With much of the nation under lockdown last year, incidents of flu seemed to vanish. Now with fewer wearing masks and more people congregating together, some believe the flu will come roaring back. Recently, a flu outbreak at the University of Michigan’s Ann Arbor campus in Washtenaw County sickened at least 525 students. At the same time, COVID-19 numbers in the United States have been rising. USA Today analysis of Johns Hopkins University data on November showed that nationwide cases were above 600,000 per week compared with under 500,000 per week in late October. Infections were rising in 34 states, and unvaccinated people remain at highest risk for infection. While great progress is being made, from boosters to the promise of a COVID-19 pill, the public must continue to sift through a steady stream of information (and misinformation). Here, William Schaffner, MD, answers questions to help you and your loved ones navigate concerns about boosters, kid vaccines, and other COVID-related issues. Dr. Schaffner is a professor of preventive medicine in the department of health policy as well as professor of medicine in the division of infectious diseases at the Vanderbilt University School of Medicine in Nashville, Tennessee. His primary interest is the prevention of infectious diseases, and he has worked extensively on the effective use of vaccines in both pediatric and adult populations.
Vaccines for Kids
Q: Now that the Pfizer vaccine for younger kids (ages 5 to 11) has been authorized by the U.S. Food and Drug Administration (FDA), what concerns should parents have regarding these shots? A: Obviously, parents will have questions, and they should direct those questions to their pediatricians and family doctors. One of the really nice things is that this vaccine is now being distributed directly to many pediatricians and family doctors who’ve signed up to get it. So the vaccine is being delivered in a setting that the parents are acquainted with and have a lot of comfort with. The vaccine has been studied in clinical trials, where parents brought in their kids as volunteers to determine what the best amount of vaccine is. The trials found that children were going to get the same kind of protective response with one-third the amount that their older brothers and sisters and their parents got. The dose also minimizes the adverse effects. Q: What adverse effects might be expected? A: There will be sore arms. There may be some headaches, or aches and pains, and a few may develop a little bit of a fever, but nothing worse than what adolescents and young adults experienced. There is myocarditis [inflammation of the heart muscle] associated with both the mRNA [Pfizer and Moderna] vaccines, although more with Moderna than Pfizer. This happened in teenage boys and young adults, and usually after the second dose. Whether it happens at the same frequency in 5 to 11 year olds is not known. There’s a hope that this vaccine-related myocarditis may occur even less frequently in younger kids than it does in teenagers. [The Centers for Disease Control and Prevention (CDC) stresses that reported incidents of myocarditis have been very rare.] [Moderna’s COVID-19 vaccine is authorized for adults over the age of 18 years and the company is waiting for a response from the FDA to its June application for children ages 12 through 17. Moderna released trial data at the end of October showing its vaccine produced a robust neutralizing antibody response in children ages 6 to 11. Moderna plans to soon submit this data to the FDA.] We all know that you can’t even cross the street with complete safety — there’s always a small amount of risk. The equation, however, solves so strongly in favor of the vaccines as opposed to waiting to get infected with COVID-19 that the American Academy of Pediatrics, the American Academy of Family Physicians, and the CDC all strongly recommend the COVID-19 vaccine for children. Q: Will there be a kid’s vaccine from Johnson & Johnson? A: Johnson & Johnson’s vaccine has been used so much less. Not only is there an issue of less effectiveness [per the American Medical Association], but also, in younger women, there has been a blood clotting disorder. There’s none of it being used in teenagers at the moment, and very little of it being used generally now. [J&J-Janssen is currently conducting research on the vaccine’s response in younger age groups, according to Child’s Health Orange County.] Q: Earlier in the pandemic, we heard that children were not getting coronavirus as much or as severely as adults. If that is the case, some adults may think then why bother vaccinating my child at all? A: It’s very hard to “un-ring a bell.” It’s very hard to give people follow-up information that is an extension of — but a change from — the original information. With COVID-19, from the beginning, it was clear that children were much less affected than adults. That remains true today, however, with the delta variant being so much more contagious, it clearly got into more younger adults, teenagers, as well as children. About a week and half ago, there were over 8,300 children in this age group, 5 to 11, who have been hospitalized with COVID-19. One-third of them have required intensive care unit admission. Also, by far, most of these children were normal children who did not have any underlying illnesses. In addition to that, there are the post-COVID illnesses and “long COVID” symptoms that can occur even after mild infection that we are concerned about. What we have learned since delta came on the scene this summer is that we have had to change our message. Yes, children continue to be less affected, but they’re now more affected than they were originally because of delta variant. So the equation has changed very much in favor of getting vaccinated. Q: Even if children are less affected, does vaccinating them help fight the pandemic as a whole? A: From the entire community perspective, that’s also important because having more children vaccinated contributes to “community immunity,” and it will also make every school safer. We’ll have fewer instances where children have to be quarantined — where you may have to close down the classroom or even more of a school — while children are under observation at home. So schools will be safer and there will be less disruption of education.
