“Covid Vaccine Update: Pregnancy, Boosters, and Kids” – with Emily Oster

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. In “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Emily Oster, welcome back to the podcast. How goes it?
Dr. Oster: It goes good. How is it going with you?
Dr. Fox: All is well. We’re enjoying traffic again in New York City. We’re back, cars are back.
Dr. Oster: You’re back. You’re back now, exactly. I feel like we’re back, sort of.
Dr. Fox: It’s actually worse, the return to the automobile has been quicker than the return to the autobus and subway. So, the traffic has been insane out here.
Dr. Oster: I also feel like people lost their ability to drive, at least where I live. So, that’s been unhelpful.
Dr. Fox: Two years not going anywhere. How do I do this?
Dr. Oster: Yeah, they can’t do it anymore.
Dr. Fox: Wow. Well, thank you for coming back. Obviously, there’s always something COVID to talk about. But I think that there’s just been so much happening with the vaccine. And I was hoping that you and I could talk about, number one, just some update on the vaccine in pregnancy because there’s been more data coming out, reassuring data, but there’s been more data coming out. Number two, I think we’ll talk about the COVID booster, both in general, as well as in pregnancy. And number three, and this is the big one, right? This is the big one, kids, vaccinating the kids. Yeah. And you’re right now waiting in line to vaccinate your children, I understand, you’re camping out like a Nirvana concert.
Dr. Oster: Oh, exactly. I was, this morning, I got a text, you know, they approved it last night. And this morning, one of my friends texted me and was like, “CVS opened at like 5:00 a.m.” Like…on the computer.
Dr. Fox: We’re getting our camping tents, let’s do it.
Dr. Oster: Exactly. Yeah, it’s so true. It’s like I’m 18 again, you know, it’s somewhat different.
Dr. Fox: A little bit different. So, let’s start with COVID vaccination in pregnancy. I mean, we spoke about this a while ago. But when we spoke about it, a lot of it was really just hypothetical, theoretical, sort of based on what we expect to be really early preliminary data about the COVID vaccine, and we’re talking about how we didn’t expect it to be any issues in pregnancy, we thought it should be effective, we didn’t think it would be dangerous. And we were encouraging of it. But since that time, a lot of data has come out. And I know you’ve written about it, and people have asked you about it. But what has been your take of the experience thus far for the vaccine in pregnant women?
Dr. Oster: The way that I’ve been thinking about it is there’s kind of two things that have changed. One is I think, over time, we have learned a lot more about the dangers of COVID for pregnant women. And I think that, you know, still most pregnant women who have COVID, you know, do okay, but I think it’s become clear that there’s an excess of risk there probably exacerbated by some kind of comorbidities. And so, I think the reason to get vaccinated has gotten somewhat more clear to me, even relative to when you were not pregnant, you should be more interested in getting pregnant. The other thing is now we have millions and millions and millions of pregnant people who have gotten the vaccine and who have, you know, not had anything, any issues with it. And so, I think that’s the other very reassuring piece of all of this.
Dr. Fox: Just like you said, most women who are pregnant tend to be young and healthy. And if they were to get COVID, even in pregnancy, they would most likely do fine, and their baby’s going to do fine. So, we try not to freak people out over it. But pregnancy definitely is a risk factor for not doing well. And if you get COVID when you’re pregnant, you’re more likely to get sick, hospitalized, ventilator, death, all these things than if you weren’t pregnant. So, yes, your risk might be low overall, but it’s certainly higher when you’re pregnant than when you’re not pregnant. And so, we have been encouraging our patients who are pregnant to get vaccinated if they’re not vaccinated already. And I think one of the issues a lot of women had is there was either just this fear of getting vaccinated because of the uncertainty, the unknown. And I think that a lot of that has been dissipated because so many pregnant women have been vaccinated. But I think there’s so much misinformation out there that people can find through the Google. And it’s terrifying. I mean, they read like, “Oh, my God, like this vaccine seems horrible. It’s poison.” Right? Someone told me today it was poisonous, which I don’t think it’s true, obviously. But what are you hearing from, you know, your listeners and your fans and your readers that’s just totally false, that’s just not true?
Dr. Oster: So, a lot of what I’m hearing is this nebulous fear around something bad could happen, we don’t know, we’ve only had these vaccines for six months, what if it had an impact in a decade? What if it had an impact in 20 years? What if it changes the baby’s DNA? What if it changes my DNA? And I think part of it just comes out as this kind of, “Well, I’m just not sure I’ve seen enough.” And I think that’s part of what makes it…what’s hard to show people about is, you know, how do you say, well, there’s always risks like that, and sort of make them see that this is not a special risk like that, of course, you can always..there is always a risk out there. I think that’s how I’m hearing it, not so much I am worried about the following specific thing, but I am worried about this general…there’s a generalized fear.
Dr. Fox: You see, I’m hearing a lot of it causes infertility, right? That’s a big one.
