The Centers for Disease Control and Prevention has signed off on COVID-19 vaccines for younger kids, but it could be months before most children in this age group are vaccinated because of hesitancy, a lack of access and relaxed mitigation efforts in schools once the vaccine becomes widely available.

Physicians and policy experts anticipate that COVID-19 vaccination rates among kids ages 5 through 11 initially will be relatively low, and it could take months to see any noticeable decrease in case rates in this age group in some places. Underserved, at-risk communities could lag in getting shots.

On Friday, the Food and Drug Administration granted Pfizer emergency authorization for its vaccine in kids ages 5 through 11. The vaccine, which is given in a lower dose than the COVID-19 vaccine for adults and teens, was 90.7 percent effective in preventing the virus in young children. The CDC on Tuesday night recommended that children in this group receive the vaccine, following the guidance of independent scientific advisers.

Although COVID-19 is less severe in young children, at least 146 unvaccinated U.S. children ages 5 through 11 have died of the virus. Many more became severely ill.

Despite these statistics, the vast majority of parents are wary. Just 34 percent of parents of 5- to 11-year-olds say they’d get their child vaccinated against COVID-19 right away, according to Kaiser Family Foundation polling. Another 32 percent said they’d wait and see. The rest said they wouldn’t vaccinate their kid or would do it only if required.

One parent, Belinda Macauley, told the FDA advisers at last week’s meeting that while she knows her young daughter’s risk of getting COVID-19 is low, she wants her vaccinated so she can see her grandmother without risk of spreading the virus.

“If the data shows the vaccine is safe and helps prevent transmission and severe disease, my family’s enthusiastically in favor of its prompt approval,” Macauley said, adding that her daughter would get it the first day it’s authorized.

But Amy Alvo, a parent of a 17-year-old who had a severe adverse reaction after receiving the Pfizer COVID-19 vaccine in March, encouraged the FDA vaccine advisers not to authorize it for younger kids, citing concerns about its possible long-term effects.

“Children are at an extremely low risk of having severe reactions from COVID. The Pfizer vaccine has no health benefit to this age group,” Alvo said.

“Uptake will definitely be slower,” pediatrician Paul Offit, a member of the FDA’s vaccine advisory committee, said of vaccinations for young kids.

Offit said that to reach herd immunity, about 90 to 95 percent of the U.S. population must be vaccinated. Roughly 28 million kids are in this 5-to-11 age group, making up about 10 percent of the population. So if only half or less of the kids in this group get vaccinated, that could make a small dent but wouldn’t significantly slow the virus’s spread, he explained.

Potential rise in cases

Some pediatricians and policy experts warn of a potential increase in pediatric COVID-19 cases once a vaccine is authorized for younger age groups due to the inevitable relaxation of virus mitigation efforts and slow vaccine uptake.

Julie Swann, a North Carolina State University professor who analyzes COVID-19’s impact on children, found that COVID-19 deaths and hospitalizations could rise, perhaps by as much as 20 percent, if masks are removed in schools as soon as vaccinations for young children roll out. Her modeling also predicted an increase in hospitalizations due to increased spread.

This projected case increase would likely hit unvaccinated children and underserved communities hardest and thus exacerbate already stark pandemic inequities.

“We are protecting the children who get vaccinated, and we are protecting the communities and the households that have a higher vaccination rate,” Swann said. But pandemic inequalities are likely to be exacerbated in areas with low vaccination rates.

Not all school districts that currently have a mask mandate plan to lift their mitigation measures once the vaccine is rolled out, but some will. For example, North Carolina state law requires school districts to reexamine and vote on mask mandates every 30 days.

“They are absolutely going to want to start lifting that mask mandate as soon as kids have the opportunity for vaccination,” Swann said.

Even states that are more strict on mask mandates may let up on school mitigation measures. Democratic Connecticut Gov. Ned Lamont said the availability of COVID-19 vaccines for younger kids could signal the end of mask mandates. While he said during a news conference last week that the state should provide time to get most kids vaccinated, he added, “At some point, it’ll be up to the schools.”

Emory University infectious disease expert Carlos del Rio said school boards should keep an eye on how much virus is in the community. The CDC defines a low infection rate as fewer than 10 cases per 100,000 people per week. It’s unclear how long it would take to get there.

“If the rate of cases in my community is below 10 cases per 100,000 people, and I have a high vaccination rate, I think you can drop masking and other nonpharmacological measures because it just is, you know, it’s Kabuki,” del Rio said.

More states are expected to drop COVID-19 mitigation measures in the early 2022 legislative session, said Hemi Tewarson, executive director of the nonprofit National Academy for State Health Policy. Last year, several Republican-led states passed mask or vaccine mandate bans. But now, nearly two years since the pandemic’s start, even the most pandemic-cautious states are getting weary of vigilance.

“There’s going to be a real push in some states to say, you know, we’re done with COVID. We don’t need masks. We don’t need to require vaccines, and we’re going to move on,” Tewarson said. Then it would be important for states to step up their COVID-19 surveillance, testing and tracking, she said.

Distribution difficulties

Currently, an unvaccinated adult can find a COVID-19 shot in most neighborhoods. But COVID-19 vaccines may not be as readily available for young kids in the weeks immediately following authorization.

In the early stages of the COVID-19 vaccine rollout, Black and Hispanic communities had a harder time accessing vaccines and were slower to get vaccinated. Policy experts fear this dynamic could play out again with pediatric vaccinations.

There are few racial or ethnic disparities for routine immunizations that kids must get to go to school, noted Jen Kates, Kaiser Family Foundation director of global health and HIV policy. These required vaccines are given by pediatricians for free and are much less politicized than the COVID-19 shots.

“Equity and disparities have been just a real prominent and unfortunate feature of this pandemic. It’s relatively easy to look ahead and say that’s not going to necessarily get solved,” Kates said.

The federal government is poised to begin distributing shots as soon as the CDC signs off on its vaccine advisers’ recommendations, but local vaccination efforts will rely heavily on provider networks and outreach plans.  

Because Pfizer’s COVID-19 vaccine for young kids requires different packaging with smaller doses, vials and needles, not every provider will immediately have supplies. Children’s National Hospital, a major pediatric facility in Washington, D.C., that has run a vaccine clinic for teens, sent out a notice last week warning families it probably would not be able to run a COVID-19 clinic for kids ages 5 to 11 for several weeks after authorization. The hospital recommended that families check with local pharmacies and health departments instead.

Pharmacies associated with the federal partners that plan to offer the pediatric vaccine expect to start receiving vaccines as early as about three days after the final CDC action, said Kurt Proctor, a National Community Pharmacists Association senior vice president. State health departments expected to get some pediatric vaccines a couple of days before the first pharmacies get it.

State health departments are trying to sign up more pediatricians to administer vaccines, but it’s been tough because of reimbursement issues, Tewarson said. Pediatricians get paid only if they actually vaccinate a kid, and it could take lots of counseling and conversation before parents decide to give their child a COVID-19 shot. That time spent counseling would be unpaid.

“There’s a good social argument to be made that if we can reach parents and get parents talking to parents about this, that probably has a greater chance of success than something that’s perceived as top-down,” said Jen Jennings, a Princeton University sociology professor.