We urgently need to talk about babies & Covid - AGAIN

Another population wide study has dropped showing Covid outcomes by age 2023-2024 and babies under 6 months old are now at highest risk of needing hospital across ALL ages (including the elderly)

A new paper has just been published on a pre-print server (i.e. not yet peer reviewed) which examined acute Covid-19 outcomes from September 2023 to April 2024 by age for all of England.

The authors considered four outcomes: A&E attendance, hospital admission for Covid, severe hospital admission for Covid, and death with Covid on the death certificate. They only included admissions where there was evidence of covid infection and a respiratory reason for admission (i.e. they exluded hospital admissions not because of Covid as far as possible). They also defined a severe admission as one needing at least two days in hospital and some evidence of oxygen or intensive care support.

The time range of 2023/24 is well within the “living with Covid” era where most adults barely think about Covid at all. Their results are pretty shocking - not because of what they show about the risk profile for adults, but because of what they show on the risk profile for babies.

I was recently an author on a paper looking at how Covid outcomes have changed for children over the course of the pandemic - this showed that babies were the only age group where things had not improved over time, as I explained in this substack post. This new paper builds on that work by separating out infants into under 6 months old, 6 months to 1 year old and also comparing outcomes to adults of all ages. The main findings are shown below, where I plotted the data given in Table 1 of their paper.

There are two main takeaways. Firstly, the risk of death for babies is very low and is highest by far in adults over 60, increasing steeply by age. Secondly, for A&E attendance, hospital admission and severe hospital admission, the risk was highest in babies under 6 months old - higher even than for people over 90! While much lower than for the youngest babies, the risk for babies aged 6 months - 1 year was also higher than most other age groups - comparable to adults in their 70s or 80s.

In absolute numbers, adverse outcomes are worse in older populations (because there are simply many more of them than the 350,000 or so babies under 6 months old). But the absolute numbers for babies are still significant for all outcomes other than death.

In our paper last month, we suggested that young babies were especially vulnerable because they are already at high risk of respiratory illness while their immune systems develop and because they mostly have no preexisting immunity to Covid.

The good news is that you can protect babies to some extent - either through a safe and effective Covid vaccine once they reach 6 months old, and/or by vaccinating their mother during pregnancy for the youngest babies.

The bad news is that these routes are not available in the UK. The UK’s vaccine body, JCVI, has recommended that only clinically extremely vulnerable children over 6 months receive the Covid vaccine. Up until now, the Covid vaccine has been available in pregnancy as part of the biannual booster programme - but this is now being withdrawn! [Thanks to Steve Griffin & Sheena Cruickshank for pointing this out]

It’s not clear quite how JCVI assessed the cost effectiveness in pregancy - the published cost-effectiveness modelling I’ve found [thank you to Duncan Robertson] only considered ages 15 years and up, while the hospitalisation data used grouped together children aged 0-4 [again thanks to Duncan Robertson]. Doing such a grouping masks the much higher vulnerability of very young babies.

The other worry I have about the JCVI analysis is that they seem to be prioritising mortality above all else. While it of course matters a lot, and babies very rarely die from Covid, hospitalisation and severe hospitalisation are nonetheless important outcomes to avoid! There is also - still - no consideration given to the benefit of vaccination in reducing chance of developing new Long Covid or other long term impacts from infection for any age group. [As an aside, a new peer-reviewed paper just reported on the signficant economic costs of Long Covid and impact on employment in the UK].

England has excellent population linked data which enables rigorous studies like this that builds the evidence on what “living with Covid” means five years since Covid arrived. And the more data we get, the clearer it is that young babies are at risk from Covid.

We need to urgently update our assumptions that “kids are fine if they get Covid” - not least by disaggregating outcomes for the under 5’s into finer age groupings - and adapt our vaccination policies accordingly. I would like to see JCVI explicitly address this new paper by Aziz and colleagues and our recent paper, and either update their advice or explain - with tranparent modelling for these age groups - why they do not think it is cost effective to either offer vaccines in pregancy and/or for children over 6 months old.

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PS I covered this content as well on a Bluesky thread today - if you are a Twitter use and considering jumping ship, Bluesky is a pretty good option!