Toolkit: When Will Kids Get Vaccinated?

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Description

Dr. Bob is joined by Paul Offit, pediatrician and Director of the Vaccine Education Center at Children’s Hospital of Philadelphia, to answer your questions about kids and the vaccines. This Toolkit is your one-stop-shop for everything you need to know about vaccinating kids against COVID-19: what ages will be eligible, when it’ll happen, how to know it’s safe, and much more.

 

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Find Paul Offit on Twitter @DrPaulOffit.

 

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Transcript

SPEAKERS

Dr. Paul Offit & Dr. Bob Wachter

Iris Wachs  00:00

Kids, can they get the vaccine, too?

Dr. Bob Wachter

Okay. Yes, kids are gonna get the vaccine. How old are you, sweetheart?

Iris Wachs

Seven.

Dr. Bob Wachter 

Seven. I think you’re gonna get the vaccine. Maybe by early next year. You ready? You ready for the vaccines?

Iris Wachs

Yes.

Dr. Bob Wachter 

Yes? Okay, good.

Stephanie Wittels Wachs

Are you scared?

Iris Wachs 

Sort of.

Stephanie Wittels Wachs 

You don’t want the needle?

Iris Wachs 

No.

Dr. Bob Wachter

Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. You just heard from avid listener 7-year-old Iris Wachs, who happens to be the daughter of one of our executive producers Stephanie Wittels Wachs. Iris has wonderful questions. And it turns out, so do the adults in her life. And I’m guessing if you’re anything like Stephanie, or me or many other people, you have lots of questions about where we stand in the pandemic as it pertains to kids. It’s a particularly interesting moment as we think about the kids because we now have vaccines that we know are spectacularly effective and safe for adults, but we don’t yet have them available for kids.

Dr. Bob Wachter

So on top of what may have been one of the most dominant controversial questions of the past year, which is what to do about the schools. We now have a ton of questions that people have about the vaccines, when they’ll be out for kids, whether they’re going to work, whether they’ll be safe, some of the nuances about the different vaccines and different age groups, and then also a lot of questions about what to do with the kids. Now that we have a world in which it’s increasingly common that the adults are vaccinated and the kids are not. So getting together with kids, traveling with kids are complicated issues until we get to a world in which the vaccines are available and have been given to kids as well as adults.

Dr. Bob Wachter

So we thought it would be useful to have a toolkit and to do that there was clearly only one guest that we could have. If someone has been on the show once before Dr. Paul Offit who is a pediatrician specializing in infectious disease, and one of the world’s experts on vaccines, immunology and virology. Paul’s day job is he’s director of the Vaccine Education Center and attending physician in the division of infectious diseases at the Children’s Hospital of Philadelphia, which is one of the great children’s hospitals in the world. He’s also the -coinventor of the Rotavirus vaccine.

Dr. Bob Wachter  02:34

So in Paul, we have one of the world’s top vaccinologists, also a pediatrician working at a children’s hospital. Paul also serves on the FDA Advisory Committee on vaccine so when if you watched the committee meet and hear about the Pfizer and Moderna and J&J vaccines, Paul was there asking always really, really good questions. So he’s in the middle of the FDA approval process, as well as being an expert on the key issues around kids and vaccines. So the perfect guest to answer all of our questions about kids, vaccines and COVID. So let us bring on Dr. Paul Offit.

Dr. Bob Wachter

Paul, thanks for coming on. When we threw this set of questions out there, we asked our listeners, do you have any questions about the Venn diagram of vaccines and kids? And there were about 10,000 questions, we’ll go quickly. But it’s incredibly hot issue and you’re obviously the best person in the universe to answer them. So before we start with a listener questions, give us a quick primer on vaccines for kids. Why were they tested early on? And is there any reason, sort of before we even get into COVID? From what we know about vaccines and kids from other diseases, any reason to believe they’d be less effective or less safe and kids?

Dr. Paul Offit 

Well, I guess the second part of your question, now, I think there’s no reason to believe that we can’t find the right dose and dosing intervals for children to make a vaccine highly effective. And there’s every reason to believe based on the data that we have in adults, as well as now children down to 12 years of age that these vaccines will be safe in terms of whether their value, though, in terms of why they weren’t initially tested. I think, you know, if you look at the epidemiology of SARS-CoV-2 infections, 92% of the deaths were in people over 55. So it was very unusual for a child to die, which is not saying that they didn’t die. I mean, there were of the 560,000 deaths or so about 180 have been in children. So, I mean, that’s still if we can prevent that suffering and hospitalization and death, even in children, even in young children, then I think we should but that’s why they weren’t initially targeted because we were trying to save lives.

Dr. Bob Wachter  04:47

Okay, well, we got a ton of questions and I’ll intersperse a few of my own in there. But let’s go ahead and start with specific questions about the vaccines. Samina Taha MD, asked when will COVID vaccine To be available for kids younger than 16. And I’ll sort of append to that. What does the approval process look like for kids? Do you have to go through the huge clinical trials again? Or is it just okay to show that they’re safe and they engender markers of immunity?

