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The conundrum of Covid vaccines for children, adolescents and youth

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By Dr B. J. C. Perera

MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL).

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

There is a lot of interest as well as differences of opinion and even misinformation regarding many aspects of vaccination of children, and young people, against Covid-19. This has led to a considerable amount of anxiety in the minds of parents, and even the youth themselves, regarding the different facets of vaccinating these subjects against the coronavirus infection that is running riot, all over the world, including Sri Lanka. Against this background, it is also pertinent to point out that there is a very definite recent increase in the numbers of children who have tested positive for the coronavirus disease, especially in some of the developed countries with facilities available for large scale testing of the general population.

There is a considerable number of differing opinions expressed regarding the need to vaccinate these age groups of subjects. True enough, it is argued that children, and young people, are not as susceptible to major effects. However, there are documented cases, though quite rare, of children, and young people, getting the Multisystem Inflammatory Syndrome (MIS-C) complication of Covid-19. That particular problem could affect several body systems and organs. It is a somewhat delayed but a rather nasty complication which, if it is not properly and promptly treated, could even lead to death. Then, of course, there is the spectacle of ‘Long Covid’, where there are persistent symptoms, particularly of a respiratory nature, for quite some time, after apparent recovery from symptomatic Covid-19. There are some reports of persistent vague symptoms, even in those who were originally not sick with symptomatic disease. It is also noteworthy that there are reports of significant x-ray changes that have been detected in some completely asymptomatic positive cases. It must also be considered that the clinical picture of Covid-19, in children, seems to fluctuate considerably, over different time periods. There is no guarantee that there is no risk at all of the disease suddenly turning quite virulent and starting to produce marked and severe symptoms, even in children. This is particularly of relevance in view of the propensity for the coronavirus to undergo mutations, as it keeps on replicating.

Children rarely become severely ill from Covid-19. However, in the US, in August, 2021, the Delta variant has landed nearly 30,000 of them in hospital. According to the American Academy of Pediatrics, nearly 5.9 million Americans younger than 18, have been infected with the coronavirus. Of the roughly 500 Americans, under 18, who have died, about 125 were aged 5 to 11. “It really bothers me when people say kids don’t die of Covid”, said Dr. Grace Lee, an Associate Chief Medical Officer, at Stanford Children’s Health, who also leads a key Advisory Committee to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. She also said “They die of Covid. It’s heart-breaking”. About one in six Americans infected, since the beginning of the pandemic, was under 18. But with the surge of the Delta variant, children accounted for as many as one in four infections in recent times, according to the American Academy of Pediatrics.

Then, of course, there is the problem of asymptomatic afflicted children carrying the virus around and spreading it, and, perhaps, much more importantly, the scenario of them taking it home and infecting susceptible adults and the elderly. With rather close gatherings during transport, to and from schools, and also in the classrooms themselves, the risks of these children contracting the virus is something quite real. There are some sporadic studies that indicate that there is some protection provided by the vaccines in actually preventing, to a certain degree, the exposed individuals from contracting the virus. This is, of course, is not 100% protection by any means, but is a rather minor but a positive reason for vaccination.

At this point in time, the only coronavirus vaccine that is universally authorised to be administered to children and, young people, over the age of 12, is the mRNA Pfizer – BioNTech Covid-19 (BNT162b2) vaccine, with the brand name “Comirnaty”. The European countries, and Australia, have been provided provisional authorisation for the use of the Moderna mRNA-1273 vaccine with the brand name “Spikevax” in those over 12 years of age. In several studies, the effectiveness of these vaccines, as well as their safety, have been established.

Yet for all that, there are some of the more recent reports of the occurrence of the extremely rare complications of myocarditis and pericarditis occurring, especially in adolescent and young males with all mRNA Covid-19 vaccines, particularly after the second dose of the vaccine, occurring typically within a few days after vaccination. Myocarditis is an inflammation of the heart muscle and pericarditis is an inflammation of the lining that surrounds the heart. Available data suggest that the immediate course of myocarditis and pericarditis, following vaccination, is generally mild and responds to conservative treatment. So far, major problems, with long-term heart functions, have been see in these cases and follow-up is ongoing to determine possible long-term outcomes. All young recipients of mRNA vaccines should be instructed to report for medical attention if they develop symptoms, indicative of myocarditis or pericarditis such as new onset and persisting chest pain, shortness of breath, or palpitations, following vaccination against Covid-19. It has to be reiterated that these complications are extremely rare. In the USA there have been no deaths reported in young people developing myocarditis, following mRNA Covid-19 vaccines.