Dr. Oster: Yes. That I hear a lot.
Dr. Fox: Right. It causes miscarriage, it causes stillbirth. I mean, and I’m saying like, this is like so not true. It’s unbelievable. And so, there’s those. I also hear the arguments that you’ve been hearing that the what if, we don’t really know. And I do think that’s legitimate, right? We don’t know long-term for pretty much anything that’s new. But I always counter with, “Okay, like, that’s reasonable to have some concern about a vaccine without long-term data. But how confident are you that COVID doesn’t have long-term problems for you or your baby?” And I would be much more worried about COVID than the vaccine. Like, I don’t think either of them are gonna cause many long-term problems with mothers or babies. But if I had to pick one that’s going to, I’d pick the virus, not the vaccine.
Dr. Oster: One of the things that I think has happened, which is, of course, too bad is that people were worried about infertility, so they didn’t get vaccinated when they were trying to get pregnant, and they got pregnant. And then it’s like, well, no, I don’t want to be vaccinated because I would have been…I should have been vaccinated before, but now I don’t want to be vaccinated because I’m pregnant. I think that that’s kind of intersecting, that those two concerns are intersecting poorly.
Dr. Fox: It’s tough in our own practice, we’ve had a lot of women get COVID during pregnancy, and we’ve been fortunate that they haven’t been so sick. But there have been women in our hospital who got COVID and were very sick and women around town and people I know. And it’s a big deal, potentially. And so, again, we’ve been really encouraging our patients to get vaccinated either before pregnancy, and we try to debunk this idea of infertility, which is just not true. Or if they didn’t get it before to get it while they’re pregnant, really, at any point in pregnancy, it’s not clear whether it’s better to get it early versus late in terms of the baby. And I don’t think people should focus too much on getting vaccinated as a strategy to protect their children after birth because those antibodies are going to wear off at a certain point. And the newborns aren’t really at big risk from COVID anyways, nor are they around a lot of people with COVID. So it’s, yes, probably, if you get it later, there’s more antibodies in the baby than if you got it earlier. But I don’t think you have to change your COVID vaccine strategy because of that.
Dr. Oster: Part of what’s hard for people in this space is that the vaccine feels like a choice. So, if you got COVID and something bad happened, it’s like it’s almost like that’s not a choice. But if you choose to get vaccinated, and then something bad happened, even if it’s incredibly unlikely, like you’re gonna feel like I chose it, right. And I think that’s come up in the context of kids, too, that even if you think, well, there’s a there’s a tiny possibility, we could never rule that out. But like, I would have chosen that. Whereas if I choose not to get the vaccine, it’s like I’m not choosing, and I think there, there’s a little bit of a frameshift that, no, I think it might help for some people just to say, “Well, actually, you’re kind of choosing to get COVID.”
Dr. Fox: Yeah, I was just gonna say that. Yeah, absolutely. I think…
Dr. Oster: But we’re not saying it like that, we’re not saying choose to get the vaccine or get COVID. But maybe we should be thinking a little bit more like that. So, either way, it’s your choice that you’re making.
Dr. Fox: Yeah, I tell people the same thing. I say, “Listen, you know, I’m not a big arm twister. I said to somebody, “Listen, you’re an adult, it’s your choice, you know, you don’t want to get vaccinated, okay,” I said, “But you should operate under the assumption that you’re going to get COVID,” right? It’s either going to be in a day, a week, a month, a year, it’s going to happen because this virus is…it’s not going away, it’s a virus, it’s not going to be eradicated, it’s going to be around, it’s going to mutate, all these things are going to happen, it’s going to keep coming, obviously, on a science end, we’re gonna have to figure out, is it as something that’s going to require a booster every year? Is it going to require a new vaccine? Is it gonna never require a booster? These are things we don’t know today, but we will know at some point exactly what the optimal vaccination strategy is.
But this virus is not going away. We’re not going to eradicate it. And so, just like the flu, you have to assume you’re gonna get the flu at some point in your life. And so, the same is gonna be true for COVID. And this idea that “Oh, I’m not getting the vaccine, but I’m not going to get COVID.” Well, good luck with that strategy. That’s really just not going to be…it’s not going to happen. It’s I mean, maybe you’ll get lucky but essentially, pretty much everyone’s getting COVID who didn’t get vaccinated, even those who got vaccinated, many are getting COVID, which is not an argument not to get vaccinated. But you see that those people aren’t getting intubated and dying, right, they get COVID and then they recover and they’re fine, which people say, “Oh, the vaccine doesn’t work because I see so many people got vaccinated and got COVID.” I was like, “Well, you know, how sick are they?”
Dr. Oster: Are they dead? Are they dead?
Dr. Fox: Yeah.
Dr. Oster: That’s kind of what it means for it to work. I mean, I think this is going to be such a hardship for people. I think part of it is just of the state of some of the messaging. And part of it is that there is very much a feeling of like, “Well, no, that’s actually not what vaccines are for.” Vaccines are for preventing you from getting very seriously ill.
