Why we keep our daughter up to date on Covid vaccines

And why that’s the opposite of malpractice.

I feel the need to speak up about the recommendation for kids to get this fall’s updated Covid vaccination. It comes on the heels of another terrible post written by a doctor here on Substack. He has a large readership, built carefully with Covid trivialization, ad hominem attacks, and political flames. This guy recently wrote that “doctors who advise a healthy child to get a 2024 fall booster are committing malpractice.” Nice inflammatory headline, sure to get clicks and stoke outrage. He calls the new updated shots boosters, committing a rookie error in terminology with his first sentence. Sloppy. I’ve done this, too, by the way, but when you’re picking fights with the CDC and thousands of pediatricians you should be at the top of your game. But instead of drawing more attention to his antics, or going line by line through his mean-spirited article, I’d rather provide a counterpoint for anyone who is considering whether to give their kid an updated Covid shot this fall.

Since my child has not had any recent Covid infection, and since the evidence of staying-up-to-date-benefit continues to outweigh risks, and since the CDC agrees with this stance, and since I care about decreasing my kid’s chance of getting Covid even if it’s just through the current surge, and since every Covid case prevented is one less roll of the dice with a novel illness we know can damage kids under the hood, and one less chance to spread a still potentially serious illness to teachers, friends, family, and especially the older generation… she’s currently up to date with her 2024-25 shot already.

Other families can make their own choices based upon how recently their kids have had Covid (assuming they test), or what they perceive to be an acceptable risk of getting Covid with immune system tools trained on old shots and infections that are much farther back in the evolutionary tree than the current KP.2 and JN.1 shots (which are pretty close to present sub-lineages). I Just hope they don’t make their decisions based upon outlier physicians, or worse yet, believe that doctors and other parents who keep their kids up to date on Covid vaccines are committing malpractice. Unreal.

Maybe there are long term risks to repeated Covid shots, but smart people are watching this. We might look back someday and find more risks than we thought. But doctors like the one I’m mentioning above are almost rooting for that, if only to justify their present radical and untrue pronouncements. One thing we know in the present moment is that kids can still get banged up by Covid. Read on.

Guidelines for this year state:

CDC recommends everyone ages 6 months and older receive an updated 2024-2025 COVID-19 vaccine to protect against the potentially serious outcomes of COVID-19 this fall and winter whether or not they have ever previously been vaccinated with a COVID-19 vaccine.

So, following these well thought out and researched guidelines is malpractice?

Malpractice is typically defined by the failure to provide the degree of care another clinician in the same position with the same credentials would have performed, resulting in injury to the patient. But when you practice according to the consensus guidelines of the Advisory Committee on Immunization Practices (ACIP) of the CDC, you have the stature and expertise of their deep analysis to inform you of the standard of care. They aren’t making stuff up, but rather:

ACIP’s recommendation was based on ongoing vaccine-preventable morbidity and mortality from COVID-19 in all age groups, vaccine effectiveness (VE) and safety data, cost-effectiveness, and equitable access to COVID-19 vaccine, including in disproportionately affected populations. ACIP will continue to evaluate new evidence as it becomes available and will update recommendations as necessary.

The American Academy of Pediatrics and the American Academy of Family Physicians agree.

In my Covidlandia updates from the past 6 months I highlighted some of the many recent studies showing that staying up to date with vaccines, even in kids, has been a good bet so far. As they say, past performance does not guarantee future results, but why keep betting on losing propositions?

I won’t rehash how the first Covid shots were a net positive for kids. They were, both for the children and the tens of millions of parents and grandparents who did not die. Part of that sum was getting kids vaccinated, too, for themselves and their families.

Instead I will remind us of the more recent studies published in ~2024 that informed my family’s decision to follow CDC guidelines and the nods from the AAP and the AAFP. I’m pasting these from previous Covidlandia posts I’ve done this year. Please make your own decisions, and I would compassionately and gratefully state that in 2024 neither choice for kids is malpractice.

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Updated Covid vaccines and boosters keep helping kids, too.

