Evaluation of mRNA-1273 Vaccine in Children

Mar 24, 2023 | Blog, News, Pediatric, Vaccines

CenExel is proud to announce the publication of the work of Kimball A. Johnson, MD, from CenExel iResearch, in the New England Journal of Medicine. Dr. Johnson participated in a study of mRNA-1273 Vaccine in Children 6 Months to 5 Years of Age

Other contributors included Evan J. Anderson, MD, C. Buddy Creech, MD, MPH, Vlasimir Berthaud, MD, MPH, Arin Piramzadian, DO, et al., for the KidCOVE Study Froup*

Abstract

BACKGROUND
The safety, reactogenicity, immunogenicity, and efficacy of the mRNA-1273 coronavirus disease 2019 (Covid-19) vaccine in young children are unknown.

METHODS
Part 1 of this ongoing phase 2–3 trial was open label for dose selection; part 2 was an observer-blinded, placebo-controlled evaluation of the selected dose. In part 2, we randomly assigned young children (6 months to 5 years of age) in a 3:1 ratio to receive two 25-μg injections of mRNA-1273 or placebo, administered 28 days apart. The primary objectives were to evaluate the safety and reactogenicity of the vaccine and to determine whether the immune response in these children was noninferior to that in young adults (18 to 25 years of age) in a related phase 3 trial. Secondary objectives were to determine the incidences of Covid-19 and severe acute respiratory syndrome coronavirus 2 infection after administration of mRNA-1273 or placebo.

RESULTS
On the basis of safety and immunogenicity results in part 1 of the trial, the 25-μg dose was evaluated in part 2. In part 2, 3040 children 2 to 5 years of age and 1762 children 6 to 23 months of age were randomly assigned to receive two 25-μg injections of mRNA-1273; 1008 children 2 to 5 years of age and 593 children 6 to 23 months of age were randomly assigned to receive placebo. The median duration of follow-up after the second injection was 71 days in the 2-to-5-year-old cohort and 68 days in the 6-to-23-month-old cohort. Adverse events were mainly low-grade and transient, and no new safety concerns were identified. At day 57, neutralizing antibody geometric mean concentrations were 1410 (95% confidence interval [CI], 1272 to 1563) among 2-to-5-year-olds and 1781 (95% CI, 1616 to 1962) among 6-to-23-month-olds, as compared with 1391 (95% CI, 1263 to 1531) among young adults, who had received 100-μg injections of mRNA-1273, findings that met the noninferiority criteria for immune responses for both age cohorts. The estimated vaccine efficacy against Covid-19 was 36.8% (95% CI, 12.5 to 54.0) among 2-to-5-year-olds and 50.6% (95% CI, 21.4 to 68.6) among 6-to-23-month-olds, at a time when B.1.1.529 (omicron) was the predominant circulating variant.

CONCLUSIONS
Two 25-μg doses of the mRNA-1273 vaccine were found to be safe in children 6 months to 5 years of age and elicited immune responses that were noninferior to those in young adults. (Funded by the Biomedical Advanced Research and Development Authority and National Institute of Allergy and Infectious Diseases; KidCOVE ClinicalTrials.gov number, NCT04796896. opens in new tab.)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in children accounted for more than 13.6 million of the documented infections in the United States as of July 2022. Infected children may be asymptomatic or have mild symptoms but can still transmit SARS-CoV-2. Despite social interventions to reduce coronavirus disease 2019 (Covid-19) transmission, Covid-19–related hospitalizations and deaths in children younger than 5 years of age (from October 2020 through September 2021) in the United States generally reached or surpassed the annual influenza-related rates observed in the period before the pandemic.

Covid-19 messenger RNA vaccines, including mRNA-1273 (Moderna), are safe and efficacious in preventing illness from SARS-CoV-2 infection in adults, adolescents, and older children (6 to 11 years of age). The mRNA-1273 vaccine is approved in the United States for use in adults and received emergency use authorization from the Food and Drug Administration in June 2022 for persons 6 months to 17 years of age. Although additional surges of SARS-CoV-2 infections due to emerging variants are anticipated and efficacy among adults and children is lower against the B.1.1.529 (omicron) variant than against other variants, two mRNA-1273 injections were shown to continue to protect against hospitalization and death.

Having a safe and effective vaccine available for infants, toddlers, and young children is critically important. Here, we report the results in children 6 months to 5 years of age in the ongoing phase 2–3 KidCOVE trial, which evaluated the safety, reactogenicity, immunogenicity, and efficacy of the mRNA-1273 vaccine.

Methods
TRIAL DESIGN AND PARTICIPANTS
The trial participants in three age cohorts (6 to 11 years, 2 to 5 years, and 6 to 23 months) were enrolled at 79 sites in the United States and 8 sites in Canada (Fig. S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). The trial was conducted in two parts, with an open-label dose-escalation phase in part 1 and an observer-blinded, randomized, placebo-controlled expansion phase in part 2. Interim results in the cohort of 6-to-11-year-old children have been reported previously. Here, we report the results of the interim analysis in the cohorts of children 2 to 5 years of age and 6 to 23 months of age through February 21, 2022.

