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Just about everyone in America is finally eligible for a Covid-19 vaccine. Now what?

The youngest children may prove to be the hardest to vaccinate.

A doctor wearing a mask holding a baby outside a house.
A doctor calms her 7-month-old son before going into an appointment for his Covid-19 vaccine on June 21 in Washington, DC.
Bill O’Leary/Washington Post via Getty Images
Umair Irfan is a correspondent at Vox writing about climate change, Covid-19, and energy policy. Irfan is also a regular contributor to the radio program Science Friday. Prior to Vox, he was a reporter for ClimateWire at E&E News.

More than 18 million of the youngest children in the United States can finally get Covid-19 vaccines, closing one of the largest remaining gaps in eligibility.

“The United States is now the first country in the world to offer safe and effective Covid-19 vaccines for children as young as 6 months old,” said President Joe Biden this week at a vaccine clinic in Washington, DC.

Children as young as 6 months old have two choices: a three-dose sequence from Pfizer/BioNTech or a two-dose regimen from Moderna. But how many kids will actually get the shots?

That’s a critical question for how the pandemic will play out over the next few months in the US. If infants and toddlers get vaccinated at the same rates as their older siblings, Covid-19 patterns may not change much, and most of the youngest children will remain at risk of illness.

Covid-19 vaccines remain one of the most powerful tools for containing the virus, but large and persistent divides in vaccination have emerged, which means the virus can continue spreading, mutating, and wreaking havoc.

Across the US, more than 78 percent of the population has received at least one dose of a Covid-19 vaccine. However, divided by age groups, there’s a clear downward trend. More than 95 percent of adults over the age of 75 have received at least one dose as of June 15, according to the Centers for Disease Control and Prevention. For people ages 40 to 49, the rate is 86.8 percent. For 12 to 17-year-olds, 69.7 percent. And for kids ages 5 to 11, 36.2 percent.

The US Food and Drug Administration only cleared 5- to 11-year-olds to receive the Pfizer/BioNTech Covid-19 vaccine in November 2021. But the vaccination rate in this age group has plateaued, scarcely climbing above the 28 percent seen in January.

For the youngest children, from 6 months to 5 years, who just became eligible for Covid-19 vaccines in June, the rate may be even lower. A Kaiser Family Foundation poll in May found that about 40 percent of parents of children under 5 said they want to hold off on getting the shots right away, while 27 percent said they would “definitely not” vaccinate their kids.

“I think as [Covid-19] prevalence declines going into the summer, a lot of parents may choose to take a wait-and-see attitude and reconsider this in the fall,” Scott Gottlieb, a former FDA commissioner, told CBS News earlier this month. “So I would suspect that uptake is going to be pretty slow.”

That’s troubling because more than 50,000 children under 5 in the US have been hospitalized for Covid-19, with a quarter requiring intensive care. More than 400 children under 4 have died from Covid-19. Vaccination rates in adults have leveled off as well, and more than 70 million Americans haven’t received any vaccine doses at all.

There are many factors contributing to these low vaccination rates. Misinformation has been a persistent barrier to immunizations. Vaccination rates diverge along political lines as well.

However, regulators and public officials have also delivered mixed messages on vaccines, masks, and exposure risks, increasing public confusion about what to do about Covid-19. Confidence in agencies like the FDA and the CDC dropped during the pandemic, with one poll last year finding that nearly half of Americans don’t trust national public health institutions. Add to that the simple fatigue of being in the third year of a pandemic: Many people want to just get on with their lives.

Covid-19, however, doesn’t care about how tired everyone is, and wishful thinking won’t make it go away. The virus is still spreading and changing, sickening millions. Getting vaccination and booster rates up remains crucial to keeping people out of the hospital and the morgue, and with one of the last remaining age groups now vaccine-eligible, the country needs a renewed vaccination push to close the final gaps. But with eroding trust in federal health agencies, the most effective messengers might be doctors and nurses who come face-to-face with the littlest patients.