Dr. Paul Offit 

Right. So I think the recent Pfizer trial answers that question. So what Pfizer did was they did a roughly 2,200 child trial between 12 and 16 years of age, half those 12-to-16-year old’s got vaccine, half got placebo. What they found was that the immune responses so called Geometric mean titre of virus specific neutralizing antibodies was actually higher in that group than it was in the say, 16- to 18-year-old group that they previously studied. So that’s good. And it was also an efficacy trial. And what they found was that there were 18 cases of disease in that trial, all in the placebo group.

Dr. Paul Offit

So therefore, it was obviously a small trial, but in that small trial, it was 100% effective. So I think what you’re gonna see is you’re going to see us work our way down. So already they started to recruit, they being Pfizer, Moderna, Johnson&Johnson, are already recruiting down to 6 years of age with an interest in going down to 6 months of age, by early next year. So we’ll gradually get those data.

Dr. Bob Wachter  06:12

And how do you sort out doses? Do you keep the same dose for a 12-year-old, but you’d then cut it for a seven-year-old, how do you sort that one out?

Dr. Paul Offit 

Right. So that’s why you do phase one studies, so called “Dose Ranging Studies”, which were done in the adults as well, where you look at say, when Pfizer settled on 30 micrograms per dose, you know, they had done, you know, lesser 10-30, you know, 60 100, they did dosing to see what induced the best immune response and at the lowest possible amount of RNA. And that’s also going to has been done and have been done here and will be done. As we move forward. It’s not surprising that it’s basically the same dose for the 12- to 16-year-old as it was for the 16–18-year-old. But you may find that you can give less messenger RNA or less vectored viruses, you go down that, but that’s why you do those dose ranging study.

Dr. Bob Wachter

And for kids medications, in general, there are a lot of medications that are dosed by weight of kids, is that ever true in vaccines? Or is it just, we’re at 30? And then for younger kids, we go to 15, or something like that as fixed doses?

Dr. Paul Offit 

You try. I mean, you just did. That’s why you have to do those studies to answer. It’s not quite the same thing. Because it usually when you get, for example, a drug like amoxicillin, you consider the sort of, you know, total body weight and total blood volume, because that matters in terms of distributing the drug into a certain amount of the bloodstream and distributing the drug into a certain amount of the volume of the bloodstream. That’s not the way vaccines work. I mean, vaccines, you’re giving the vaccines a shot, it’s taken up locally by the lymph node, where it’s processed and presented to the immune system. And there’s not as dramatic of a difference as there would be for between a young child and an adult in that range.

Dr. Bob Wachter 

Got it. Megan O’Dell Scott asked: “which vaccine is more likely to be approved for kids? I know the mRNA is a new technology. Has this been tested in kids before? Will the more traditional route like J&J be easier and safer for kids?”

Dr. Paul Offit  08:06

I don’t know how traditional J&J’s vaccine is. I mean, it’s a replication defective human Adenovirus type 26 that has been used in West Africa to try and prevent the spread of Ebola virus. So that’s the experience with that vaccine. I mean, there is no childhood vaccine that uses a replication defective human, or Simian adenoviruses. So all of these are basically new territory. But again, I mean, that’s why you do the phase one trials to see at what dose you can induce an immune response safely. And then you go to phase two trials where you know, you make sure that it consistently induces that immune response safely. And then you do as Pfizer did the 12- to 16-year-old, a small phase three trial, I don’t see us doing the kinds of size trials in children that we did in adults where you’re doing, you know, 30,000-40,000, the kinds of studies they’re talking about, are between three and 6000 at the most.

Dr. Bob Wachter

And do you think it’s likely that it will be two doses for the mRNA vaccines and one dose for the J&J they’ll use the same dosing intervals that they use for adult?

Dr. Paul Offit 

Yes, although I would offer the caveat that the J&J vaccine is currently undergoing a two-dose trial in the United States, which will probably be available by the second half of this year. They certainly if you look at that J&J vaccine, into preclinical studies, meaning non-human primates, there clearly was a boost in virus specific neutralizing antibodies with that second dose. Similarly, with the so-called Phase 1-2 A trials in humans, when you gave that second dose, you also got a boost at about 2.5-fold greater for virus specific neutralizing antibody. So that may correlate also to better clinical responses, meaning higher levels of efficacy in clinical trials. And so we’ll see. So that it may end up being a two-dose vaccine.

Dr. Bob Wachter 

Study, Stephanie Arsenald asked: “I heard Dr. Offit on the news saying that it wasn’t likely there would be a vaccine for kids under six because most of them don’t have ACE2 receptors.” First of all, did you say is that accurate? “And if so, why are kids catching COVID if they don’t have those receptors?”