In a most reassuring publication, released on 22nd October 2021, hot off the oven so to speak, both BNT162b2 (Pfizer-BioNTech) and ChAdOx1 nCoV-19 (AstraZeneca) vaccines offered substantial protection against death from coronavirus disease 2019 (COVID-19) caused by the B.1.617.2 (Delta) variant, according to a study published in The New England Journal of Medicine. Meanwhile, another study, also published recently in The New England Journal of Medicine, suggests that the BNT162b2 (Pfizer-BioNTech) vaccine was highly effective against both documented infection and symptomatic COVID-19 with the Delta variant among adolescents, between the ages of 12 and 18 years. The latest information available to us seem to confirm the benefits of Covid-19 vaccinations in adolescents and young people.

The most recent development, from the standpoint of Covid-19 vaccinations for children, is the application due to be made by Pfizer to the Food and Drugs Administration (FDA) of USA for authorisation for usage of its Covid-19 vaccine for children, 5 to 11 years of age. In a highly anticipated announcement, Pfizer has said that a Phase 2/3 trial showed its Covid-19 vaccine was safe and generated a “robust” antibody response in children, aged 5 to 11.

These are the first such results released for this age group for a USA Covid-19 vaccine.

The trial included 2,268 participants, ages 5 to 11, and used a two-dose regimen of the vaccine, administered 21 days apart. This trial used a 10-microgram dose, which is one third of the 30-microgram dose that has been used for those 12 and older. Pfizer has said that the 10-microgram dose was carefully selected as the preferred dose for safety, tolerability and immunogenicity in children 5 to 11 years of age.

Participants’ immune responses were measured by looking at neutralising antibody levels in their blood and comparing those levels to a control group of 16 to 25-year-olds who were given a two-dose regimen with the larger 30-microgram dose. Pfizer has said the levels compared well with older people who received the larger dose, demonstrating a “strong immune response in this cohort of children, one month after the second dose”. They have further stated that the vaccine was well tolerated, with side effects generally comparable to those observed in participants, 16 to 25 years of age.

However, it is a matter for some concern that this data has not yet been peer-reviewed or published in a reputed medical journal. Pfizer has said that it plans to submit the data directly to the US Food and Drug Administration for emergency use authorisation. Apparently, the FDA officials have said that once the data is submitted, the agency could authorise the vaccine for younger children, in a matter of weeks.

Albert Bourla, Chairman and Chief Executive Officer of Pfizer, said in a statement “Since July 2021, pediatric cases of COVID-19 have risen by about 240 percent in the USA, underscoring the public health need for vaccination. These trial results provide a strong foundation for seeking authorisation of our vaccine for children 5 to 11 years old, and we plan to submit them to the FDA and other regulators with urgency”. Pfizer also said that it is expecting trial data for children as young as six months as soon as the fourth quarter of this year.

In addition, Moderna Incorporated plans for double enrolment in a trial of its Covid-19 vaccine in children under age 12, following a request from U.S. regulators to collect additional safety data. Moderna’s study will enrol an estimated 13,275 participants aged 6 months up to 12 years old, according to a listing on the clinicaltrials.gov website. In a post from late July, the Cambridge, Massachusetts-based company said it would seek to enrol about 7,000.

As things stand now, the scientific information regarding the feasibility of administering the Covid-19 vaccination to very young children is, at best, in a state of flux at the present time. We need to await the results of several on-going Clinical Trials. The Sri Lanka College of Paediatricians will keep a close watch on the developments and would take all necessary steps to advise the authorities on the best course of action, when more tangible evidence from Clinical Trials emerge in the future.

The gut-feeling of a lot of authorities involved in child healthcare is that it would be possible to vaccinate even young children against Covid-19 in the not-too-distant future. The benefits due to be gained seemingly appear to be that much more important and would override the very rare undesirable effects in our quest towards victory over this pandemic that has brought the entire world to its knees.



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Features

Issues in ‘terror’ refusing to go away

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It’s the biggest single loss of life from terrorism in Moscow since Chechen separatists took hostages in 2002 at the Nord-Ost theatre, where at least 170 people, including the dozens of attackers, died during a botched rescue mission.

The hearts of sensitive people the world over are bound to be with the Russian people in this their hour of profound grief. Those 140 or more men, women and children who were brutally killed, besides others who were seriously wounded, at a concert hall in a Moscow suburb recently by rampaging gunmen, were part of the peace-loving ‘silent majority’ of Russia. Their agony is bound to make all righteous hearts bleed for them in empathy.

The mindless act of terror will stand condemned by all right-thinking people and it would be correct for civilian publics and governments the world over to increasingly and unanimously decry the maniacal burst of brute force and stand in solidarity with the Russian people.

