By S. Mitra Kalita
At last, the babies qualify.
This week, the U.S. begins another vaccine rollout after weekend approval by the U.S. Centers for Disease Control for the youngest group yet. The Moderna vaccine will be administered in two doses to children six months to 5 years old. Pfizer will be administered in three doses for children ages six months to 4 years old.
Children have been among the hardest populations to move the needle on when it comes to vaccination rates. We asked Dr. Mark Horowitz, who has been partnering with Epicenter since the very beginning of our vaccine efforts for his thoughts. You can catch him on our podcast here or read edited excerpts below. And remember, Epicenter volunteers are standing by to help. Call us at (917) 818-2690 or email us at firstname.lastname@example.org.
Epicenter: Will you be offering the new vaccine?
Mark Horowitz: I have not gotten shipping confirmation from Department of Health on infant and pediatric vaccines. I’ve preordered 100 doses of Pfizer, 100 doses of Moderna. My order was accepted but as of a few minutes ago there’s no shipping date yet. I expect it’s imminent now that both the CDC and FDA have signed off on it. So I’m pretty sure sometime this week it will be shipped and received the next day.
Epicenter: The question we will be asked, as we were before, is Moderna versus Pfizer. Thoughts on which one is best?
Dr. Horowitz: I decided to offer both vaccines just like I decided to offer all three of the adult vaccines because I think people deserve a choice. But the answer to the question — Pfizer and Moderna is the same answer as it was for adults: whichever goes into your arm is the right one.
Epicenter: There’s deja vu all over again from what we went through the first time, right?
Dr. Horowitz: Of course. How are we going to get parents to accept the vaccine? There’s a certain number of parents who are enthusiastic about it, and will be lining up at our door on day one. But there are still a lot of questions that parents have and the answers are emerging slowly. First of all, parents say, “Well, my kid had COVID this spring, why do I need to give them the vaccine?” And the answer is the same as for the adult vaccine. The hybrid immunity, that is to say natural immunity plus the vaccine is better than disease-induced immunity alone because we know that it wanes with time.
We get parents saying that the data is not enough to convince them, whereas the data on the adult vaccines is overwhelming, we’re talking about an 88-90% reduction in hospitalizations and chance of death. For kids it’s 50% or less. But even one kid dying is too much.
Epicenter: Do you think that’s why the city is seeing a lagging in the 5-12 range versus adults? It’s because of these data points?
Dr. Horowitz: Sure, the uptake on older kids and adolescents has been only 50% in the city and less in other areas. So we’re going to go through the whole hesitancy thing again. We have to have reasonable and evidence-based answers for parents and allow them to make the best decision they can for their kids. The efficacy is not as great as it is for adults, but it’s still pretty impressive. It certainly prevents death to a great degree. When you look at all of the other childhood vaccines that we offer, COVID still has a higher mortality among children than the majority of those. Kids very rarely died of measles or mumps. The childhood vaccines that we give are for diseases that are serious, but not usually fatal. Whereas this has a defined mortality rate that’s probably higher than most of those diseases. So there’s a good reason to give it.
The community health aspect of this is important as well. If you’re giving a kid a vaccine, that will reduce the amount of virus they carry in their system if they are exposed to the virus, then they’re going to spread it to their parents, grandparents, neighbors, and teachers less efficiently, if at all. So there are compelling reasons to get it. I’m very excited about offering it to my patients but I understand the questions. We’re going to have to go through the same process we went through a year or 14 months ago with people who had vaccine hesitancy. The answer is to have really open minded, non-judgmental discussions with them and try to help them get the information they need to make a smart decision for their kids.
Epicenter: I talked to two moms today. One mom said, “I wish I knew whether masks would be mandatory in the fall or not.” That’s one piece of feedback. The second was from a mom who said, “If my 3-year-old wants to do any activities, she’s going to have to get the vaccine.” I thought that was interesting, that there are these external factors that parents are also weighing as they’re deciding what to do.
Dr. Horowitz: And the other external factor that weighs heavily on this is our mayor. He really makes policy to a significant degree with the schools. I like him very much, but he’s very motivated to normalcy. He wants a return to normalcy as quickly as possible for social, political, and economic reasons. He may not be as data-driven as our previous mayor was.
Epicenter: That’s a really good point. The other piece that I wanted to make sure you address, because you can definitely say “I told you so” on this one — a few months ago you said to me that we shouldn’t be using the language of “boosters,” we should just be saying this is the course of the vaccine. These are the doses of a regular vaccine. What prompted that? And what do you think of that now? Both in regards to children and adults.
Dr. Horowitz: It’s a semantic issue and I think the semantic issue is critically important. People’s willingness to take another dose of the vaccine is colored by their perception of the importance of that vaccine. So if someone’s already had two doses of an mRNA vaccine, and they’re told they have to have a booster, they’re going to be less willing to take it than if we say, “We recommend you have a third dose.”
I don’t know that I can explain that but I think the semantics of it really impact people’s perception of the vaccine. Therefore, in my office, I always refer to it as a third or fourth dose. If patients scratch their head, I say, “The first booster is your third dose. The second booster is your fourth dose. Remember when you took your kids to the pediatrician for the polio vaccine? They got five doses altogether. They didn’t get two doses and three boosters, they got five doses altogether.”
The knowledge of immunity against SARS-CoV-2 is evolving. We now know that two doses is probably not enough to last a long time. It lasts a year, maybe more, but not enough to last a long time. I have medical students in my office and all of the patients over the last 6 or 7 months who tested positive initially for Omicron and now BA.2, when the students see me talk to them, one of the students said to me “How much clearer could it be, that a third dose allows you to have an illness that’s much milder than just two doses.”
So I tell patients who test positive these days, “You’re going to be more bored than sick. The first day or two is not pleasant at all.” But from then on out until they convert to a negative test and can go back to work, they watch a lot of Netflix.
Epicenter: Where are we on the rollout as you’re seeing it as a primary care physician? Who’s still coming to your office to get vaccinated and what are their reasons for delays, if you’re seeing any of those?
Dr. Horowitz: My practice mostly consists of insured people who are educated. They’re from all walks of life, but very few of them harbor any significant misconceptions about the vaccine. I will see a very small number of people who remain unvaccinated, and I’m not ashamed to use this term, I think those people are deluded. I think they have delusional beliefs about the vaccine. I’ll ask them, and I’ll try to enter into a discussion. But at this point we’re not seeing vaccine-hesitant people, we’re seeing vaccine-resistant people.
A woman said to me that a doctor she follows on the internet says that there’s crushed up fetal parts in the vaccine. I can show her the list of ingredients on my phone, all sorts of patient education slides — and there’s a very short list of ingredients, none of which are fetal cells. But there was nothing I could do to convince her because she’s really deluded.
Most of the people who are still getting vaccinated are getting third or fourth doses now. They’re getting those doses because they qualify for it, because they have vulnerable family members, they’re getting them before they travel to a place they perceive there may be more of a risk. I was on an airplane for six hours the other day, I kept my mask on the entire time, and in the waiting room at the airport there were clearly people coughing so I think travel is a risk we’re taking right now. Particularly traveling within the New York area, where BA.2 is so endemic right now.
But the rollout, just in terms of this particular family doctor, 98-99% of my patients are vaccinated and 60-70% of them have had a third or fourth dose, that is to say they’re boosted. The people who are coming in now are seeking a third or fourth dose.