Dr. Paul Offit  10:10

Right, so the virus SARS-CoV-2 virus binds to cells via this so called ACE2 receptor, it is a maturation receptor. In other words, as you get older, the quantity of ACE2 own cells increases. That’s clear, that was a jam paper, that’s clear. And that was the explanation for why it is that disease in the less than 5-year-old is, is very, very uncommon, it’s not absent, but it’s very, very uncommon. I mean, the fact is, even children less than 18 generally get this virus less frequently, and generally get it less severely. I mean, that is true. I mean, you know, I work at Children’s Hospital, Philadelphia, I see what comes into our house. But we’re right next to the hospital, the University of Pennsylvania, where they admitted people over 18 years of age, there’s a clear difference in the diseases that we’re seeing in those two hospitals.

Dr. Paul Offit

So it is true that the virus is less now, it’s not absolute. I mean, certainly someone five or less can get this disease. It’s true, but it is less common, I hope I didn’t say that they don’t get it. But in any case, there is an interest in going down to six months of age and studying this vaccine because at the very least children grow up and you know, you want them to be immune to this virus as soon as you can reasonably get them immune and safely get them immune.

Dr. Bob Wachter

So Jay Walberg asked a question, that’s a good follow up: “why would we want to vaccinate a population that isn’t at risk of severe outcomes, particularly if all the adults who want to be vaccinated will be protected.” So are we trying to get the kids vaccinated because of the risk to them? Or because society can’t get out of this mess until we reach herd immunity. And the kids have to be part of the numbers to reach out that when I spoke to a leading epidemiologist from Israel, and she made the point that even if we get all the adults, we can’t get to herd immunity, because there are so many people under 18 in the country.

Dr. Paul Offit

And so in this country, I think it’s a lovely 22% of people are less than 18 years of age. And if you want to get to 80 plus percent population meter, you would need to at some level, vaccinate children, you’re going to have to do that. That’s certainly true. And children grow up. This virus, I mean, as depressing as this is to say, this virus is going to be with us in the world for a long time. And so you’re going to need to vaccinate children at some point. And so if you can vaccinate them safely, early, that would be the easiest.

Dr. Bob Wachter  12:19

This tension of how safe does it need to be for a very young kid, if you really believe that the kids essentially have a zero risk of getting super, super sick, it does strike me as a somewhat different issue, you know, then for a 63-year-old to think about getting the vaccine, even if there’s a one in a million chance of a side effect, hell of a lot likely to get sick and die from COVID. But for a two-year-old, that’s a different calculus. So how do you think that went through?

Dr. Paul Offit

No, that’s a perfect point. Obviously, if you get the vaccine is a 75-year-old, where you have a very high chance of dying, should you wire this? The risk benefit calculation is much different than say, for a two-year-old, where you have an infinitesimally small chance of being hurt by this virus. So sure, I mean, I think that’s why that’s true, really, for all vaccines and children. Basically, we always know that they we have to hold us to the highest standard of safety because they’re so generally unlikely to suffer severe disease. But that’s what that has to be part of the calculation. Certainly here, I mean, you know, you will get this virus is unusual in the sense that it really does target older people. I mean, it’s, you know, flu also, you know, obviously kills older people, but not nearly as disproportionately as this virus them.

Dr. Bob Wachter

Mara Maas MD asks: “What trials are currently enrolling kids, and are there resources for parents interested in enrolling their kids in a COVID vaccine trial?” And I’ll just ask parenthetically to you, if you had a kid, would you want them enrolled in the trial? Or would you be thinking I’m going to wait until the results are out?

Dr. Paul Offit

Right, so there are currently trials going on with children down to six months of age for all three vaccines now So I think we’ll have those data by early next year for the youngest one. Sure if I had a child. I mean, I think that that we have so much information about these three vaccines in adults, you know, down to 18 years of age that I had a child I would feel comfortable enrolling them in a vaccine trial.

Dr. Bob Wachter  14:23

This came from an anonymous voicemail.

Female Voicemail 

And something that I’m curious about is whether or not there will be like an effort to get high risk children vaccinated sooner. I have a 10-year-old soon to be 11-year-old type one diabetic. His dad and I are both vaccinated, but we’re just kind of still feeling like we can’t ease up on the precautions that we’re taking until he’s vaccinated or until the transmission is lower. So really, it just I would just like to know like, if there’s any effort for high-risk children to be able to get vaccinated sooner, or if we’ll have to wait until next December, that seems like a really long time. Thanks.

Dr. Paul Offit 

I certainly know in our hospital because the Pfizer vaccine is now approved down to 16 years of age. So for the 16- to 17-year-old person who is higher risk in our hospital, the attempt who we see in our hospital, the attempt is to try and vaccinate them. So our feeling is a 16- to 17-year-old high risk population first. So I imagine that would also extend as we go down to 12. And then younger, I, you know, it should be soon I would think that Pfizer would be if they haven’t already submitted to the FDA for approval down to 12 years of age, but our committee hasn’t been formed yet to decide on that. The FDA vaccine Advisory Committee, so I’m not sure when that’s gonna happen.

Dr. Bob Wachter

Will it be the same committee, your committee that hears the younger kids that heard the earlier vaccine?