This is a time of formidable challenge for the Putin regime. The domestic and international issues growing out of the tragedy are numerous and wide-ranging and the impartial analyst would be right in taking up the position that ‘course correction’ by the regime is needed in a number of areas. To begin with, the question needs to be asked whether President Putin did right by stating unreservedly that ‘radical Islamists’ were behind the attack.

It could very well have been that the attackers were driven by some sort of fanatical religious zeal but considering the harm it could do to the religious susceptibilities of peace-loving followers of Islam, the term ‘Islamists’ could best have been avoided by the Russian President. Former US President Donald Trump resorted to phrases, such as, ‘Islamist terrorists’ quite often and the practice, as could be seen, did not do the world any good.

The likes of the Russian President ought to know by now that indiscreet and controversial labelling of people has the effect of alienating them and eventually radicalizing them against governments and polities.

However, what the world needs now is reconciliation and bridge-building among communities. Putin’s words could result in Muslims further distancing themselves from the wider Russian public. The consequences of such distancing could be distressing for the Russian people.

Such labelling could also have grave implications on the foreign policy front for the Putin regime. If the ISIS was indeed the mastermind behind the concert hall carnage, Putin’s pronouncement could only further antagonize ISIS and other such outfits that have been waging wars of attrition against the Russian state in the Middle Eastern theatre in particular.

If some intelligence agencies are apprehensive about more terror attacks inside Russia they could very well be correct because the Putin regime, even at this juncture, is not perceiving the advisability of following a reconciliatory course in its foreign relations. The Putin regime is obliged to halt in its tracks and take cognizance of the possible fallout on the Russian people of its policy indiscretions.

Interestingly, intelligence failures are currently occurring in what seem to be the most security conscious states of the world. There was the case of Israel in October last year and now Russia. If the Russian state thinks that rule in perpetuity by President Putin could bring it enduring stability, the recent bloodbath has proved it wrong.

Apparently, national security could not be the sole key to good governance. While national security is indispensable for effective governance, good governance is also a coming together of a number of major elements, such as, redistributive justice and cordial coexistence among communities and religions. A policy of attaching priority to national security could enable repressive governments to remain in power for some time but it would not help the people concerned much.

On the question of intelligence failures, the Putin administration seems to have attached too great an importance to ‘national pride’ and not taken into consideration intelligence information coming from the US. Going by current reports, the Russian security establishment had been warned of an impending ISIS terror attack by its counterparts in the US but had failed to act on the warning. If this is true, the security of the Russian people has not weighed heavily with the Putin regime. Well-wishers of the Russian people are likely regret such neglect on the part of the regime.

Given the complexities of the issue of ‘terror’, there is unlikely to be an international consensus on its definition and on ways of resolving it any time soon but states could cooperate for the time being on managing the conundrum effectively. Accordingly, Russia could cooperate on this basis with the US and vice versa, for example. Information-sharing should not be fought shy of, besides other ways of cooperation.

Right now, the world has no choice but to collaborate on managing ‘terror’ until long term solutions are found to it. What needs to weigh on governments’ minds is the fact that ordinary publics pay a prohibitive price for their blunders in handling ‘terror’.

This is a crucial point that the political and security establishments in small Sri Lanka as well need to keep in mind, particularly in relation to the Easter Sunday bombings. In the latter case, governmental blundering and negligence of duty at the highest levels of the state brought catastrophic consequences for the people. To make matters worse, the wrong-doers in this crisis are yet to be brought to justice.

With the allegation that Ukraine had collaborated with the perpetrators of the concert hall carnage, President Putin seems to be in an attempt to deflect accountability for the blood-letting from his regime to an external quarter. This allegation, though, remains to be proved. Moreover, the fact remains that a massive intelligence failure on the part of the security agencies of the state brought about the devastation.

These attempts to point to an external source for the current tribulations of the government should also be seen as part of the Putin regime’s strategy to remain powerful at home. The strategy has been tried out time and again by repressive governments that are apprehensive about their power ebbing away from them in the wake of internal crises. The ploy enables political strongmen to resoundingly rally the people behind them, while giving the impression that they are remaining strong and in total control of the state.

If civilized norms are to be given a chance to prosper in international relations, democratic development needs to be prioritized by governments and the world community under the leadership of the UN. ‘Terror’ has its roots in mainly socio- economic deprivations and the world has no choice but to strive towards ending them.

Repressive rule, however, is no guarantor of social and economic equity and it is only democratic dispensations that aim at socio-economic equity or democratic development that could bring about this state of affairs to at least a degree.

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Kate, the brave!