Dr. Fox: Yeah. I mean, yeah, it’s like the flu.
Dr. Oster: They’re working great. They’re working so great.
Dr. Fox: Yeah. Exactly. I mean, the COVID vaccine that the numbers are for people who’ve been vaccinated or communities who have been vaccinated, or towns where the vaccination rate is high, the infection rate does go down, and you are less likely to get COVID If you got the vaccine, but the thing that really drops is the hospitalization rate, intubation rate, and death rate. And so, if you look at a hospital that still has high rates of admissions, the people who are sick in the hospital are the ones who aren’t vaccinated like 99 to 1, it’s just such a difference from before when there was no vaccine and everybody’s getting sick. And so, it’s a really important message that the vaccines are not meant to prevent the disease, although it might, it’s more meant to keep you from getting ill, or you to get it. And that’s an important message. Let’s move on to the booster. So, let’s leave pregnancy aside for now. Just in general, how do you explain to people, like, why do we need a booster? Like, what’s up with that? Does it mean the vaccine doesn’t work? Does it wear off? Like, how do you talk to people about this?
Dr. Oster: Yeah. So, I think the way that I talked to people about this is the following. So, when you first get vaccinated, your immune system responds in two ways, it creates antibodies, which are available to fight the virus if [inaudible 00:11:38] virus, and that’s the part of the immunity that everyone kind of has come to understand pretty well. And then there’s a second thing that your immune system does, which is that it creates cells, memory cells, which remember how to make those antibodies. And over time, the antibodies themselves decay. And that makes a lot of sense because you’ve been exposed to many pathogens in your life, and if your blood was clogged up with the antibodies of every disease that you had ever encountered, there wouldn’t be any space for whatever the other stuff that goes in there.
And so, antibodies decay over time. But these memory cells do not decay, or they decay differently, or they decay more slowly. But those memory cells take a little bit of time to ramp up their production. And so, if you are exposed to COVID and you have no antibodies but you have memory cells, you may get a breakthrough case, you’re more likely to get a breakthrough case because you don’t have the antibodies right there to get them, but you do have the memory cells. That’s the sort of place that I start because I think partly it’s hard to explain why you might want a booster without explaining that piece in the beginning. And so, when we talk about waning immunity in the first place, we talk about like I got vaccinated, and now, you know, six months later, I’m more likely to get a breakthrough. That’s because the antibody levels are going down. But the reason that people are still not being hospitalized and still dying [inaudible 00:12:59] lower rates is because of those memories.
Dr. Fox: Right. I think the other thing that’s important is when they did the vaccine originally, and they said it’s two shots. I mean, that was their best guess, I mean, but who knows, right? I mean, they’re just guessing. When you’re vaccinated as a child, some things are one-shot, some things are three, some things are five, I mean, it’s just one of these things that you can’t know the day you develop the vaccine is it most effective after one shot, two shots, three shots, you have to sort of figure that out. So, I tell people that the booster could also just be, “Hey, you know, maybe we always needed three shots. And maybe ultimately, the COVID vaccine won’t be called the two-shot vaccine, and it’ll be three. You’ll get it on day 1 and day 30 and day 180.” I don’t know, whatever, something like that. And that no one would think twice about that if they said that originally, but since it’s called the booster, everyone thinks that there’s a problem, all of a sudden, it does not mean there’s a problem at all.
Dr. Oster: Like, there’s a set of people that are people with immune compromise, where really they needed three in the first place. Like, there’s not…it’s totally appropriate to call it a booster, they just needed three shots. It’s not a booster, it’s just that they need a three-shot regimen. So, maybe that’s true of everybody. Or maybe this is something that needs more of, you know, a booster approach at some…more of like a true booster approach likely for Tdap or something where immunity wanes over time. And as you say, I’m not…it’s not clear, there’s a lot of a kind of grace, it’s between…we’re just not there yet, are we gonna want to refer these things? And are we gonna think about the vaccine? But what I mean, what I think is important to note to people is that if you have had two shots, you are still very, very well protected against hospitalization and death even, you know, six months out, even if you are more likely to get a breakthrough. What I think the booster is likely to deliver is protection to those breakthrough infections. And that’s what we’re seeing, you know, in the Israeli data, and so on.
Dr. Fox: Yeah, and I think for some people that’s more important than others, right? So, for some people who maybe are much like sicker or more elderly or have more medical problems or whatever it is, they may say, you know, “I want to be as protected as humanly possible because I’m borderline if I’m gonna get COVID even if it’s a breakthrough infection, maybe I’ll be the one who has to be hospitalized. So, I don’t want any part of that.” Or someone who’s younger and healthier and got vaccinated twice is like, “Listen, enough is enough. I’m okay if I get COVID because I’m like highly confident I’m not going to get really sick from it.” And maybe they don’t want the booster. Again, I don’t think it’s risky to get the booster at all. I don’t think it’s a dangerous proposition, but it’s unclear today who needs the booster. Like, is it everybody? Is it some people? It’s just something we can’t know today, right? You have to do an entirely new study to figure that out and that takes time. And so, we don’t know.