Dr. Paul Offit

I would imagine so. I mean, either that or they just skip our committee, but I imagined we would be asked to approve to extend the approval down to 12 years of age.

Dr. Bob Wachter  16:05

And what’s your sense of the timing? So if Pfizer announced their results on 12 to 16, last week, I guess in a press release, what would the normal timing be before then that could go up for EUA?

Dr. Paul Offit

So usually, the FDA reviews all the clinical data, and then they have because it’s an addcom meeting, they have to announce it in the Federal Register at least 15 days before the meeting. So it hasn’t been announced yet. And so you know, it’s at least two plus weeks away, I would imagine soon, but a guy knows as much as you do about this.

Dr. Bob Wachter 

Okay. That’s scary. Do you think it’s going to be kind of a step wise? All right, we got 12 to 16 for Pfizer. And then three weeks later, we got 12 to 16 for Moderna. And then next week, we have seven to 12 for J&J. Is it going to be kind of this matrix of three different vaccines times three to five different age intervals. And we, every week or two, we hear about a new group times a new vaccine. Is that how this is gonna work?

Dr. Paul Offit

I think I agree with all of that, except for every week or two. Every few months, but I do think yeah, I think that’s the way it’s going to play out would be step by step.

Dr. Bob Wachter 

Well, okay, Sherry asked: “Should breastfeeding moms get the vaccine? Is it safe for the baby?”

Dr. Paul Offit

Yes. I mean, the you know, there’s now a lot a lot of experience, actually with mothers who are breastfeeding, who have gotten this vaccine and women who are pregnant who’ve gotten this vaccine. And as of a few weeks ago, there were at least 30,000 women who were now signed into the so called “Be Safe System”. So if you get a vaccine and you’re pregnant, and the CDC, typically when a vaccine is not studied in pregnant women as these vaccines weren’t, that pregnancy was a cut, was an exclusion criteria for any of these trials. But nonetheless, people get pregnant during the trials because lifelines weigh. Now usually what the CDC will do in a situation like that, it’ll say, it’s contraindicated for use because we don’t have the data. They didn’t do that here.

Dr. Paul Offit

And I think the reason is, it’s clear, one thing is clear is that if you’re pregnant, and you’re infected with SARS-CoV-2, you’re more likely to suffer severe and occasionally fatal infection, than if you’re a woman of the same age who wasn’t pregnant. So the benefit is there. Same thing with flu, if you’re pregnant, infected with flu you’re more likely to be hospitalized, and more likely to die than if you’re a woman who’s whose same age and hence, the flu vaccine for pregnant women. I think this fall into that category, but we didn’t have data. So what’s happened is they have this so called “Be Safe System” which is on your iPhone, they your followed weekly, to make sure that you’re good.

Dr. Paul Offit  18:27

And then if your baby is born up to six months of age, to make sure that there’s no problems with the baby. So, so far, there haven’t been any problems of biologically, I can’t imagine why there would be problems. But you know, you have to be open minded to these things. But I think right now, the benefits of that vaccine outweigh what are at the moment only theoretical risks.

Dr. Bob Wachter

And at some point, are we going to hear that one of the vaccines has been quote tested in pregnant women, and it’s coming up for the FDA for a specific approval, or is it just going to be like it is now they haven’t said not to, and then you ask your doctor and your doctor says go ahead and get the vaccine

Dr. Paul Offit 

It works usually is that the FDA typically licenses a product or in this case, approves the product, and which only says the company can now distribute it. That’s all that says the recommending bodies, the CDC, the CDC then says I think you can do what they did was with pregnancy was they said a woman could reasonably choose to get the vaccine. I think if you can gather enough data where you can say clearly that it’s safe, then I think they would move to the next step, which is a recommendation rather than you can get this if you can reasonably choose to get it.

Dr. Bob Wachter 

Great. One more breastfeeding question. Becky […], said: “As a breastfeeding vaccinated mom, how much benefit is concurred to my less than six-month-old baby who’s only drinking milk versus my two-year-old toddler who’s drinking a small cup of day”

Dr. Paul Offit 

Well, so in theory, if you if you can develop a so-called Secretory IgA response that you passively transfer to the mucosal surface of your baby, there is a value that your baby’s mucosal surfaces are being bathed with antibodies directed against this virus now It’s not going to last for a long time. And again, really the little babies are the ones who probably at least risk, but you also transmit if you get the vaccine during pregnancy, you know, you will transfer passively transfer antibodies through the placenta to that baby, they probably are protected for about another six months or so even longer frankly. we learned that from the measles vaccine.

Dr. Paul Offit  20:22

I mean, when the measles vaccine was first introduced, you know, most women had already been naturally infected with measles, so they had fairly high titers of measles antibodies. That vaccine was when it was originally introduced was recommended for the 9-month-old, but there were still enough passively transferred antibodies through the placenta from mothers who’d been naturally infected was pretty much everybody that they had to move into 12 months of age, then 15 months of age, I mean, now to get away from those passively transferred antibodies for the interfered with the immune response. Now, we’ve sort of marched back again, because the immune response induced by vaccination is not quite as high as that induced by natural infection.

