and only a fraction of them get long-term problems, it would be a massive problem. The total cases of infected people would be high. One fear factor is “Long Covid”, this difficult to describe umbrella term of complaints like “fog in the head”, ongoing weakness and troubles breathing. How much children are affected is not clear, depending on country and study, the numbers fluctuate. An Italian study showed, that a third of all infected children between 6 and 16 years of age reported health issues for longer than 4 months. In February, the British Virus Watch reported, that 4,6 percent of all 4700 infected children had symptoms like difficulties breathing or tiredness for longer than 4 weeks. The university College London calculated, that 5 percent of all children get long covid.
The data is unclear, because it’s still unclear, what a normal reaction to the infection is, what the consequences of isolation and home-schooling are, and where long covid begins. “You have to be terribly careful with all those numbers, that you don’t confuse different effects with each other”, warns Reinhard Berner. He does not want to say that long covid related to children is nonsense, “It really exists, and for the affected kids it is a real problem.” The effects can be measured on adolescent athletes, who were not even close to their previous level pre-infection even after half a year.
Even then, children seem to be affected extremely rarely by long covid. If 15 percent have been infected so far in Germany, and if only one in one hundred got long covid (less than in the named studies), we should already have more than 20,000 cases. “But that’s not the case”, says Berner, “they would flood the practices.” Because of this, he estimates the fraction of young long covid patients as much lower. From the UK, despite rumours, paediatricians do not report an alarming increase of long covid cases or hospitalizations of children.
But still this age group is heavily affected by the pandemic, but just not physicially. Paediatricians of the TU Dresden looked at 1500 students, averaging 15 years old, 12 percent already infected. Surprisingly, in both groups of infected and non-infected, the same percentage of students reported typical long covid symptoms like problems remembering things, pain in the abdomen or extremities and a bad mood. The collateral damage of the lockdown, the psychological strain, says Berner, is a much greater risk than potential infection.

What’s the next step when it comes to vaccination of children?

Currently, only BioNTech’s vaccine is allowed to be used on children and adolescents from 12 years up. BioNTech says it will have finished testing on children between 2 and 11 years in autumn. The results of studies on children from the age of six months on could follow at the end of the year.
Even then, BioNTech’s vaccine is only recommended in rare cases to be used on children and adolescents by the “Ständigen Impfkomission (Stiko)” [Addendum: German regulatory body on vaccines], for example when they have certain preexisting conditions that make them vulnerable for a severe covid-19 case. It’s not clear if the use of the vaccine outweighs the potential side-effects, explain the members of the Stiko. The British brother of the Stiko, the “Joint Committee on Vaccination and Immunisation”, has basically said the same thing in a statement released only at the start of this week.
There is little data on the vaccine risk for the broad juvenile population. Scientists in the USA, where millions of children and teenagers have been vaccinated, have noted a risk for the inflammation of the heart after a mRNA vaccine (BioNTech and Moderna). Especially boys between 12 and 17 have a higher risk of said Myokarditis: Approximately 1 in 16,000 boys, which have received both doses, has begun suffering from the condition. For girls, the risk is considerably smaller, for young adults even lower. Myokarditis can be treated well, but not much is known about long-term effects. Relevant governmental bodies in the USA (and Israel) have reached the conclusion that the use of the vaccine outweighs the risks and have upheld the recommendation for teenagers. In the near future this will not happen in Germany, the Stiko has given strong signals, that it will keep holding back until more data comes in.

How many people must be vaccinated for herd immunity?