And it’s one of these things. And that’s why it’s hard to say, you know, when they say the booster is available, should I get it? I don’t know. Like, you know, I don’t know if you should get it. No one knows if you should get it, you can get it I don’t have a problem with it, it’s not dangerous, but I don’t know if you need it. I don’t know if I needed it. I got two shots. I got two vaccines, and I was fine. I’m like 98% sure I got breakthrough COVID in the summer, I wasn’t really sick but I like had a cold for a day. And then a week later, I couldn’t taste anything. So, I’m pretty sure I got it. You know, so okay, but, you know, I had like no symptoms. And then I don’t think I needed a booster because I probably had antibodies off the charts. But I’m planning to go to Israel, and it’s a requirement. So, I got the booster, right? Okay, I’ve got the booster.
Dr. Oster: Yeah, that’s why my husband got the booster, too.
Dr. Fox: Yeah, so, fine, that’s why I got it.
Dr. Oster: There’s a lot of Israeli boostering, yes. I was like very anxious about trying, in the sort of period in which we’re going to see a bunch of [inaudible 00:16:33] like trying not to get…to have COVID, even a breakthrough case because I’m concerned about spreading it.
Dr. Fox: I’ve sort of been giving that message to my pregnant patients as well when they asked me about the booster and I tell them, “Listen, if you’ve never been vaccinated and you never got COVID, I’d be a little more, you know, forceful about saying you really should get the vaccine, you know, you don’t want COVID, it could have that consequences. Like you don’t wanna be part of this.” But for someone that’s already been vaccinated, and they’re like, “Should I get the booster? I’m pregnant.” I was like, “Listen, well, how do you feel about it? Like, are you someone who really wants the booster because you’re worried about yourself, or you’re worried about a family member, or whatever it is? You do want to get COVID because you don’t to be quarantined, or, you know, whatever.” And I say, “Fine, like, I’m totally supportive of it. I think it’s safe for you, I think it’s safe in pregnancy. Great, do it.”
But if you’re the type of person who’s like, “I don’t know if I need it, I’m really weirded out about getting a booster while I’m pregnant. I was so uncomfortable getting it in the first place. And I just don’t want it…” I’d be like, “I think that’s okay, too because the likelihood of you getting very sick is so low now that it’s a little nuts for me to, like, push you to get the booster when we just don’t know if you need it.” And that’s how I’ve been approaching it with my pregnant patients. And it’s a little bit…I don’t wanna say it’s wishy-washy because I’m not being forceful about it, but I don’t feel comfortable telling them, like, “You don’t need it, don’t get it,” because they may want it or telling them, “You absolutely should get it,” because they may not want it. And there’s really uncertainty about the booster in pregnancy for efficacy, not so much for safety. I’m totally fine with the safety.
Dr. Oster: One question I get a lot is, you know, I had a question like, “I want to pass antibodies to my baby, you know, shouldn’t I get this in the same way that I get the Tdap?” Right, in the same way that we sort of give people like a boost on their pertussis, or whatever, so they have those antibodies before they can get vaccinated, shouldn’t we sort of have that same thing for COVID, right? I mean, I think that practically, that makes sense. I mean, obviously, the difference is, you know, your infant’s probably at significantly more risk for pertussis than it is for COVID. Maybe that’s not right, but…
Dr. Fox: No, no, I think it is right. I think that’s an important thing. First of all, if you want to pass on something to your children, I recommend trying to get them a trust fund, that’ll help them more than COVID antibodies, I think. You know if you’re…
Dr. Oster: If you are choosing.
Dr. Fox: You’re in the position to give them a trust fund, God bless. The Tdap was originally not something we did but then there was an outbreak of pertussis and pertussis is really dangerous to newborns. I mean, it’s really dangerous. And so, the thought was, you know, if we give all the pregnant women a Tdap, which is a tetanus booster, but it has the pertussis or whooping cough booster, and if we give it in the third trimester, these babies will be born with some level of immunity, not perfect immunity, but some level which will, sort of, carry them over for the, you know, whatever amount of months until they get vaccinated as babies. Great. And it seems to have been really helpful and it works and it reduces the risk. The same seems to be true for the flu. The reason we give the flu vaccine in the third trimester is not for the baby, but more so for the mother. And it’s not just the third trimester, we give it in any trimester, but it has been shown to reduce the risk of flu or illness in flu in the newborns.