Dr. Bob Wachter 

Got it. Okay, let’s toggle to a bunch of questions that are kind of in the safe or not safe genre. I’m sure you’ve heard of many of these before. So Gina […], who also was an MD, said: “Adults are all vaccinated kids or not. When we get together for dinner, per CDC allowances, what’s okay for the kids to do? Outdoors only? Masked whenever indoors? Kids eat outside? Practical advice, welcome!

Dr. Paul Offit

I’m not sure I’m the best person to this. But I would say it’s just sort of a common-sense thing. If you’re indoors, if a child’s old enough to be able to wear a mask, I think that makes sense. The thing, here’s the thing that worries me, it’s, if you’re I mean, I’m fully vaccinated, I got two doses of Pfizer’s vaccine. But when I go outside and walk to the grocery store, for example, or go to the deli down the street, I always wear a mask. And it’s not the main reason I wear a mask is not because I fear that I would be asymptomatically infected and therefore contagious. It’s that I fear the variance. Because especially the variants like the Brazilian variant, the South African variant, and now the New York variant, which are like, which sort of similarly worrisome to those other two.

Dr. Paul Offit  22:09

My vaccine will protect me against severe critical disease caused by those variants, but it won’t protect me particularly well against, you know, mild to moderate disease. I mean, it’s not nearly as effective at doing that maybe 50%, 55% 60% effective according to those vaccine trials. So that’s the reason I do that. So until we get control of this virus, which I think we definitely can do by the end of the summer, or fall, then I’ll feel better. But for now, I would just say hang in there. I mean, still last week, we would have 50,000, 60,000, 70,000 cases reported, which you can assume is off by a factor of three, because those are just the people who got tested and were found to be positive. And a lot of people don’t get tested. And you still had, you know, 800-1000 deaths a day.

Dr. Paul Offit 

We have not gotten on top of this virus yet. So but we can, and I think we will by the end of the summer, assuming that people get vaccinated. Well, one thing that worries me a little bit as you look at sort of what percentage of seniors have gotten vaccinated, and right now it’s about 55%. Well, I think I don’t think there’s a state in this union right now that doesn’t offer that vaccine for people over 65. So I think that 55% number should be much higher. And I worry that it’s not higher.

Dr. Bob Wachter

Yep. Shana […] asked a series of questions. Let’s start with the first: “Should unvaccinated kids go to sleepaway camp, assuming they want to, should all summer camps require masks?”

Dr. Paul Offit

I think it depends how things move as we move into the summer. But I think it would be reasonable for summer camps to require masks if when you’re outside and running around and playing. I can see not wearing a mask there. But if you’re inside in a cafeteria or inside doing certainly doing you know things where you’re really close together, I think it would make sense for now, to require mask but again, it does depend on where we are over the summer. I mean, the thing that works against this virus, there’s a number of things working against this virus. One is natural immunity. I mean, we have when they say 30 million people who’ve been infected. Those are just people who’ve been tested and found to be infected. If you do antibody surveillance studies, that numbers off by a factor of three, it’s probably the CDC FDA meeting we had a few weeks ago picking flu strains, the CDC estimated 85 million people who’ve been infected, I think it’s probably close to 100 million.

Dr. Paul Offit  24:19

That’s 25% to 30% of the US population is already immune, essentially from natural infection. Plus, you have now about 22% of the adult population. That’s been that fully vaccinated. Good. That’s good. So we’re getting there. And the other thing and this, this never gets played, but I am going to stand by the statement because I really think it’s true. I think weather matters. I still think this is a seasonal virus even though there wasn’t good evidence that SARS won, or MERS was and here’s why I say this. Look at the death pattern for when this virus first came into this country. When it came in when it started killing people at the beginning of March of last year. first week of March of last year. It shot up the number of deaths shot up 2000 a day 2500 a day, and it stayed there.

Dr. Paul Offit 

Then as we started to move into spring, it came down. So there were many days in the summer, last year would be a few 100 deaths a day, occasionally 1000, often a few 100, then we started to move into the fall and winter months and it took off, right? You had, then you’d have 2000 deaths a day, 3000 deaths and 4000 deaths a day, and it really took off, then it started to come down again. And you know, people wonder why it’s coming down. And I think vaccines is part of it. And I think natural immunity is part of it. But last summer, that was a largely susceptible population without a vaccine. And nonetheless, the numbers came down, I am convinced, it is a respiratory virus, most respiratory viruses are winter viruses and spread by small droplets.

Dr. Paul Offit 

Those are usually winter viruses. So I’m still sticking by the fact that one of the things working against this virus is the weather and when people go on national television and say they’re expecting this sort of spring surge I know you should never make a prediction about this virus. I just don’t see it. Certainly not in terms of deaths. I mean, if you look at Michigan, for example, the number of cases which they talk about endlessly, in television now, the number of cases is clearly dramatically increased, but not the number of deaths, that’s still sort of stayed relatively low. So we’ll see.