Vaccines remain essential, but they’re running into their limits

The good news is that Covid-19-related deaths in the US are far below their peak when the omicron variant of the SARS-CoV-2 virus roared through the country this past winter. It’s also true that, in general, Covid-19 is less likely to cause severe illness and death in younger people. But given how readily some of the newer variants and subvariants of the virus can spread, those small fractions add up.

For children under 4, the omicron wave led to five times as many hospitalizations as the delta variant wave, and the majority of those hospitalized kids had no underlying health problems. Infants under 6 months had the highest rates of hospitalization. Researchers are also still learning about how a Covid-19 infection can cause long Covid, particularly in children. A recent review paper looking at studies covering more than 80,000 children and adolescents found that more than one in four experienced long Covid.

“It’s a game of Russian roulette,” said Paul Offit, director of vaccine education at the Children’s Hospital of Philadelphia. “It’s not five empty chambers. Maybe it’s 100,000 empty chambers. But why play the game?” It’s important, then, to avoid infections in the first place and to build up immunity with vaccines.

Beyond reducing hospitalizations and deaths across all age groups, vaccines also shrink transmission rates. But as the SARS-CoV-2 virus has mutated, it has become more elusive. The subvariants of omicron, like BA.2.12.1, BA.4, and BA.5 — now the dominant sources of new infections — are more likely to evade immune protection from vaccines and from prior infections. That means they are more likely to cause reinfections or breakthrough infections.

Immunity against infection also wanes over time, and many Americans are more than a year out from their initial round of shots. Protection against severe illness remains largely intact, though, which is why most people who experience a breakthrough infection only endure a mild course of sickness.

All of these factors are playing out right now in sporadic Covid-19 outbreaks in some parts of the country. School events and summer camps have shut down. Thousands of flights in the US were canceled this month due in part to Covid-19 cases among airline employees. Community transmission of Covid-19 remains high across the country, meaning more than 100 new cases per 100,000 residents over the past week, according to the CDC.

Map showing US Covid-19 transmission by county
Most of the US is facing high levels of Covid-19 transmission this week.
Centers for Disease Control and Prevention

As summer heat forces people to stay inside in air conditioning, cases, hospitalizations, and deaths are poised to rise further in many states. With the prevalence of at-home Covid-19 testing, many infections remain uncounted in official statistics.

Precautions like wearing masks and social distancing are thus still necessary in some circumstances, like in enclosed environments. However, closing gaps in vaccination, especially in children, is more urgent than ever. “We could get another variant that’s completely different from omicron,” said Jason Newland, a professor of pediatrics at the Washington University School of Medicine in St. Louis. “We could get a variant that can completely escape [immune protection], and that’s going to happen if we don’t continue to vaccinate.”

Convincing the holdouts, however, will take finesse. Vaccine hesitancy and refusal have only become more entrenched.

Regulators have fumbled their message and goals for Covid-19 vaccines, but doctors and nurses can help recover it

Managing a public health crisis like the Covid-19 pandemic requires health officials to talk clearly to the public, but in the US, it has been the most consistently botched part of the pandemic response.

That has impaired the vaccination campaign, but also hampered measures to encourage wearing face masks, testing for Covid-19, and deploying treatments.

Government agencies have also made some baffling decisions during the pandemic that have undermined public confidence in their work, including the Covid-19 vaccines they’ve vetted for adults and young children. Early in the pandemic, the FDA — seemingly under pressure from the Trump administration — granted an emergency use authorization to hydroxychloroquine as a treatment for Covid-19, despite weak evidence for its effectiveness. It later revoked it.

With Covid-19 vaccines, the FDA decided to grant emergency authorization on a rolling basis as manufacturers completed their clinical trials in adults and older kids. The agency considering doing the same for vaccines for kids under 5 when data from Pfizer’s clinical trials emerged in February, but the agency instead decided to wait and consider Pfizer’s and Moderna’s Covid-19 vaccines for young children together, pushing the timeline for emergency use authorizations back to June.

Officials said that was because the Pfizer trial showed the vaccine was weaker in younger children with two doses, so they wanted to see if immune protection was stronger after three doses.

