Israeli health officials are gearing up for their next COVID vaccination campaign: Children ages five-11, pending expected approval this week by the US Food and Drug Administration.
Around one-third of Israel’s population is under the age of 17, which means that despite its previous stunning vaccination and booster rollouts, the country lags behind many others in terms of percentage of total population jabbed.
Also, Israel is unlikely to reach the ever-changing coveted level of herd immunity if children cannot get inoculated.
But it is likely that the situation will change soon.
FDA scientists are expected to vote on Tuesday on giving children a modified dose of the Pfizer vaccine. Briefing documents released over the weekend ahead of their meeting said the scientists believe the likely benefits of giving the Pfizer vaccine to young children outweigh the risks.
If the FDA votes favorably, the Centers for Disease Control will meet on November 2-3 to make its recommendations on how the shots should be administered. Israel is expected to follow and approve the shots a few weeks later.
Health officials believe there are many reasons to vaccinate children. The number one motive is to protect them.
Some 65% of all positive cases in the last few months have been under the age of 19. The Delta variant has infected children more than previous ones – in Israel and all over the world – leading to skyrocketing numbers of kids in hospitals.
“In some places, all pediatric intensive care unit beds were taken by COVID-19 patients,” said Israel Medical Association president Dr. Zeev Feldman.
While in general children tend not to develop severe cases of COVID-19, the last few months have shown that they can. Images of children on ventilators or even hooked up to ECMO machines have plagued the evening news. In Israel, around 10 children died of the virus, although the majority of them suffered from underlying medical conditions.
In addition, there have been increasing reports of youth developing long-COVID and life-threatening pediatric inflammatory multi-system syndrome (PIMS), whose features are similar to those of Kawasaki disease and toxic-shock syndrome.
Fewer than 100 Israeli children are known to have been diagnosed with PIMS, but around half of these cases have been during the Delta wave.
Moreover, even with the Green Class outline, thousands of Israeli children are sitting home in isolation, after missing nearly a full year of their education to Zoom school in 2020.
“We should consider the effect of vaccination on the education system,” said Israel Pediatric Society head Prof. Zachi Grossman. “An open school year where children are not sent to quarantine every day or two is also the target of vaccination - to enable them to have a healthy lifestyle.”
VACCINATING CHILDREN could also help Israel better control the level of disease in the country at large.
“I see some anti-vaxxers saying there is no excuse to vaccinate children to protect society, but I disagree. There is definitely a reason to vaccinate children or any population in order to protect society,” said Hebrew University of Jerusalem epidemiologist and public health physician Prof. Hagai Levine.
Both boys and girls, for example, get the papilloma vaccine, although it largely protects women against cervical cancer and other cancers of the vulva and vagina.
However, health officials have said that one should be cautious when talking about “herd immunity” as a result of vaccinating kids.
While at the start of the pandemic it seemed that having less than 75% of the population immune to the virus led the country to herd immunity, that percentage rose to around 90% with the Delta variant and is ever-changing.
“I think we should stop looking for the holy grail of herd immunity,” said Levine. “Herd immunity depends on specific attributes of the population, the environment and the pathogen – targets that move with time. So, will we get herd immunity if we vaccinate children? We don’t know.”
Nor is there any guarantee that vaccinating children will mean that another variant couldn’t enter the country and partially undo their protection, as we saw with previous waves.
“We can talk about vaccinating kids and then see a real decrease in the number of cases, and then in two months the ‘Omega’ variant – a variant that does not exist yet – will make its way to Israel and things will get tough again,” explained Prof. Cyrille Cohen, head of the immunology lab at Bar-Ilan University.
Though he noted that what doctors have seen thus far is that while some vaccinated people will still contract the virus, they are much less likely to develop serious disease. As such, one of the strategies to prevent a severe fifth wave would be to vaccinate as many as possible in the population, Feldman said.
Data released by Pfizer last week showed 90.7% efficacy against the coronavirus in a clinical trial of children five to 11 years old. While only several thousand kids took part in the study, as opposed to around 40,000 adults who were enrolled in the initial Phase III Pfizer study that led to its FDA approval, Grossman explained that this is expected and acceptable.
He said that the purpose of the study was not focused on vaccine efficacy but on ensuring that a sufficient number of neutralizing antibodies were induced by the vaccine in children, which they were.
“These are immuno-bridging studies,” Grossman explained of the Pfizer trials for kids five to11 and the previous one for teens 12-15, for which the vaccine already received emergency use authorization from the FDA. “If the vaccine succeeds to show quite a good level of antibodies, we can presume that the effectiveness will be similar to what was seen in earlier studies that looked at 40,000 adults.”
He said that the study also largely demonstrated vaccine safety.
The FDA scientists said that it could be assumed that the number of heart inflammation cases – the most severe potential side effect of the vaccine – observed in the younger age group would be similar to that seen in 12-15-year-olds. Pfizer scientists suggested it would be even less, given that younger children are given a dose that is only one-third the amount being administered to older kids.
A study published by Israel’s Clalit Health Services and Harvard University in August found that unvaccinated people who contracted COVID-19 were four times more likely to develop myocarditis than vaccinated people were.
BUT QUESTIONS REMAIN, said Levine.
For instance, there is still a lot of uncertainty around long-term effects – both beneficial and adverse.
Scientists also do not fully understand what contribution the vaccine will make in preventing transmission in community or society. It is likewise unclear if the vaccine prevents long-COVID, something children often develop after experiencing asymptomatic cases of the virus, and one of the reasons doctors are eager to jab youth.
“One issue for those who are pro-vaccinating children are the potential complications of COVID, such as long-COVID and PIMS. But does the vaccine prevent this? We would like to see some evidence for that,” Levine said.
And what about dosing almost 12-year-olds, for example? Levine said his daughter will turn 12 in two months. Should he wait to vaccinate her with a higher dose after her birthday or give her the lower dose a few months before?
And finally, there is a question of where children should get inoculated – in schools, health clinics or community centers?
A recent survey conducted by Bar-Ilan University found that despite all these questions, the majority (57%) of Jewish Israeli parents of children five to11 will get their children vaccinated if the FDA approves the vaccine.
The survey was carried out between September 23 and October 3 by Dr. Liora Shmueli of the school’s Program for Public Health and Health Systems Management and included a representative sample of 894 of the country’s Jewish parents.
Some 27% of parents said they would vaccinate their kids within less than one month of the jab being available, and 27% said they would vaccinate within one to three months. The rest said that they would wait four months to more than a year, or that they would not vaccinate their children at all.
However, some 60% of parents said that including children in a Green Pass that would facilitate travel would accelerate their decision to vaccinate. Another 50% said administering the vaccines within the education system would encourage them to inoculate their kids faster.
Levine suggested that rather than rolling out the campaign to all kids all at once, the country could consider vaccinating the highest risk population of children first and then others.
“Right now, the data from what we hear looks good,” Cohen said. “But these are kids and we want to be extremely sure we are not doing any harm.”
Feldman and Grossman, however, said that Israel should move vaccination of youth forward as soon as possible.
When the FDA approved vaccination for older children 12-15, the third wave was on the decline in Israel and health officials questioned the need to rush a mass vaccination campaign for this age cohort. As such, at first, the Health Ministry approved the vaccine but did not “recommend” it – leaving it up to parents to inoculate their kids if they felt they were at high risk of developing severe disease, lived with someone high risk, or their kids were considering traveling abroad.
A month later, after massive outbreaks at schools started the Delta wave, the Health Ministry recommended vaccination and launched a dedicated teen campaign.
“We know new variants exist and are entering Israel already,” Grossman said. “This time, we should not gamble.”