Dr. Bob Wachter  26:09

Yeah, the seasonality, it’s always confused me, I get if people are outside and outside is safer, there’s a reason why it might be seasonal. The idea that there’s something about the ambient temperature that makes a huge difference in the nanosecond that it takes for the virus to go from somebody’s throat to the back of someone’s nose that never made much sense to me. So explain how seasonality works independent of just people being outside more.

Dr. Paul Offit

Yeah, this is easy. No idea. I mean, what anybody normally says they say like, it’s a virus spread by small droplets. Therefore, when things get more humid, this is what I was taught both in when I was a resident as an infectious disease fellow. And now an infectious you know, attending that when it gets more humid and you’re spreading things by small droplets. So those small droplets accrete require water more and so therefore, they drop more quickly. That’s always what I was taught.

Dr. Paul Offit 

But you know, you have Rotavirus, for example, let’s say winter gastroenteritis virus, Polio is a summer gastroenteritis virus, they’re both RNA viruses. I’m not sure why they’re both not envelope RNA viruses, one seat has different they have differences. And as in Brazil, Rotavirus is a year-round disease, whereas in the US a temperate climate, it’s only a winner disease. Flu is a year-round disease in Brazil, even though it’s only a winter disease, for the most part in the United States. Why those things are true? I have no idea. But they are true. I mean, there are there is a seasonality to viruses.

Dr. Bob Wachter 

Always makes me comfortable to learn that you don’t understand it. When I don’t understand that I just assume you do. Robin […] asked a few questions about vaccinated grandparents: “So if vaccinated the grandparents traveled to see an unvaccinated baby, is it safe for them to interact with the baby while unmasked after right after they get there?” And so, you know, we’ve had versions of that question, but there’s specific ways for grandparents interacting with babies.

Dr. Paul Offit 

I think the answer to the question is abundantly likely, yes. And there is something to be gained from a skin to skin contact with this little loved one, you know, I mean, there is there is a positive to that. And I think the risks are small, they’re not zero, I think the minute you walk out of the house, the risk is no longer zero. And so then the question is, is how big of risks to what extent can you reasonably mitigate risk? And those are there, those just don’t have absolute answers. Mostly just sort of a common-sense thing and just do the best you can. But no, I think they’re how can I stand up and say, don’t kiss your grandbaby? What would that make me?

Dr. Bob Wachter  28:34

Well, it’s a hard question, because at some level, it might make you prudent, but it also doesn’t feel human. So but your answer today is your senses, this is very likely to be safe enough to be a reasonable thing to do. And the human need to do it is so strong, that it’s certainly understandable.

Dr. Bob Wachter

How should vaccinated parents determine when it’s safe to send unvaccinated children to daycare? Is that different than other settings?

Dr. Paul Offit

I mean, we’re seeing more disease children. And I can tell you what our hospital we are certainly seeing more disease in children. And I think the reason is, is because we are going back to school and not all schools are the same in terms of their ability to mitigate spread. So I think you have to be careful. I think it depends on what’s going on in the community. I mean, if the community as a general rule of the schools tend to reflect the community or in the cases where they’re good about mitigating risk, they’re even better than the community. So I think that’s really where you should take the lead is whether there’s a problem. If there’s a big problem in the community, I would hold off.

Dr. Bob Wachter 

Okay. A few more general questions. Kristen Stevenson asked, we’ve sort of touched on pieces of this, but maybe just to have it as a discrete question. “When can kids stop wearing masks? Do you think we’ll get to a point absent vaccination for kids, that the community rate would be low enough that we could say to kids, you can stop wearing masks, even though you’re not vaccinated?”

Dr. Paul Offit  30:10

Yes, I think we can get to the point where the community risk is so low that we feel more comfortable about that. I do. I think we’re going to benefit from the summer. Because I do think it’s a winter virus and then what’s gonna what worries me is it may be a little bit of fool’s gold, because if we don’t get to adequate population, immunity from natural infection, or immunization, by late summer, early fall, you’re going to tell how good we did with vaccination. When the next winter comes, if my hypothesis about this being a winter virus is correct, it’s either going to be a little bump next winter, if we did well, and it’s gonna it’s gonna be a big surge if we didn’t do well. So we’ll see.

Dr. Bob Wachter 

Few more. Joan […] asked: “Is it true that kids are more susceptible to the new strains of COVID?” So sort of a general question, how will the variants play out with kids? Any reason to think it will be different in kids than in adults?

Dr. Paul Offit 

I think that they do vary, especially the so called B117 variant, the UK variant is more contagious, it appears to bind more avidly to the ACE2 receptor it reproduce itself at a grade level, so therefore, adults or kids are more susceptible to that virus. That’s why that’s what we mean by more contagious.

Dr. Bob Wachter

And it’s sort of become dogma in COVID, since the very beginning that the kids are less susceptible to the, younger kids particularly are less susceptible to catching the virus does that B117 overcome that or just, they still are less susceptible, but they are more likely to get this one because all comers are more susceptible to it.