The difference with COVID is twofold. Number one, at least as of now, they’re not going to get, you know, vaccinated at 3 months or 6 months. And so, you’re waiting for a time period that’s not going to happen. So, that’s number one. Number two, it doesn’t seem to travel amongst newborns the same way that something like whooping cough does, I mean, they’re not going to get COVID in the same way maybe from their siblings or from their parents or from walking down the street or whatever it is. And as far as we can tell, it’s not dangerous to newborns like whooping cough is, to the same degree, the vast majority of infants who they happen to find test positive for COVID are not very ill, it’s less so than all those other viruses that they get when they’re, you know, when they’re infants and newborns. So, the benefit doesn’t seem to be as great. And so, again, if someone wants to do it because they just feel more comfortable, fine, like, okay, it’s probably gonna work. But the benefit is not so huge. So, we don’t, like, push it in the same way we do the Tdap vaccine.
Dr. Oster: For me, I think so much of what I hear is just people who are really afraid. And, you know, they kind of feel like if we don’t have this, if I don’t have the vaccine, you know, I can’t, I’m not going to be able to, like, let my child, you know, out of my house at first, you know, until they’re able to be vaccinated, so, you know, for a long time. And they think you’re trying to force them. I try to like also sort of gently indicate the stuff that you just said about, you know, this is not a high-risk age group. You know, you shouldn’t think about it quite like this. But I also think there’s a point at which [inaudible 00:21:16] maybe it is helpful because it is almost a mental health benefit, I don’t say that like in a negative way, just like, there’s a way to have this out of fear that maybe actually productive.
Dr. Fox: I think that’s real. I would not, you know, poopoo that. I think that’s a real benefit. If someone is very anxious about COVID, and either getting a booster is going to make themselves less anxious for their own health or for their baby’s health or for anything, great, I think that’s quite a good reason. Because the anxiety over COVID can be crippling, as you know, some people, they won’t leave their homes, and they will, you know, they’re just really, really afraid. And if this is going to make them less afraid, and make them be able to function and enjoy, you know, parenthood and, you know, enjoy raising a child and going out, I think that’s wonderful. Great. I do think that, you know, I’m not concerned about someone who has anxiety for COVID. Like, that’s fine, but I do…it’s one of the reasons I really have regret how the messaging came out initially about COVID. And all of the news that was out about it, and how much it was scare tactics and fear. And every time someone got sick and died, they’re posting it on CNN, and it’s just inundating people with horror, and it really terrified people.
And I think, you know, in some regard, it’s good because people realize to take it seriously. But in some regard, it was really overboard and unnecessary, particularly with kids. I think that was just, I mean, yes, I think it’s really important to get the word out, like if you’re over whatever age, do not get COVID. Right, it is a bad, bad thing. Like, it’s really a life and death thing. But if you’re under 5, to scare people, it just seems so out of proportion to reality of what the actual risk is when you compare it to flu, when you compare it to accidents, car accidents, drowning, like whatever you want to pick that the horrible things that can happen to our children that keep us up at night, COVID is lower down on the list than all of them in terms of the likelihood. And so, yes, stay up at night worrying about your kids like we all do. But, you know, rank COVID towards the bottom, not towards the top of all those things.
Dr. Oster: The real cost is, you know, somebody…I do these, like, Instagram things, and people ask me questions, and today somebody asked me, “Is it safe to take my 20-month-old to the library?”
Dr. Fox: No, they should not hear books, books are bad. Oh, it’s tough. It really has a negative effect, socialization and just enjoyment and I don’t blame people for being afraid. I think that just the way we live nowadays and how media is done and how information is gathered, there’s so much opportunity to scare the crap out of people. It’s so easy to do. And it’s effective. It’s really effective.
Dr. Oster: And people like to read that stuff. I mean, you know, it’s clickbaity, it’s what people are willing to read or interested in reading or are compelled to read or whatever is the word there. And so, it isn’t really your fault and yet at the same time, you know, it’s really damaging.
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So, let’s move on to the big updates, the vaccine for kids. So, number one, let’s talk about, sort of, how they suddenly…not suddenly, how they determined that the vaccine is something that they’re going to approve or recommend, or approve but not recommend, or whatever it is for kids, offer for kids? Where did that data come from? And how do you explain how it’s different from the data we got from adults? Because I think that’s an important distinction that needs to be talked about, A, why it’s different, but B, why it might not matter that it’s different?
Dr. Oster: Because the kids are…it’s not so much that they’re littler or because they’re younger and their immune systems are less developed, there was a need to do a completely separate trial, basically almost to go back to like the drawing board on the vaccine trials for kids because they needed to try a lower dose, they give a dose of 30 micrograms for adults, and for kids 12 to 15. But when they went back, they actually tried many different doses. And they came to a dose of 10 micrograms, a third of the size of the adult dose for kids. And then having, sort of, established that dosing schedule, they then ran a phase two, three trial with about 2500 kids, this is the Pfizer data where they gave half of them the vaccine and half of them the placebo.
