Next frontier: The case for vaccinating schoolchildren
There is a growing view in the medical community that child vaccination for Covid-19 must be considered urgently – and well before reopening Australia’s international borders.
The Australian Medical Association’s federal council is poised to examine the challenges around childhood vaccination and adopt a formal position, after its Western Australian branch declared itself in favour.
The issue is understood to have been raised during the most recent Covid vaccine forum, a fortnightly Zoom hook-up of 95 key people involved in Australia’s vaccine rollout – politicians, epidemiologists, doctors, regulators, bureaucrats and advisers.
But while it has also been discussed informally among Australia’s first ministers, vaccinating children is yet to feature as an official agenda item for national cabinet. Governments have not taken a formal position.
Currently, the AstraZeneca vaccine is approved in Australia only for use in people aged 18 and over. For the Pfizer vaccine, the minimum approved age is 16.
Australia’s pharmaceutical regulator, the Therapeutic Goods Administration (TGA), is urgently considering a Pfizer application to have its Covid-19 vaccine approved for use in children aged 12 to 15, amid concerns that the risk of children both carrying and succumbing to the Delta strain may be greater than with earlier variants.
AMA federal president Omar Khorshid suggests the challenge this issue poses is more acute for Australia than in some comparable countries, where higher adult vaccination rates have created greater progress towards herd immunity. Khorshid says it must be addressed before any move to fully reopen Australia.
“A big question for Australia is: will the vaccination status of our children delay the international borders reopening?” Khorshid says. “Is it the right thing to do to bring Covid into Australia by opening our borders if our children are not vaccinated? … We need to consider that properly as a country before we just assume we can open the borders once the adults are done.”
Khorshid says while no firm data is available at this stage to suggest the Delta strain is more severe overall than earlier strains, it is certainly more infectious.
Hospitalisation rates in Britain indicate the Delta strain may be affecting children more than the original virus and other variants.
It is not clear yet whether the proportion of children falling ill appears greater because more adults are fully vaccinated and so fewer of them are being hospitalised, or whether Delta affects children more than other strains.
Khorshid and others in the medical community say the possibility of the latter should concern Australian policymakers.
“I think that’s quite an important question,” he says.
“But I’ve not seen anybody who’s got the answer.”
The AMA president suggests Australia should deal with the issue as a matter of urgency and ideally “get going on that group before the end of the year”.
“There’ll be an awful lot of worried parents if they see the borders reopening and their children are not vaccinated,” he says.
Khorshid notes that children who become infected also risk acquiring “long Covid” – producing the lingering, debilitating symptoms of a chronic illness. The earlier in life that strikes, the worse the lifelong prognosis may be.
Vaccinating children is not a straightforward proposition, however. The Pfizer vaccine has not been approved anywhere for use in children younger than 12, but the company is running clinical trials overseas in two other age cohorts – children aged five to 12 and six months to five years.
Medical experts note that the physiology of children is different and their immune response is generally more dramatic, meaning if an adult vaccine is to be used in the absence of a child-specific alternative, the dosage needs to be significantly and carefully adjusted.
Ideally, separate vaccines are developed for children.
The AMA’s WA branch spokesman, anaesthetist Dr Andrew Miller, is firmly in favour of vaccinating children as soon as approval is given.
“They can’t get this under control without childhood vaccination,” Miller says. He calls any suggestion that Australia can reach 90 per cent vaccination among adults a “complete fantasy”.
The WA branch has passed a resolution saying Australia should take necessary steps to keep community transmission as close to zero as possible until the TGA and the government’s key medical advisers, the Australian Technical Advisory Group on Immunisation (ATAGI), have investigated vaccinating children.
This week, a rift emerged between the government and ATAGI when Prime Minister Scott Morrison appeared to say the advisory group should be blamed for problems with the vaccine rollout.
Having deferred to the medical advice for 18 months, Morrison suggested its changing nature – which reflected changes in risk – had caused delays.
“I’m simply saying that we received medical advice that has changed on two occasions,” Morrison told ABC Radio’s AM program on Thursday. “And that medical advice, as I made very clear to ATAGI at the time, was based on an assumption that the cases in Australia would remain low. Now, I never made that assumption.”
He said the group’s initial assessments were based on low case numbers. “Now, when the case numbers increase, as you’ve seen from ATAGI now, their advice changes … Now, I’ve always understood that; but I think it has created some confusion in the public. I think that is the case.”
ATAGI’s deputy chair, Monash University infectious diseases physician Professor Allen Cheng, pushed back against Morrison’s comments. Cheng emphasised that ATAGI was an independent expert committee of medical professionals, who were “not politicians” and whose role was to provide advice to government.