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Kate and William

By Dr Upul Wijayawardhana

BBC viewers were in for a great surprise when the main news bulletin at 6 pm on Friday 22nd went straight to a video of Kate, Princess of Wales, without the customary mention of news headlines. Dressed in a long-sleeved white top with narrow black bands across and light blue jeans, seated on a bench in the +-Windsor Castle with spring blooms in the background, what she told whilst nervously moving her fingers and faltering voice at times, shocked the nation. Many an eye would have been wet by the time she finished her two-minute statement wherein she explained that following the planned surgery she had in mid-January, a cancer had been detected unexpectedly and she is in the early stages of having preventive chemotherapy. She added:

“This of course came as a huge shock, and William and I have been doing everything we can to process and manage this privately for the sake of our young family. As you can imagine, this has taken time. It has taken me time to recover from major surgery in order to start my treatment. But, most importantly, it has taken us time to explain everything to George, Charlotte and Louis in a way that is appropriate for them, and to reassure them that I am going to be ok. As I have said to them; I am well and getting stronger every day by focusing on the things that will help me heal; in my mind, body and spirits.”

It would have taken enormous courage to declare to the whole world that she is being treated for cancer at the age of 42 but it would have been even more difficult for Kate to explain to their three young children aged 10, 8 and 5 years that she is afflicted by a disease that usually affects much older people. The public announcement coincided with the start of the Easter break in schools, which may have been done purposely to protect the three young royals. There was a tremendous outpouring of public sympathy not only because of her predicament but also for the graceful manner in which she delivered her message. Many thoughts that her staff may have written the message but it transpired later that she had written the message herself and the recording had been done in one-go by BBC studios.

She won the hearts of many families affected with cancer as she ended her message with the following: “At this time, I am also thinking of all those whose lives have been affected by cancer. For everyone facing this disease, in whatever form, please do not lose faith or hope. You are not alone. “

At the time of a great personal tragedy, thinking of others similarly affected showed the great humane qualities of the Princess and it becomes even more significant considering the horrible period she went through.

On 17 January, it was announced that the Princess of Wales had undergone planned abdominal surgery for an undisclosed medical condition that was not cancer, at The London Clinic and that she had postponed all of her public engagements and duties until after Easter. Around the same time, King Charles was admitted to the same hospital for planned prostatic surgery and it was later announced that an unrelated cancer had been detected during the procedure. As the King was to have a course of treatment for this, he too was forced to withdraw from public duties but he continued to conduct the affairs of state including the weekly meetings with the prime minister. The absence of two of the most senior royals from public duties piled the pressures on Queen Camilla and Prince William.

On 27 February, a thanksgiving memorial service was held for King Constantine II of Greece, the last monarch of the country and godfather to Prince William, at St. George’s Chapel at Windsor Castle where Prince William was due to give a reading but he withdrew at the last moment citing ‘an urgent family matter’. Rumour mills went to overdrive to explain all these and conspiracy theories abounded. In addition to extensive media attention, social media were full of inuendoes.

To calm the waters, a photograph taken by Prince William showing Princess of Wales embraced by her three children was released on Mother’s Day, 10 March, but it was a disaster, mostly due to an overreaction on the part of news agencies. As the photograph seem to have been edited, they issued a ‘kill’ notice in spite of many commentators pointing out that almost all royal photographs released since the time of Queen Victoria have been edited! Wonder whether there was a secret hand behind this action!

To her credit, Princess of Wales, who is a keen photographer issued an immediate apology admitting that she, like many amateur photographers, “occasionally experiments with editing”. But it was not enough to stem the tide in the sewer of social media and Kate had no choice but to come out with the statement which, hopefully, would make conspiracy theorists leave her in peace for recovery from a major unexpected illness.

Associate editor Camilla Tominey’s comment in the front page of The Daily Telegraph of 23 March on this is hard to better:

“We already knew that social media was a sewer, occupied by faceless rats intent on infecting others with their disease of hatred. But their cruel treatment of Kate since it was announced she was undergoing abdominal surgery in January has been sickening beyond belief. From the peddling of hurtful conspiracy theories to the propagation of unsubstantiated lies, the keyboard warriors have inflicted an unnecessary amount of suffering on a woman now undergoing chemotherapy after a major operation. Shame on them.”

Whilst Kate received numerous messages of support from ordinary folk as well as world leaders, perhaps the best being from President Macron, the message from her estranged brother-in-law and his American wife is most intriguing: “We wish health and healing for Kate and family, and hope they are able to do so privately and in peace.”

In addition to increased awareness of prostatic problems and cancer due to King Charle’s illness, Kate’s diagnosis has raised the issue of cancer in the young. Many experts are expressing the opinion that cancers in the young are on the rise and this may be due to environmental factors. I am sure, when she returns to active duties, Kate would actively support further research in to this issue, in addition to continuing her many charities.