So, they’re actually really looking for kind of two things in these data. So, first, they’re looking for safety. And I would say that’s like the main focus was just, you know, is this safe? Are we seeing adverse effects? And the second thing, they’re looking for efficacy. And in this case, the main measure of efficacy was whether the kids developed antibodies at levels that were comparable to the levels of antibodies developed in adults. So, they actually looked directly at the antibody levels because as we said, COVID is very rare in kinds, hospitalization is rare, and death is rare. So, these kind of outcomes that they looked at in the trials for adults, you couldn’t really look at in the trials for kids because it was underpowered, you weren’t gonna…in fact, there were no hospitalizations among kids in either the trial or…and in the treatment arm or in the control arms. So, there was no way to look at efficacy in that way, so they had to look at it in a kind of served an outcome antibody way. But both of those looked good, and the efficacy looked good. And so, that is the sort of the approval here. That’s the data anyway.
Dr. Fox: Right. I think that’s an important point to focus on, that they knew, right, they expected that the kids in both groups, right, vaccinated or unvaccinated, were going to do well from an overall picture, meaning hospitalization rates, death rates, they didn’t expect kids who were unvaccinated to get really, really sick because we knew that, we hadn’t seen that sort of in the wilds, right? People getting…kids getting COVID all the time, there were not a ton of hospitalizations, and there were very, very few deaths. And so, they sort of knew that. And so, on the one hand, if you want to do a study showing you the vaccine’s effective, you can either do a study that’s huge, right, a million kids in each arm. And so, whatever few deaths there might be in a million kids, you can see if it prevented those, but the problem is that’s extremely expensive, it takes forever, and you may not get two million kids to even sign up, you may never get that done. And if it does get done, you’re gonna find out, you know, five years from now. So, that’s not really a great option.
So, the other option is you pick another outcome, like the antibody levels, which is…it’s like it’s what we call a surrogate outcome, like it’s useful, right? It tells you that they responded properly compared to the people who didn’t get a vaccine and wouldn’t respond, and so it tells you like it sort of works to give you the antibodies, but it doesn’t really tell you is it therefore necessary, right? That’s the question, right? It sort of says yes, it does what we think it’s supposed to do in terms of antibodies. But whether it’s necessary or not depends on what is the risk of getting really sick. And since that’s very low, it changes the equation compared to, let’s say, older adults.
Dr. Oster: Yeah. And so, one of the things that was interesting about this, I was actually surprised, I thought they would see almost no real-world efficacy at all but actually, although there were no hospitalizations or deaths in either group, they actually do have some COVID cases in the control group, which was about 700 kids, they had 16 cases, in the treatment group which is about 1500 kids, they had 3 cases. So, actually, you know, the efficacy…So I think there’s a glass half full, glass half empty way to picture that. I think one thing is, okay, there are 700 kids and only about 16 cases of, you know, symptomatic COVID. That seems [inaudible 00:30:13]. But of course, if you do the math on the rate actually, it was 90% protective against getting COVID at all. So, I mean, that’s encouraging given that I think many people are anxious about getting COVID. [inaudible 00:30:30] in case they will be seriously ill, they don’t want them to get it for many different reasons.
Dr. Fox: Yeah. And I think it’s also cool that the data, again, with infection rates, that the efficacy that they showed, the infection rates was basically the same give or take as what we’d seen in adults, right, about 90%-plus effective in reducing getting infection. And, again, in adults, it also showed a reduction in hospitalizations and deaths, but you wouldn’t see that in kids. But I think that there’s a lot of, you know, scientific basis to extrapolate that it probably reduces the risk of everything in kids by about 90%. But since the risk is so low baseline, you might not know that, but as you said, for the glass half full, for people who are concerned about their kids either getting COVID themselves because they’re worried about them getting sick or because they’re just worried logistically, I don’t want my kid to get COVID, like, I don’t want to deal with that, I don’t want them to be out of school, or because I don’t want them to pass it on to my uncle who’s diabetic and refuses to get vaccinated. And I don’t want to, you know, never have him in my house ever again.
So, you know, there’s a lot of reasons you may want your kid to not get COVID other than I’m worried about them, you know, being hospitalized. I think that this is really important data to show that it’s probably going to be effective in that sense. On the other hand, you know, for people who are like, “I really don’t like giving vaccines to my kids, I’m really freaked out by this, I’m really…I’m not worried about COVID, I’m not, you know, the kids are gonna be okay,” I think it’s also quite reasonable to say, “I’m not going to vaccinate my kid for a disease that I don’t think is so concerning.” And so, I think it leaves room for both, sort of, sides of the coin to make an informed decision about it.
Dr. Oster: I agree. And I think that there’s almost a third side of the coin. So, one of the things I hear a lot from people is this trial had 2200 people, 1500 of them were vaccinated, that’s not enough people for me. You know, I don’t want my kid to be the 1501st person to be vaccinated, you know, I need to see more.
Dr. Fox: Well, your kids are going to be the 1501st.