Dr. Paul Offit

That’s it, I think it’s they’re more likely to get this because it’s been more avidly binds to the ACE2 receptors that they have and replicates better. So yes, they like the adults are more susceptible.

Dr. Bob Wachter

But one would think still less than if they were older?

Dr. Paul Offit

Definitely. I mean, our hospital is an example, we have a COVID ward in our hospital. And what we see is not what the adults see, in terms of severity of disease/

Dr. Bob Wachter  32:05

Even with B117 around?

Dr. Paul Offit 

You look, you know, there’s probably been 180 child deaths from this virus among the 560,000 people who have totally died from this virus.

Dr. Bob Wachter 

Michael Smith asked: “What’s the incidence of long COVID in young children?” Do we know that?

Dr. Paul Offit 

I think we’re learning that I had the virus hasn’t been around that long. I think we are learning that. We certainly see a lot of missy in our hospital, you know, the so called Multi System Inflammatory Disease when I was on service last two weeks, I saw five cases. And it’s pretty scary. I you know, it is, what’s weird about this virus is it doesn’t really cause viremia, you know, less than 1%, or fewer than 1% of people who get this virus are infected with this virus can have it detectable in the blood. Nonetheless, it you know, it causes a heart disease, liver disease, kidney disease, sort of brain fog. I mean, you see that in these kids.

Dr. Bob Wachter 

Rarely? in the early two, when Missy was first reported, it was a real worry that you’d see a bunch of kids who did not get sick from COVID. But then months or a year later would come down with this pretty, pretty nasty, scary disease. How has that played out in terms of how prevalent that is?

Dr. Paul Offit

I guess I think so a couple weeks ago, there were something like 4000, 5000 or so children who’d been reported to have Missy, I’m sure it’s higher than that, because we see a lot of it’s obviously a spectrum of illness. We saw, you know, a kid last week who had a very mild form another kid who had a more severe form. So there’s a spectrum there. And how that plays out over time. I mean, do those kids then more likely become what we call an adult’s long haulers. We’ll see.

Dr. Bob Wachter 

Yeah, and do we know anything more? There was also earlier reports about MRI’s in kids showing some evidence of heart involvement. And of course, you know, if that’s happens in a 10-year-old, you’re worried about whether that’s going to have a consequence over a lifetime? Do we know anything more about that a year later?

Dr. Paul Offit

Right. We certainly know that that specific heart enzyme proponent can leak into the, when those cells get damaged, that particular heart specific enzyme will then leak into the bloodstream. And we see that commonly. So I think there’s certainly subtle or damage in many of these kids who have this syndrome, which often can be an asymptomatic infection initially, and then three, four or five weeks later present with this multi system inflammatory disease, so they’re not shedding the virus anymore. They just have an antibody response to the virus and are this is their immune response immune system working against

Dr. Bob Wachter  34:29

As you’re thinking about the kids and their risk, let’s say with that vaccination, are you more worried about these kinds of long-term effects or more worried about acute COVID and getting really sick and potentially dying from the acute infection?

Dr. Paul Offit

No, that’s a great question. I’m more worried about the long-term effects. I mean, it’s very, very rare for a child to die of this virus but not so rare for them to get this multi system inflammatory disease. So I do worry about what the long-term effects of that are, you know we do. The studies haven’t been great here when Kawasaki disease first sort of raised had the United States in the 1970s. Very early studies were done looking at, do we do benefit, offer benefit by giving intravenous immunoglobulin or steroids or aspirin and those studies were done. And so clearly a pattern emerged as to what you should and shouldn’t treat them with. Steroids didn’t work. In fact, we made them worse. Aspirin did work, you know the IVIG did work to prevent those long-term heart problems.

Dr. Paul Offit 

Here, it generally though those studies haven’t been done, I think because we’re in the midst of a pandemic. So it’s basically on steroids and IVIG. For all, there was recently a paper in out of the UK looking at people who got steroids or intravenous immunoglobulin, or both or nothing to see whether it is obviously a retrospective study. And it wasn’t all that big. And I didn’t think it was great stratification in terms of degree of illness, but it did feel like anything made a difference. So I think I’m sure it does, I’m sure it’s something there’s a therapy that makes a difference here, but we are going to have to learn as we go here. And we don’t really know a lot about how best to treat this yet.

Dr. Bob Wachter

Yeah. All right. Last question. This comes from […]. We had an episode a week or so ago with Art Caplan, an old colleague of yours, talking about vaccine or immunity passports or authentication. And this listener asked what is anticipated as far as vaccine mandates for kids and teachers in schools. The teachers obviously could be mandated any point that kids want assumes after vaccines are approved. For kids, from you being a keen observer of vaccines over many decades? What do you think is likely to be the state of requirements for vaccines for kids and for teachers?