Our hearts go out to you Kate and we wish you a rapid and complete recovery!

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Mother…her pillar of strength

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Chit-Chat

Minanga Abeyesundere

Over the past few weeks, I’ve had readers inquiring whether it’s possible for me to do a little Chit-Chat scene with the spotlight on some of our models as that would also make interesting reading, they say.

Well, why not…and this week I’m doing just that, with more to follow.

01. Tell me something about yourself:

My name is Minanga. I’m 20 years old. My close friends and family call me Mini. I have completed my degree in Visual communication and currently focusing on my modelling career. I’m the youngest in my family. I am a person who sets certain goals for myself and will definitely try my very best to achieve them the right way. I generally don’t give any thought to people’s negative words and opinions. I love to travel with my family and cherish my time spent with them.

02. What made you decide to be a model?

I have always liked to do modelling for as long as I can remember. Then, as I grew older and taller, than most people my age, my friends and relatives kept telling me to go into modelling. This made my desire stronger to pursue this field. I decided to first start my studies and then, subsequently, start my modelling career. I must state that it was Brian Kerkoven who saw my potential and gave me a chance to show my talents and capabilities. My first runway show was modelling one of Brian’s designs. I will always be thankful to my mentor and agent, who has taught me everything I know about this field. He is always willing to give his feedback whenever I ask him.

03. What do you think sets you apart from other models?

I would say I give my 100% to every show and photo shoot and am always willing to learn from my senior models. I can adapt to different styles and looks, whether it’s high fashion, casual, or even themed shoots.

04. What clothing do you prefer to model?

As a model, one cannot really have a preference, but I prefer not to model very revealing clothing. That is my personal preference.

05. What do you think is the most important aspect of modelling?

I believe that as a model, you must always remember to model every outfit to do full justice to the hard work that has gone into making it by the designer and their team.

06. If you could change one thing about yourself, what would it be?

Minanga: Currently focusing on her
modelling career

I don’t really want to change anything about myself. I am very happy with myself. My flaws, despite their imperfections, are what make me who I am.

07. School?

Holy Family Convent, Bambalapitiya. I was in the basketball ball team for a short period.

08. Happiest moment?

There have been so many wonderful moments in my life that it’s hard to choose just one! But if I had to pick, I would say one of my happiest moments was when I achieved a personal goal that I had been working towards for a long time. It was such a fulfilling feeling to see all my hard work pay off, and to know that I had accomplished something meaningful to me.

09.What is your idea of perfect happiness?

My idea of perfect happiness is doing what I’m passionate about and living in the present moment because, if you really think about it, that’s all we have. It’s always only that present moment. It’s all about being happy in that moment and making the best of it.

10. Your ideal guy?

A person who is confident enough in himself to give me the freedom to follow my dreams and goals.

11. Which living person do you most admire?

The person I admire the most is none other than my mother. She has always been my biggest motivator, supporter, and pillar of strength. She has always supported me in following my dreams and never discouraged me from pursuing my interests, providing me with invaluable advice whenever needed. My mother has such a significant influence on every aspect of my life. She has been there for me through thick and thin, guiding me and teaching me valuable life lessons. I will always be grateful for her presence.

12. Which is your most treasured possession?

My most treasured possession, up until now, is an emerald ring I got from my mum, which she had from her childhood. As we are both May born, we share the same birthstone.

13. If you were marooned on a desert island, who would you like as your companion?

I would love to have my brother and sister as my companions. They’re always there for me, and we have so much fun together. We could keep each other company, come up with creative ways to survive, and keep each other’s spirits up.

14. Your most embarrassing moment?

It’s a secret for me to know and you to find out.

15. Done anything daring?

Not anything as of now but there are some on my list, like sky diving, travelling overseas alone which I would love to do.

16. Your ideal vacation?

Spending a weekend at Kandalama Hotel. I love the vibe there. I also love the architecture of the hotel and how it blends into the jungle around it. It’s so calming and peaceful.

17. What kind of music are you into?

I like pop music and even music from the ’80s.

18. Favourite radio station:

I don’t really listen to the radio. If I do, it’s in the car with my family, and we listen to Gold FM. I would say I am an old soul when it comes to music.

19. Favourite TV station:

I’m also not a person who watches TV. I watch Netflix movies, and movies at the cinema. I love watching movies with my mum. She is my movie buddy.

20. Any major plans for the future?

Yes, first, I want to be a supermodel, here in Sri Lanka, then model internationally and bring pride to my country. I also want to start up my own business in Merchandising.

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