Booster Shots
Q: Some people have asked if we need to get boosters, does that mean the vaccine isn’t working? What do you tell them? A: Everybody anticipated that, at some point, a booster may be necessary. If this had not been a pandemic, and this vaccine were being brought to market in a conventional way, I think it would have been a three-dose vaccine just as with the traditional hepatitis B vaccine. We have other vaccines where we have to give three doses in order to secure long-term protection, and this is turning out to be the case with this vaccine. Every vaccine does not provide lifelong protection, so we have to get boosters periodically. We get a flu vaccine every year, and we’re supposed to get our tetanus boosters every 10 years. With all the hullabaloo surrounding COVID-19 vaccines, I think some people have misinterpreted what it means to get a booster. Any number of vaccines are really very, very good but you still have to remind the immune system occasionally (with a booster) to shape up so that it can continue to be effective. Q: Is there any sense if we will be needing COVID-19 boosters regularly for years to come? A: We don’t know yet. But already scientists are anticipating that if we do have to get an annual booster, a combined influenza and COVID-19 vaccine might be the best option. If you combine the COVID-19 vaccine with the flu vaccine, you only have to roll up the sleeve once in the fall. Q: Are there any concerns now for people who want to get the flu vaccine and the COVID-19 vaccine together in one visit? A: No. Just remember that both of these vaccines can produce local reactions, including sore arms. So if you do get them simultaneously — one in the left and one in the right arm — you may have two sore arms the next day, so don’t plan to enter a weightlifting contest. Q: Should boosters help as we see more breakthrough cases? A: We are seeing more breakthrough cases, and the boosters should help. I think we all have to remember that this is a vaccine with certain characteristics that are absolutely aimed at preventing severe disease. That means that there’s still going to be some transmission, even among vaccinated people who can get minor illness. If we vaccinated 100 percent of everybody, almost all the infections we would see would be minor. It is still the case that the vast majority of people who are hospitalized with COVID-19 are unvaccinated. Q: How has the booster program been going? A: There’s been a good but not overwhelming interest in boosters. In part, I think that’s vaccine fatigue. And there may also be a certain amount of confusion about who can get the booster [but that should all be clear now that all adults age 18 and older can get the additional shot]. Q: Is there any reason that people should be concerned of a more powerful reaction to a booster shot compared with their first shots? A: No, the reactions do not appear to be enhanced. They’re the same order of magnitude as after the first or the second dose. I got my booster, and I had a sore arm for three days, as I did before. I also had little chilly sensations, and I said, “Good — my immune system is in good shape and working on that vaccine.” Q: Do people who have had the virus and recuperated need to get vaccinated at all since they have acquired a certain amount of immunity? A: When you recover for COVID-19, you will have some protection, however, after getting the vaccine, your antibody levels go up to a much higher level than after the natural infection. That’s why it’s recommended that everybody who’s recovered should nonetheless be vaccinated because higher antibody levels are said to confer more benefits, longer protection, and more secure protection against variants.
Looking Ahead
Q: What are you most concerned about in the immediate future? A: For the immediate future, I’m concerned about influenza. I think we’re going to have more than we had last year, when we had virtually none. That’s because we were all locked down and masked. I can’t tell you whether we will have a mild, moderate, or severe flu season, but we will have some flu. I’m just concerned that lots of people still have not availed themselves to getting their flu shot. It’s that time of year when flu cases are just starting. I haven’t seen any data yet about influenza and influenza vaccine acceptance. Q: Are you concerned we’ll see a rise in coronavirus cases in the winter months ahead? A: It’s very tough to predict about COVID-19, but there are already parts of the country where they’ve seen a plateau and then an uptick. There’s also a concern again about people gathering indoors when it’s colder. There will be more opportunities for transmission. While we don’t know what’s going to happen this winter, the virus hasn’t gone away. Clearly, if you haven’t been boosted, get your shot; and please, if you haven’t been vaccinated at all, get started and get that first dose.
