Summary:

This document has been prepared by the South African Paediatric Association (SAPA) to assist primary  health care workers, general practitioners, and paediatricians in the ambulatory / out-patient / home-based care of children with SARS-CoV-2 infection.

Important considerations  Children with mild COVID-19 can be safely managed in isolation at home. Children with moderate or  severe  COVID-19  require  hospitalisation;  clinical  signs  include:  tachypnoea,  lower  chest  wall  indrawing, <92% oxygen saturation in room air, restlessness, difficulty in completed feeds or speaking  sentences. Not specific to COVID-19, the integrated management of childhood illness general danger  signs for children under 5 years are:

• inability to drink or breastfeed
• vomiting without retaining any fluids
• lethargy or unconsciousness
• convulsions

In addition, heath care workers need to be mindful of the presence of dehydration, persistent fever  and WHO signs of multisystem inflammatory syndrome in children (MIS-C)*.

There is limited evidence for the use of medication in the management of ambulatory COVID-19 in  children. The following proposed medications have been suggested based on expert opinion and or  extrapolated from adult studies. In general, the ambulatory/home-based management of children  is largely supportive with close monitoring for signs of deterioration.

Summary

The South African Paediatric Association (SAPA) supports the use of the SARS-CoV-2 Pfizer/BioNTech (Comirnaty) vaccine in children aged 12 years and older. However, it has some reservations that need to be addressed.

We believe:

1. Global vaccine equity is important, and countries with surplus vaccines should be sharing available stocks with countries unable to meet the demand of vaccinating high-risk groups. This principle applies to South Africa too.
2. The current priority populations for complete vaccination in South Africa are people over the age of 65 years and health workers.
3. Children aged 12-17 years with co-morbidities should be prioritised for vaccination. These include children with chronic respiratory, renal, cardiac, vascular and neurological conditions.

There are public health arguments both for and against the vaccination of children aged 12-17 years.

Arguments in favour of vaccination:

• Many children are still at risk of acquiring SARS-CoV-2 and the vaccine offers protection against severe disease and its acute and long-term complications. 1,2
• Children with Covid-19 can transmit the infection. Offering children vaccines may potentially reduce the risk of SARS-CoV-2 transmission and thereby the extent or severity of subsequent waves.
• In previously infected children, a single vaccine dose is expected to boost any naturally acquired immunity.
• The reported serious adverse events related to vaccination such as myocarditis are rare (about 20-30 episodes per million doses administered to adolescents) and the risks from COVID-19 complications, including myocarditis, far exceed the risk of any adverse event(s) from COVID-19 vaccination in all age groups. 3,4
• Vaccination offers the possibility of a return to normal activities and fewer disruptions in the lives of children, including schooling, sport, recreation, and other social activities.
• Vaccinating children may also have potential psychological benefits by reducing children’s concerns regarding falling ill and dying.

Arguments against offering vaccination:

• Offering the COVID-19 vaccine to children distracts from efforts to reach other priority groups for vaccination.
• In South Africa, a large proportion of children may have already have had COVID-19 (mostly asymptomatic) and have natural immunity.
• A single dose of Pfizer vaccine offers only partial immunity and clinical protection.
• If South Africa has enough vaccine supply to vaccinate children, then this should rather be shared with other African countries who do not have sufficient vaccine doses for higher priority groups.

Consent for vaccination

• The Children’s Act (s129) states that children can consent to medical treatment, including vaccination, if:
  a) the child is over the age of 12 years; and
  b) the child is of sufficient maturity and has the mental capacity to understand the benefits, risks, social and other implications of the treatment.
• Even though adolescents can choose for themselves, it is important for parents and caregivers to listen to their children and discuss the risks and benefits of vaccination. Learning to make good choices is an important part of children’s development and growth. Finding out about the vaccine and then weighing up the risks and benefits should be a positive experience.5

SAPA’s position

SAPA supports the South African government’s decision to vaccinate children aged 12 to 17 years. Vaccination of children 12-17 years old is of potential benefit to children at an individual level and to society. The benefits of vaccinating this age group far outweighs the risks.

However, SAPA believes that:

• Specific actions must be taken to reach and offer the COVID-19 vaccine to children at higher risk of severe COVID-19.
• A commitment to the provision of two doses of vaccine to high-risk children (with comorbidities) should be made.
• Resource allocation for reaching all people over the age of 65 and health workers must be prioritised over those allocated to vaccinating children.
• South Africa should be actively seeking to share its supply of vaccines with other African countries

This position paper represents the view of the South African Paediatric Association, a professional society representing paediatricians in the public and private sector in South Africa. The position is supported by the Paediatric Management Group.

References

1. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/covid19- vaccine-what-parents-need-to-know
2. https://yourlocalepidemiologist.substack.com/p/vaccines-continue-to-be-safe-for
3. https://www.nature.com/articles/d41586-021-02740-y
4. https://jamanetwork.com/journals/jama/fullarticle/2784132
5. Press Statement, 20 October 2021 “Consent for Covid-19 vaccination in children”. Children’s Institute UCT & Centre for Child Law

SAPA Scientific committee

Despina Demopoulos
Ziyaad Dangor
Mignon McCulloch
Haroon Saloojee
Gary Reubenson
Neil McKerrow