Dr. Oster: I totally agree. And I think that’s kind of the…you know, I’m a little worried that some of this because it’s already been so polarized that it will get very polarizing kids right away. As opposed to being able to say, look, the cost-benefit calculation is a little bit different here. But if you are interested, if you’re feeling, I need to see more data, good news, in another three weeks, there will be millions of people who have, you know, click [inaudible 00:32:56] the first appointment, and you will see. And if there are, you know, things like myocarditis, which we don’t expect much in this population, but if there are things like that, that happened that are very rare, we actually may pick them up in the first few weeks. And if people said, you know, I just need to see, you know, 2500 is not enough, I need to see 3 million, let’s encourage them to kind of revisit it in 3 weeks or revisit it in 3 months.
Dr. Fox: Yeah, it won’t take long to get a lot, a lot of data.
Dr. Oster: It won’t take long. Yeah.
Dr. Fox: Yeah, and I promise CNN will report all the complications, so.
Dr. Oster: Yeah, exactly. I mean, you’re gonna hear about it, somebody gets myocarditis, you’re gonna hear about it, it’s not going to be hidden. And we found out about this in older kids and young men pretty quickly because there’s a tremendous amount of scrutiny.
Dr. Fox: Right. So, overall, are you very pro-vaccinating your kids because, again, you’re concerned about, you know, friends and family who may get sick from them, or just because of them getting sick themselves? Or is it more just logistics, like, I want to get my kids out of masks into camp out of school not dealing with this?
Dr. Oster: So, I think I would vaccinate my kids anyway, like, I would vaccinate my kid even if the reasons I’m gonna give you were not there for the reason that I would like them to not get COVID. And the main reasons that I will vaccinate my kids are that the logistics issues that, you know, like, if we want to travel, it will make it much easier to do that. You know, if they get exposed at school, I don’t want them to have to quarantine. There’s a bunch of things that are set up now such that it would just be much easier for my life if my kids were vaccinated. And the other thing is that I am worried about family members who are at higher risk. Some of them may or may not be fully vaccinated. I don’t want my kids to get them sick. So, I think it’s not really that I’m worried my kids would get very sick, it is more that I just would like to be able to move to a place of more normalcy and I think to do that will be assisted by them being vaccinated.
Dr. Fox: I’m curious, you get asked a lot in terms of, you know, policy and trying to craft these on a bigger level. What’s your thoughts about schools that are considering mandating the COVID vaccine for kids? I mean, they do it already for certain vaccines. It’s not unheard of to have a mandated vaccine. You know, a lot of, you know, most schools or states, you can’t go unless you have a measles vaccine or, you know, you some sort of crazy exemption. How do you feel about that for the COVID vaccine? Do you feel it’s the same, or is it really something that they may want to pump the brakes on that?
Dr. Oster: I certainly think that I would be very, very reluctant to consider mandating the COVID vaccine during this school year. I don’t think that it’s a good idea given that there are a lot of people who would like to wait, who would like to see more and given that, you know, that’s not an unreasonable position. So, I’m a little anxious at some of the discussions about okay, let’s, you know, mandate it by January 1st, it doesn’t feel right to me. I think a lot of places will start mandating it for next fall. I can see an argument in favor of that. I think the sort of argument in favor is well, we mandated a lot of things like measles. I think the argument against is we don’t mandate a flu vaccine. And how exactly is this different from flu? And I think that’s a conversation that places will have. And I think we’ll see, we’ll see policies that go in both directions on this. I mean, at some point, I would like to also see them mandate the flu vaccine, at least some of the time actually flu is something that is spread a lot among kids and at schools. So, I have a complicated set of feelings about that.
Dr. Fox: Yeah. And it’s tough. I think this is also…at least in my lifetime, I don’t know what it was like when, you know, the measles vaccine came out and whatnot. It’s the first time I think that the idea of vaccination has been so polarizing with large numbers on both sides, right? There was always a subset of people who were very uncomfortable vaccinating their kids, period, right, whatever it was, and you know, there was all this is about autism, which was very unfortunate because the data really wasn’t true. But hey, you know, two-and-a-half years ago, there were people out there will be called anti-vaxxers. And, all right, but it was a very small percentage of the population. The vast majority of people didn’t think twice about their kids getting vaccinated for measles, mumps, rubella, and Tdap, and all these things and going to school and having it mandated, fine, like, no one cared.
But then, since COVID became such a political issue, a polarizing issue, I mean, everything about it was just split down the middle, you know, different states in the country, people, red, blue, all these things, that the vaccine is now so much more heated than the other vaccines. And it’s almost hard to be…to give a logical answer why that is, it’s just become that way, that people are, “I’m not getting my kid vaccinated, I’m gonna move to another state if they mandate it.” It’s like, oh, my God, like they never said that about something else, but people are so passionate about it in both directions. And I’m not judging either side. I’m just saying that that’s the reality. And we’ve never seen anything like this before with vaccines.