Dr. Paul Offit  36:34

Yeah, I’ll show you now why I get so much hate mail, I think that it is prudent to have mandates for if the vaccine has been shown to be safe, it’s been shown to be effective if there is plenty of vaccine available. If you know that children can catch this virus and transmit it to others, including other children, or teachers or vice versa. I think everyone should get vaccinated, who can, I mean, assuming you’re not allergic to a component of the vaccine that causes a severe allergic or anaphylactic reaction, get the vaccine. So in a better world, we all have that knowledge. We all now know it’s safe and effective, and it works. And this is a virus that can be terrible. And so we all choose to get the vaccine but doesn’t work that way.

Dr. Paul Offit

So some people choose not to get, I mean, you look at Ron DeSantis, Governor of Florida just recently said that no city, no district, no locality can reasonably ask for sort of once vaccines abundant can ask for basically a vaccine passport that you can’t do that because it’s quote unquote, a privacy issue. A privacy issue? I mean, if I step on a rusty nail and go to the emergency department and get it cleaned out, and the emergency department physician says you should get a tetanus vaccine and I say no, I don’t want a tetanus vaccine. I have just risked tetanus. But I have only risk it for myself, nobody’s gonna catch tetanus. For me. That’s not true with this virus. When you choose not to get this vaccine, you are making a choice for other people. And that is not your right I’m sorry, I don’t think you have an inalienable right as a US citizen to catch and transmit a potentially fatal infection.

Dr. Paul Offit  38:04

Now, you often don’t know who those people are that you’re infecting. But that doesn’t make it any less awful. And you know, there are 1000s of people in this country who can’t be vaccinated, because say they’re getting cancer chemotherapy, they depend on those around them to protect them, you have a right as a member of the society, an obligation as a member of the society to protect yourself and those around you. It’s not an individual choice. It’s not, it’s a choice you’re making for others. So I’m all for vaccine passports, I’m all for mandates. We shouldn’t need them, in a better world, we wouldn’t need them. But unfortunately, in his country, which is founded on the basis of individual rights and freedoms, we think we have rights that frankly we don’t have.

Dr. Bob Wachter 

Good. Even if you get some hate mail, I think that feels like so clearly the right thing. And particularly when we’re talking about the kids, it seems tragic to believe that someone will choose not to get vaccinated and put other kids and the teachers at risk. And so particularly with these vaccines that are so remarkably effective, and so astoundingly safe, so I appreciate your passion on that one. Paul, thanks so much, really appreciate all you’re doing to educate us. And this is a rapidly evolving issue, but really, really important issue. And obviously from the response we got from our listeners, a lot of people care deeply about it. So thank you for teaching us.

Dr. Paul Offit 

My pleasure. Take care.

Dr. Bob Wachter

Special thanks to Paul Offit for a terrific episode. There are a lot of questions, still some uncertainties. But at least in my mind, Paul cleared up a lot of the issues around when vaccines will be out and it seems likely to be relatively soon that they’re going to be effective and kids and they’re going to be safe and kids and hopefully we can start getting the kids vaccinated maybe as early as late summer or the fall. That would be terrific. We have a number of other wonderful episodes coming up here on in the bubble. Natalie Dean, who’s one of my favorite people to follow on Twitter is a biostatistician at the University of Florida.

Dr. Bob Wachter  40:11

But unlike most of the biostatisticians, I know she speaks clearly and vividly and is really very good at explaining complicated topics. And we have given her an incredibly complicated, controversial topic. And that is the fourth wave, is there going to be one? How big is it going to be? lots of debate about that right now. And we will learn from Natalie. Where things are likely to head in the next month or two. We’ll also do an episode on what we can learn from history. And we covered a couple weeks ago, we covered the HIV AIDS epidemic. But we’ll go back a little bit further in history to learn the lessons from both the influenza epidemic in 1918.

Dr. Bob Wachter 

And the end of the Polio Scourge, which happened in the 50s. We’ve already lined up, John Barry, the author of the fabulous book, The Great Influenza. Still, I think, a New York Times bestseller today, even though it came out a while ago, because so many people want to learn about the lessons from 100 years ago from influenza. And we’ll also have another terrific guest talking about polio, and particularly what happened with the sprint to try to get polio vaccines and what happened once they were vaccines are available, how they got out there and what lessons there are about that for today. Finally, we will have another episode, we haven’t talked much about the global picture for COVID. But obviously, there’s a ton going on all over the world with the same kind of split screen that we’re seeing here in the United States, some countries doing reasonably well. Some countries still getting hammered.

Dr. Bob Wachter 

The issue of variants, and then something we’ve been thinking more and more about, which is this issue of if we don’t vaccinate the rest of the world, and we will not be safe here in the United States has a lot to think about as we talk about the rest of the globe. And I’m thrilled that an old friend Nicky Laurie, who is an expert on global vaccination has had leadership roles for that, in both the US government and some important international organizations will come in and talk to us about the global picture. So plenty of great stuff coming up here on IN THE BUBBLE. hope you will join us and please stay safe and get vaccinated. We’ll talk soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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