What Should Be Done to Protect Children from COVID-19 in the UK?

THE START OF THE PANDEMIC When COVID19 reached the UK in early 2020, the emphasis was, appropriately, on caring for adults. From spring to autumn 2020, COVID19 had minimal direct impact on children, with few severe cases or deaths. School closures and other restrictions meant children were mixing much less than usual, and when schools reopened they were protected by bubbles and, at times, masks. This also meant that children suffered fewer severe respiratory illnesses than in a ‘normal’ year. However, children’s health was affected in other ways: many elective National Health Service (NHS) treatments were suspended, space was taken in several UK paediatric intensive care units (PICUs) by adult patients, and unmet need grew for diagnosis and treatment of physical and mental health problems and for child protection. So there were a range of risks to children, but what about direct risks from COVID19? Serious illness requiring intensive care is relatively rare in childhood. Across the four nations of the UK, 26 PICUs are commissioned, but in 2020 a single PICU was unlikely to admit more than a few children with severe COVID19. However, among them there were some with a pandemicrelated paediatric phenotype, the paediatric multisystem inflammatory syndrome temporally associated with SARSCoV2 (PIMSTS; affecting the kidneys, heart, lungs and brain). The existence of an excellent national audit, collecting data from PICUs, allowed it to be characterised, while further insights came from enrolment of children in large national studies, such as the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) study and Randomised Evaluation of COVID19 Therapy (RECOVERY) trials. FROM ALPHA TO DELTA Fortunately, the initial policy responses were effective and paediatric cases fell, but by autumn 2020 a new Alpha variant had emerged, spreading rapidly once schools returned. Over 3 winter months (see figure 1) NHS England recorded 2603 hospital paediatric admissions, the national audit recorded 348 PICU admissions (COVID19 infection and PIMSTS), and the Office for National Statistics (ONS) recorded 5 deaths caused by COVID19 in children aged under 15 years old, and 14 deaths in children aged 15–19 years old. Underlying health conditions emerged as risk factors for adverse outcomes, especially deaths. Following a calmer period in spring 2021, during which schools resumed and the adult vaccination programme progressed, ‘Freedom Day’ in England on 19 July removed most remaining mitigations, including in schools. The new and more contagious Delta variant spread rapidly in all confined spaces, including schools, and although very few infected children were seriously ill, high rates of COVID19 infection meant that the absolute numbers rose steeply. There was, however, some good news. The UK medicines regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), approved the Pfizer/BioNTech vaccine for use in children aged 12–15 years on 4 June 2021, and the reduced (1/3) dose dose Pfizer/BioNTech vaccine for use in children aged 5–11 years on 22 December 2021. However, in contrast to equivalent bodies elsewhere, the Joint Committee on Vaccination and Immunisation (JCVI) did not follow regulatory approval of these vaccines with their own prompt approval for use in healthy children. The JCVI minutes (19 August 2021) indicate that only a threshold for PICU admission ‘greater than 100 per million’, which was the risk faced by children with underlying health conditions and similar to the ‘adult at risk definition’, justified offering vaccination. Approvals were therefore granted only for children with underlying health conditions or living with a vulnerable family member. The JCVI were concerned about rare cases of postvaccine myocarditis, which despite having a mild clinical course, carries the potential for longerterm risks. Yet the US Centers for Disease Control and Prevention found the risk of myocardial injury from COVID19 greatly exceeded the risk from vaccination in children aged 12–15 years old, with an even better safety profile for the vaccine approved for use in 511 year olds, for whom the risk of myocarditis is ~1 per million. In the European Union, Israel and North America children aged 12–15 years received