Dr. Oster: I don’t understand how much of it is just the general polarization associated with the pandemic, how much of it is the mRNA aspect of this, you know, what exactly has driven the polarization? I think part of it is it’s obviously very self-reinforcing. But once you decide, then you’re on that side. And like, you know, people like to be on sides. And that’s not very helpful for the discourse. And so, particularly around kid vaccines, it really does feel to me like there probably is reasonable space on both sides. And I’m concerned we’ll never get to it.
Dr. Fox: Yeah, I mean, yeah, I think people at a certain point just decide, I’m digging my heels in, that’s it. You know, as you said, I’ve chosen a side and I’m going with this. And my youngest is in high school, so I’m not in the world of, you know, whatever it is, 5 to 11-year-olds being vaccinated. And there was a real question about when the vaccine came out for the high school kids, what should the high school do? And on the one hand, it’d be like awesome if everyone’s vaccinated because it just makes life so much easier in the high school and, you know, to worry that the teachers don’t worry as much, and to worry about, you know, this and the quarantining, and it’s great. And ultimately, in the high school we go to in the community, the vast majority of kids are going to get vaccinated anyways, their parents were fine with it.
But when they’re deciding whether to make it mandatory, you know, one of my arguments against that was, it hadn’t been FDA approved at the time, but even when it was, it was brand new. It’s tough. Like, I don’t think it’s unreasonable for someone to say I don’t want to vaccinate my 15, my 16-whatever-year-old daughter against COVID with a new vaccine. Like, again, even though I personally am in favor of it, and my kids were all vaccinated and, you know, that’s just how I feel, I don’t think that someone’s outside the pale of the community if they don’t agree with that right away. And like you said, I think that at a certain point, we have to like just pump the brakes on some of this and see what happens over a year or two, let the heat die down a little bit, and get some more data, and get more people comfortable, and that sort of calming effect can spread quickly. But when the second that comes out, everyone’s saying do it, do it, do it, again, people dig their heels in, they feel like they’re being forced to do something. And people resist when they’re forced to do something.
Dr. Oster: You know, there’s been a lot of discussion of this kind of stuff in California because Newsom came out very…has come out very hard in mandates, you know, to the point of saying, I think, if you’re 12 to 15-year-olds are not mandated, we’re going to disenroll them in school, like, you know, like, soon. I mean, that feels to me…the thing I don’t like about that is both, kind of, the stick aspect of it, and also, a lot of the people who are afraid who may be affected by that they don’t want to vaccinate their kids are underprivileged in other ways. And I think that, you know, the idea that we’re going to disenroll a bunch of, like, low-income kids in Oakland because their parents are afraid to give them a vaccine for a disease their child will not get very sick from, I think that kind of suggests not a great set of policy priority.
Dr. Fox: Yeah, we have the same problem in New York. And, you know, there’s so much, obviously, with vaccination and with, sort of, trust in the medical care system that is cultural based on experience, and there’s a lot of thought that’s put into this thing, you know, how do we get, you know, medical care and good medical care to people of all communities? And because disproportionately, everybody knows that, you know, at least in my world, like in pregnancy, women who are, you know, minorities have much worse outcomes. And so, why is that, right? There’s all these…people are trying to address it and figure it out and to solve it. And with vaccination, that’s also the case. So, New York, you know, in different communities, in like the Black and Hispanic community, the vaccination rate is much, much lower.
And I don’t think it’s an issue of access, it’s available everywhere. For whatever reason, you know, they don’t…the people in those communities who are there don’t want to get vaccinated, either maybe it’s a trust issue, maybe it’s a cultural thing. I’m not really sure. It’s obviously not my expertise. But okay. But then we start putting all these mandates on and it ends up causing a bigger problem because now, you know, you can’t go into a restaurant unless you’re vaccinated. You can’t go to school unless you’re vaccinated. Now, whatever disparities existed, we’re making them worse, not better. And I find that very concerning. I don’t know the solution. I’m not an expert in this. I’m just one person, you know, who sees things and whatever, but it’s really troubling.
Dr. Oster: I completely agree. I think we have generated a layer on top of an already very complicated set of issues, yet another complicated set of issues, and probably it is not helping.
Dr. Fox: I really do appreciate that you’re out in the world talking about this, trying to write about it in a way that’s understandable, that’s reasonable, that’s thoughtful, that’s data-driven. I encourage everybody who doesn’t already listen to you…although I think everybody who’s on this podcast already loves you. But if there’s, like, one person out there who’s like, “Hey, who’s Emily Oster? Who is that? Who’s Emily Oster?” Yeah, google her. She’s great. You know, you have your newsletter, which I used to call a blog, but now I know it’s a newsletter. And obviously, you have your books. And, you know, you write a lot of articles, and you’re out there, and I think it’s terrific. And yes, so again, thank you so much for coming on the podcast to talk about the vaccines again, and about COVID. I totally appreciate it. And I really always look forward to, you know, reading your work and hearing what you have to say on this.
Dr. Oster: It’s always great to talk to you. Thank you so much.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.