In a U.S. surveillance study from July 2022–September 2023, vaccinated children aged 6 months–4 years had fewer emergency room visits and hospitalizations with COVID-19 than unvaccinated children.

Vaccine effectiveness for preventing ER visits or hospitalization in those receiving >2 vaccine doses was 40.0% when compared to unvaccinated children.

Another study showed that Covid vaccination in kids was extremely (>90%) effective at preventing severe disease and hospitalization in kids during the previous Delta and Omicron waves.

Over 2,000 have died in the United States from Covid, with many also developing lasting damage from infection.

COVID-19 vaccine is tied to a 40-50% lower risk of long COVID in kids

Long Covid is estimated to affect 0.5 - 2% of children. Doesn’t sound that bad, but multiply that by 73 million children under age 18 in the U.S. (And the percentage could easily be higher as you’ll see in the last study quoted towards the end of the post.)

Do you know what the long term effects of repeat Covid infections will be on kids in 20 years? Me neither. I worry about that, much more than I would consider worrying about approved vaccines.

Vaccines continue to work well for kids

For any parents who are still considering whether or not to vaccinate their kids, these numbers are hard to argue with:

• Among adolescent 12 to 15 year-olds during the Delta period, vaccine effectiveness (VE) was 98.4% against SARS-CoV-2 infections —> 99.0% (mild disease), 98.7% (moderate-to-severe disease) and 99.0% (ICU admissions).

• Corresponding VEs during Omicron in adolescents were 85.5% —> 87.0%, 84.8%, and 91.5%.

• Among children 5 to 11 year-olds during Omicron, VE was 74.3% —>

  73.5%, 75.5%, and 84.9%.

What about myocarditis? In this study, published in Annals of Internal Medicine, risk for myocarditis was similar in the vaccinated versus unvaccinated groups during Delta, and lower in the vaccinated groups during Omicron.

Not sure this photo is relevant, but I liked it nonetheless :) By Abigail Miller

Kids that received the bivalent booster last year did great

They had a 54% reduction in Covid illnesses.

Good for them, their families, their schools, and their communities. Published in JAMA.

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Kids can get banged up by Covid, too.

It is estimated that 5.8 million children in the U.S. may be impacted by long Covid symptoms and ongoing problems. From the lead author of the review paper published in Pediatrics, Dr. Melissa Stockwell: 

A lot of what we know about Long Covid really does come from adults, there’s much less that’s known about kids. And I think that pediatricians, for many of them, Long Covid isn’t really on their radar. That’s been hard for families who have talked to us in RECOVER: they know something’s wrong with their child, they go to the doctor, and at best, the doctor doesn’t know what they’re looking at and doesn’t know how to manage it. And at worst, the doctor doesn’t believe the family and the child… 

This is another reason why I keep my child up to date with Covid vaccinations. They have been shown to keep adding benefit, though most studies are in adults.

I don’t listen to doctors and others who trivialize Covid, even in kids.

In a large study, vaccination was associated with 30% to 50% lower risk for long COVID in all age groups.

Although the majority of people in the U.S. are vaccinated, many still grumble about it and refuse to get additional recommended boosters. So here’s yet another reassuring study published in The Lancet.

That 30-50% reduction in long Covid emerged from a powerful study of 10 million vaccinated and 10 million unvaccinated people in three European countries. I subscribe to New England Journal Watch, and I like how they interpreted this result further:

The large size of this study, inclusion of a never-infected comparison group, analysis of symptoms before the pandemic, and the study's statistical rigor provide strong evidence that COVID-19 vaccination lowers risk for long COVID. This protection is seen in all age groups, including young adults. Because young adults can develop long COVID, perhaps vaccine boosters should be recommended more strongly in this group.

Boldface emphasis added by me. I’ve consistently been advocating for this all along, and have been frustrated by thought leaders who narrowly consider the purpose of vaccination “just to prevent hospitalization and death.”