“Based on evolving evidence, we’ve had to change that advice as new information became available,” he told Guardian Australia. “We’re always very conscious of the impacts of our recommendations on the program and vaccine confidence generally.”
Cheng emphasised that the government makes the decisions and runs the vaccination program. “We provide advice – those are our terms of reference.”
The Morrison government is now offering an incentive for parents in Sydney to keep their children home from childcare, announcing that the federal government will again cover the gap in fees for missed days while restrictions are in place.
Andrew Miller suggests more substantial thinking is required. He is appealing to leaders’ political instincts, demanding urgent planning on vaccinating children.
“Nothing turns off a voter quicker than the idea you might damage their children by not making plans for them,” he says.
He argues it is “more likely that children will be damaged by Covid than by any of these vaccines”.
Concerns about children have implications for reopening schools in Sydney and for keeping them open anywhere else that outbreaks occur.
As of late this week, three schools in suburban Melbourne were closed after infections were detected, at least one involving a grade 4 student. At 11.59pm on Thursday, the state went into a hard lockdown that will run at least five days.
“Schools in affected areas should only be open to children of essential workers,” Andrew Miller says, arguing that increased ventilation and mask wearing would help.
“We can only use the methods we have until vaccination is high enough to protect everyone – so, more than 85 per cent probably for all, including kids.”
Deakin University epidemiology professor Catherine Bennett notes that vaccinating children was always part of the rollout plan – right at the end of the final stage, subject to TGA approval.
But she also believes the emergence of the Delta strain, with its different characteristics, should prompt a rethink on urgency.
“Delta now challenges our old thinking about transmission,” Bennett says. “Children didn’t seem as good at getting the virus, let alone spreading it. That seems to have changed.”
She warns that leaving children unvaccinated could expose them to serious illness and turn them into virus-spreaders – which they have not been with other strains. It could potentially also help generate new strains and higher levels of transmission.
“If we concentrate all the cases into unvaccinated people under 18, we might see serious illness because usually rare events will start to be seen … and we might get a variant that causes more serious illness in the young,” she says.
Bennett says this could create a situation in which new variants are more virulent but still transmissible, rendering unvaccinated people – including children – very vulnerable.
Professor Bennett says opening the borders while significant portions of the population remain unvaccinated could also expose Australia to new strains of the virus against which existing vaccines may be less effective.
“It’s a complex picture,” she says, conceding it requires taking measures to protect against things that might – or might not – happen.
“But if we don’t protect against it,” she warns, “one or more will.”
The medical experts’ warnings about children potentially puts them on a collision course with business, which is pressing government not to wait for adult vaccination rates of 80 or 90 per cent before reopening the international border.
Australian Industry Group chief executive Innes Willox is among those urging the government to consider the economic consequences of aiming for a vaccination rate that may be impossible to achieve quickly.
“Once people have the opportunity to be vaccinated – everyone around the country – that’s where we should draw the line,” Willox told Sky News on Wednesday.
“If we start having epidemiologists say, ‘Oh, we need 80, 90 per cent of the population covered’, the reality is, we’re not going to get there for a very long time and we’ll get stuck in these [lockdown] cycles. So, we’re going to have to make a choice at some point around how to approach the future.”
The New South Wales chief health officer Dr Kerry Chant suggested recently that school-based vaccination for children was likely to occur, but not until next year.
“As a public health practitioner, I’m a strong advocate for vaccination,” Dr Chant said during a press conference on July 4. “At the moment, our priority is vaccinating older people and adults and as the vaccine supply [increases], I think we can have these conversations about children. But I would be expecting that in 2022 we would be looking at rolling out vaccines for schools – for schoolchildren. But really, it depends.”
At the time, Chant said the priority still needed to be the elderly and other vulnerable groups, as well as essential workers. “But we have seen with the Delta strain that it is more transmissible and obviously the more people we can get vaccinated, the better.”
Omar Khorshid says that, to date, Australia’s medical advisers have been focused on the individual benefit from vaccination.
He says they have prioritised vaccination’s impact on individual health over the collective benefit to the wider community of having various groups of people vaccinated – including children.
“It would stop children being a source of virus into the community,” Khorshid says of childhood vaccination.
“I think it’s a no-brainer that if we have a safe and effective vaccine, it should be made available to children.”
But, he adds: “It’s a bit theoretical when we don’t have a vaccine to offer them.”
This article was first published in the print edition of The Saturday Paper on Jul 17, 2021 as "Next frontier: The case for vaccinating schoolchildren".
A free press is one you pay for. In the short term, the economic fallout from coronavirus has taken about a third of our revenue. We will survive this crisis, but we need the support of readers. Now is the time to subscribe.