The bad news: to be frank, true herd immunity will not be reached. At least not in the sense that the spread of the virus will be halted entirely. The good news: every vaccinated person makes it harder for the virus to spread. In that way, we protect the ones that cannot be vaccinated, like little children. The RKI has, at the beginning of July, calculated different scenarios, what quota is necessary to at least control Covid-19: 85 percent of the population aged 12 to 59 must be fully vaccinated, and 90 percent of the population from 60 years old. If we reach that quota in the summer, people follow the AHA rules [social distancing, hygiene measures, face masks], reduce their contacts somewhat, then a fourth wave in autumn and winter is improbable. Currently, the vaccination quotas are only at 44,8 percent for 18- to 59-year-olds and at 74,9 percent for people over 60. It’s not likely that we reach the necessary quotas in time, especially since the Delta variant will spread faster and the fourth wave could begin sooner, says RKI scientist Stefan Scholz, who participated in the analysis: “Many vaccinations would happen only after the begin of the wave, and thus too late.”

Can you protect children by vaccinating adults?

Of course, children can infect each other in schools and preschools. Effective hygiene concepts and masks (for older children) are a good way to protect them from Sars-CoV-2. But the best way to protect them from infection is really the vaccination of the adults in contact with the children.
Studies from the health department of Israel show how useful vaccinations of adults are. The results only allow the single conclusion, that the way of the infection is mostly from the adults to the children and not the other way around. Israeli epidemiologists have compared communities with high rates of vaccinations and small rates of vaccinations. The result was clear: The more older people receive the vaccine, the lower the danger of infection for the little ones. According to paediatrician Reinhard Berner, not even the Delta variant will change that. Therefore, he calls the adults to action when it comes to vaccinations.
A possible faster rate of vaccination for the adult population wouldn’t just be the best protection for the youngest of our societies, but also for all those, who cannot be vaccinated or don’t build enough immunity. There are, since Delta, so called breakthrough infections all over the world, i.e., infections of fully vaccinated people, but those are in general harmless.
But can’t infected pass on the virus to children (or adults)? That possibility cannot be entirely ignored, but the risk is low, according to Israeli scientists. : They checked how many viruses vaccinated but infected people excrete: it’s about 3 to 4,5 times lower than unvaccinated infected. It’s enough for the PCR test, the US scientist Eric Topol reported via Twitter, but it’s not even enough to fully sequence it. The risk of transmission is probably low.

How can we convince more adults of the vaccine?

People shouldn’t come to the vaccine; the vaccine should come to them. That’s the shortest way to put it, according to scientists of the Cosmo project, who have done a recent survey. “Visiting Vaccination” they call such offers which should exist in apothecaries, via vaccination bus or at universities and schools. Those places would be preferred by people the most as an alternative to vaccine centres or doctor’s practices, those are the newest results of the project, which is a result of the cooperation of the university of Erfurt, the Robert Koch-Institute and the Yale institute for global health in the past year. The make vaccination as simple as possible: That’s the most important thing which would lead to more vaccinations.
Other measures have little effect, the scientists discovered. Even a pretty high financial incentive of EUR 1000 “only increased the willingness to vaccinate by about 6 percent”, said the psychologist Sarah Eitze, a member of Cosmo. Benefits for the vaccinated, like being able to visit the cinema or theatre without a test, “don’t a positive effect on the decision to vaccinate”. How about punishments? From the entire spectrum of possibilities it’s the worst one, says Eitze, “It might even backfire and lead to a negative effect on the people currently considering”.
It’s a tricky part of the pandemic. The Stiko does not want to give a general recommendation of vaccinations for children and adolescents, because they don’t have enough data to evaluate the risk and benefits. This age group won’t be vaccinated in any meaningful amount at least until autumn. In this situation, it cannot be avoided that children and teenagers will be infected little by little. But according to current research, that doesn’t mean that a lot of young patients will get very sick. We are still missing data to evaluate the rare side-effects of a corona infection in children accurately. If the children return to schools after the summer holidays, free and unburdened by any measures, it leaves a heavy remainder risk for parents and politicians. The slower the virus spreads, because parents, teachers and educators are vaccinated, the more time we gain to get new data and results.

Our authors spoke with paediatricians, epidemiologists and psychologists for this article and have evaluated German and international studies – for example the register of the university clinic Dresden, which collects health data nationally in Germany. You can find our sources here.