Some kids still being hospitalized with MIS-C after Covid this fall

MIS-C causes different body parts to become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, and gastrointestinal tract. It occurs within 2-6 weeks after Covid. While the condition can be serious or fatal, most children recover. The CDC reports for 2023:

• 117 pediatric cases of MIS-C after Covid were reported, with half of those ending up in the ICU. Many more cases can be assumed to have occurred in the outpatient world. Being in the ICU as a kid is terrifying, for kid and parent.

• 82% of these children were unvaccinated.

• Of the 20 vaccinated children who were reported, 60% had waned immunity at the time of their MIS-C illness, presumably from not being up to date on vaccines.

Myocarditis and vaccines? Minimal worries at this point.

Also from the CDC: Oregon health officials investigated potential sudden cardiac deaths among young people after COVID-19 vaccination but found no clear association. They examined death certificates and vaccination records for individuals aged 16-30 who died from cardiac or undetermined causes between June 2021 and December 2022 and did not find evidence linking the vaccines to sudden cardiac deaths in this age group.

Vaccines benefit kids, so keep them up to date, too.

A study from the CDC: During December, 2021–October, 2023, receipt of ≥2 doses of an original mRNA COVID-19 vaccine was 52% effective against pediatric hospitalization and 57% effective against critical illness related to COVID-19, when the last dose was received within the 4 months preceding hospitalization, but protection decreased over time.

These findings support existing recommendations that children and adolescents aged 5–18 years remain up to date with COVID-19 vaccination.

Kids with long Covid can’t run and play as well. Objectively.

There has been a lot of gaslighting, trivialization, and dismissal of the potential harms of Covid in kids. Most seem to be doing pretty well after Covid, but many are not. Estimates for the incidence and prevalence of long Covid in kids range from about 1% if you check with the CDC… to 10 - 20% if you check with this recent study published in Pediatrics. That would be up to 6 million kids with some combination of:

…(lingering) cough, headaches, fatigue, and loss of taste and smell, new symptoms like dizziness, or exacerbation of underlying conditions. Children may develop conditions de novo, including postural orthostatic tachycardia syndrome, myalgic encephalomyelitis/chronic fatigue syndrome, autoimmune conditions and multisystem inflammatory syndrome.

A recent study in The Pediatric Infectious Disease Journal confirms that 90% of kids with suspected long Covid who underwent exercise testing had objectively impaired functional capacity (expressed by a low VO2 peak), signs of deconditioning, and cardiogenic inefficiency. This compared to just 10% of kids without the diagnosis of long Covid.

To me this shows that we should still be keeping kids up to date with recommended vaccines, not sending them immediately back to school when sick with Covid, and asking them to wear a mask when they return to school while still contagious with Covid to protect their teachers and friends somewhat.

Has such altruism been thoroughly trashed? Why?

Vaccine contrarians (like the person who compelled me to write this post explaining my decision) are quick to dismiss any study that shows benefits (like the ones above) if they are not randomized controlled trials (RCTs). And yet these same cherry pickers will aggrandize any lesser studies or even case reports that suit their preconceived notions. But it turns out that actually running an RCT, especially one that has lasting value, is a lot harder than merely calling for an RCT, especially during a pandemic with moving targets.

One could also argue that staying up to date with vaccines becomes even more important as we culturally abandon things like prioritizing good ventilation, staying home when sick, testing for Covid, or wearing a mask when sick/trying not to get sick for whatever personal reason we might have.

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Once again, the above is just a sample of some recent studies that caught my attention and made the cut for monthly updates of relevance to primary care. There are lots more out there. Consider them. Consider the CDC recommendations and referenced studies. Consider your family’s unique circumstances.

Just don’t consider CDC and FDA-approved and recommended vaccinations malpractice. That’s ugly discourse, and insulting to the earnest scientists, health policy experts, and parents who are doing the best they can as the data keeps rolling in, the long term effects of Covid illness and vaccination keep coming into focus for us to scrutinize, and an indifferent, novel virus keeps evolving as we try hard to live with it.

Take good care.