“I know that may have created some question there, but I think the right thing happened, which was we made sure that the data ultimately supported our authorizations,” Peter Marks, who is in charge of vaccine approval at the FDA, said during a webinar in June.

But Adam Cancryn at Politico reported that the agency was also trying to shape public reaction to the vaccines. “They worry that authorizing a single vaccine and then, soon thereafter, another one might make it harder for the administration to promote the shots and undermine confidence in their effectiveness,” Cancryn wrote.

The decision was frustrating for many parents who were desperate to immunize toddlers and babies — and the effort to outsmart the public undermined the urgency around vaccines that health officials have been trying to convey.

The FDA was already reeling from revelations of its too-cozy relationship with the industries it’s supposed to regulate and its shortfalls in its other mission to protect the food supply. The FDA did not respond to requests for comment.

President Joe Biden holds a baby while visiting a Covid-19 vaccination clinic hosted by the District of Columbia’s Department of Health in Washington, DC, on June 21, 2022.
President Joe Biden called Covid-19 vaccines for babies a “historic milestone.”
Sarah Silbiger/Bloomberg via Getty Images

For the Pfizer/BioNTech vaccine for kids under 5, there’s another complication: It has to be administered in three doses. The Moderna vaccine for this age group is given as two doses. It’s already proven to be an immense challenge to get a second dose to adults, so getting two or three shots to little kids may prove even harder.

Though the FDA’s and the CDC’s missteps during the Covid-19 pandemic certainly didn’t help things, they’re only the latest in a longstanding erosion of confidence in government, said Herschel Nachlis, a professor of government at Dartmouth College. “The larger trust issue has been ongoing for decades,” he said.

Most people are not paying attention to specific FDA decisions, but muddled messaging and frustration with the pandemic on top of political polarization means that the US may already be approaching the limit of how many people will get vaccinated.

“There’s this background idea that if we did everything right that everyone would fully agree and [vaccine] uptake would be extraordinarily high,” Nachlis said. “I think there are a lot of assumptions baked into that view that unfortunately might not be true anymore.”

As for the people who have been vaccinated, it’s not clear yet whether they’ll need more or newer shots in the future.

Vaccine manufacturers are already developing Covid-19 vaccines targeted at the newer variants. FDA advisers this week voted 19-2 to recommend booster doses of Covid-19 vaccine reformulated to counter omicron as part of an immunization campaign ahead of an anticipated fall surge in infections. Earlier this month, they also recommended that the agency authorize another Covid-19 vaccine, this one developed by Novavax. In May, the CDC expanded booster dose eligibility to 5- to 11-year-olds.

“I think Americans right now are confused about what it means to be ‘fully vaccinated,’” said Offit. “I think we need to define for the American public — and for me, frankly — ‘What’s the goal of this vaccine?’”

Right now, it’s not clear exactly where vaccines fit into the broader US public health response. While considering new vaccines, officials are also relaxing the measures that do help prevent infections, like social distancing, requirements to wear face masks, and testing mandates.

So parents and other concerned people might do better to talk to their doctors rather than wait for guidance from the government. “What I would encourage parents to do is have a frank conversation with your pediatrician or with your trusted medical provider to be able to think through what the questions are, what the risks are, what the benefits are, so you can make a really good decision for your family,” C. Buddy Creech, president of the Pediatric Infectious Diseases Society and a vaccine researcher at Vanderbilt University, told reporters this week.

Sara Oliver, a pediatrician who advises the CDC on Covid-19 vaccines, said during a webinar in June that talking to parents and kids one-on-one is going to be key to winning over the hesitant. “I think we need to be very understanding of the families who say, ‘I just need a minute, I want to think about it,’” she said. “Giving space for people who have very reasonable questions, and have them answered, is how we get those numbers up.”

Of course, the pandemic doesn’t end at the water’s edge. In addition to vaccinating young children, getting the rest of the world immunized is critical: It will save lives in those countries, and it will also keep a lid on new variants that could spread.

As exhausted as everyone is, the campaign to immunize against Covid-19 must continue to gain momentum around the world. Otherwise the cycle of infection spikes and drops will continue to derail the push to end the crisis.

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