This far into our shared pandemic experience, everyone seems to be as dug into their preferred narrative as a tick.
Accordingly, we might save ourselves the common unpleasantries of this fraught time by making some concessions here at the start, before I tell you what I think about vaccinating our kids against COVID.
First, if you are convinced vaccines are all an attempt by Bill Gates, or Tom Hanks, or No Doubt to take over your brain with microchips (can’t help but ask: why go to all that trouble when social media already does the job?)- I’d recommend you read no further. If you would refuse a vaccine even if Hippocrates vouched for its effectiveness, Mother Teresa for its safety, and if it were directed against the Andromeda Strain- seriously, please, read no further.
Similarly, if you knew for certain that the sky had fallen on us all the minute we heard of coronavirus in Wuhan, and if you would readily get repeated vaccinations directly into your eyeballs to defend against it no matter how apparently low your personal risk – then, frankly, you need read no further either.
Is anyone still with me? This is for you.
The general case for vaccination is utterly decisive, and stronger all the time. This is not because the vaccines- any of them- is a panacea, perfectly and permanently effective, and perfectly free of risk. None of the vaccines now available, and none that might follow, is any of that. In fact, nothing in all of Medicine is any of that.
Rather, the vaccines clearly and reliably do what they were intended to do: prevent infection with SARS-CoV-2 much of the time, and prevent serious illness from SARS-CoV-2 nearly all the time.
They do that with a non-zero, but very low rate of complications. These complications are both reported through the VAERS system, and under active study by an entire ecosystem of public health researchers. When the rate of complications has crossed a given threshold, as it did for blood clots in young women receiving the J&J vaccine, and for myocarditis in young men receiving the mRNA vaccines (Pfizer and Moderna)- all the right things happened. The information was made public right away; the matter was investigated by the CDC, the FDA, and ACIP (the Advisory Committee on Immunization Practices); and in the case of J&J, there was a brief pause in use of the vaccine until the magnitude of risk had been clarified.
In both cases, continued use of the vaccines was approved by all relevant authorities, and affirmed by independent research. But “carte blanche” was not issued. The J&J vaccine acquired a warning label about the low but still concerning risk of blood clots in young women. The mRNA vaccines may yet acquire a similar label regarding myocarditis in young men.
But this is all as expected. No vaccine, ever, and no medical intervention, ever, achieves zero risk. All such interventions are worthwhile anyway if, and only if, they represent a monumental reduction in risk relative to the “alternative.” In the case of the COVID vaccines, the relevant alternative is taking your chances with SARS-CoV-2- and the verdict is clear. The vaccines do, indeed, represent a truly dramatic reduction in risk relative to the virus for most of us: most adults, and anyone with chronic health problems. I say this both as someone who maintained at the start, and still does, that COVID19 was not a big threat to very healthy people, especially if also young; and as someone who personally weathered acute COVID19 very well at age 58 due to such good health, but has also had to contend with residual long-haul symptoms for 6 months and counting.
In a world that ran on reason instead of rants, epidemiology instead of ideology, and that differentiated idle and misguided opinion from actual expertise- the matter of vaccination in adults would be settled by now. But what about kids?
Healthy kids- including teens and tweens- have been at very low risk of harm from SARS-CoV-2. They can get it, clearly- but when they do, they don’t tend to get very sick. The goal of vaccination is to generate a wide gap between the risk of infection and the risk of the vaccine; that gap is the measure of “personal benefit.” When the risk of infection is low enough, demonstrable benefit from vaccination is hard to achieve. That, to date, has been the situation for healthy kids under age 18.
That may no longer be true, however. The Delta variant is apparently both more likely to infect young people, and more likely to make them sick when it does. There are as well some indications that kids may be subject to long-haul syndromes even if not seriously ill with the acute infection (again, as someone who is living that scenario, I recommend giving it the respect it deserves). The pertinent “math,” then- the magnitude of risk reduction of vaccine versus viral exposure for kids- is at present a moving target. As it moves, it is shifting the balance in favor of vaccination for teens and tweens.
But that case is not yet decisive. Nor, as a parent, do I think we can justify vaccinating our kids to protect other adults who have chosen not to be vaccinated. I am a proponent of herd immunity by reasonable means, but I cannot sanction vaccinating any child unless there is personal benefit for that child.
With all of that in mind, here is where I land. The case for vaccinating healthy kids has, to date, been something near a toss-up, and the best way to decide toss-ups in medicine is with values. If your personal values are better served by vaccinating your healthy kids, the available data suggest you are doing a very reasonable thing. If your personal values are better served by deferring that same action, the same data validate your choice. I certainly encourage you to confer with the pediatrician you know and trust to help you resolve doubts, and come down on the right side of the fence.
I would further suggest you favor, at least until we have more information, the mRNA vaccines for your daughters to avoid the blood clot risk associated with the J&J adenovirus vaccine; and that you favor the J&J vaccine for your sons to avoid the myocarditis risk. These risks are low, as noted, but if they can be avoided entirely, I think we should do just that.
My children have all been vaccinated against COVID, but they are young adults now, making autonomous decisions. Were they younger, it would be a close call- but given what’s going on with the Delta variant, my wife and I would have them vaccinated.
In light of the epidemiologic tossup, my fellow parents could make defensible decisions in either direction. But that could very well change as the data change, so if I may, one final tip. Changing your mind as data change is not “waffling,” not “inconsistency,” not a marker of some moral elasticity. Rather, it simply means you are paying attention- and that, you certainly should do.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.