Eligible children were healthy, but children with stable chronic conditions (e.g., asthma, diabetes mellitus) were also included. Additional inclusion and exclusion criteria and information on the trial oversight, conduct, and design are provided in the Supplementary Methods section in the Supplementary Appendix and in the protocol, available at NEJM.org.

TRIAL PROCEDURES
In both parts of the trial, the vaccination regimen involved two doses of the mRNA-1273 vaccine or saline placebo administered by intramuscular injection 28 days apart. In part 1, the 25-μg and 50-μg dose levels were evaluated in children 2 to 5 years of age, and the 25-μg dose level was evaluated in children 6 to 23 months of age. After a review of safety and immunogenicity, a 25-μg dose was selected for evaluation in children in both age cohorts in part 2, and the data and safety monitoring board concurred (see the Supplementary Appendix).

In part 2 of the trial, children who were 6 months to 5 years of age were randomly assigned in a 3:1 ratio to receive two injections of mRNA-1273 (25 μg each) or placebo, administered 28 days apart. The primary objectives were to determine the safety and reactogenicity of mRNA-1273 in children 2 to 5 years of age and children 6 to 23 months of age and to infer efficacy on the basis of the noninferiority of the serum antibody geometric mean concentrations and serologic responses among these children as compared with those among young adults (18 to 25 years of age) who received two injections of mRNA-1273 (100 μg) in the phase 3 Coronavirus Efficacy (COVE) trial, which previously showed efficacy of the vaccine. Secondary objectives were to determine the incidences of Covid-19 and SARS-CoV-2 infection, either asymptomatic or regardless of symptoms, after administration of mRNA-1273 or placebo.

SAFETY ASSESSMENTS
In parts 1 and 2, solicited local and systemic adverse reactions that occurred within 7 days after each injection were recorded daily. The same solicited local adverse reactions (pain, erythema, swelling, and axillary swelling or tenderness) were assessed in the two age cohorts. Among children 37 months to 5 years of age, the systemic adverse reactions assessed were fever, headache, fatigue, myalgia, arthralgia, chills, and nausea or vomiting. Among children 24 to 36 months of age and 6 to 23 months of age, fever, irritability or crying, sleepiness, and loss of appetite were assessed.

Safety assessments included unsolicited adverse events that occurred within 28 days after each injection and adverse events leading to nonreceipt of the second injection, discontinuation from the trial, or both; serious adverse events; medically attended adverse events; adverse events of special interest (including acute myocarditis or pericarditis and multisystem inflammatory syndrome in children [MIS-C]); and SARS-CoV-2 infection assessed from day 1 through trial completion. Surveillance for symptoms of myocarditis or pericarditis was conducted during safety telephone calls, with referral for medical assessment by a provider if needed. SARS-CoV-2 infection was assessed by means of reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay performed at specific time points, and SARS-CoV-2 infection and Covid-19 cases were surveilled with the use of safety telephone calls and questionnaire prompts in electronic diaries completed by the parents or guardians of the participants.

IMMUNOGENICITY ASSESSMENTS
Immunogenicity assays are described in the Supplementary Methods section in the Supplementary Appendix. Neutralizing antibody geometric mean concentrations were assessed with the use of a validated pseudovirus neutralization assay in part 2 of the trial.19,20 A serologic response was defined as an increase in the neutralizing antibody concentration from below the lower limit of quantification (LLOQ) to a concentration that was at least 4 times the LLOQ, or at least 4 times as high as the baseline value if the baseline concentration was equal to or above the LLOQ. Antispike binding antibody levels against SARS-CoV-2 variants were evaluated with the use of a Meso Scale Discovery assay.

INCIDENCES OF COVID-19 AND SARS-COV-2 INFECTION
The incidence of Covid-19 was defined in accordance with the guidelines of the Centers for Disease Control and Prevention (CDC). This definition included at least one systemic or respiratory symptom and a positive RT-PCR assay for SARS-CoV-2. In a separate analysis, we used the following definition from the COVE trial: at least two systemic symptoms or at least one respiratory symptom and a positive RT-PCR assay. As a sensitivity analysis, the incidence of Covid-19 was evaluated on the basis of any positive Covid-19 test, including home tests. SARS-CoV-2 infection (regardless of symptoms) was assessed by means of RT-PCR or Elecsys (Roche) nucleocapsid protein serologic assay (Supplementary Appendix).

STATISTICAL ANALYSIS
Details of the statistical methods are provided in the Supplementary Methods section in the Supplementary Appendix and in the statistical analysis plan (available with the protocol). The analysis populations are described in Table S1.

Safety was assessed among the participants who received at least one injection (safety population), and solicited adverse reactions were assessed among the participants in the safety population who had any data collected on solicited adverse reactions (solicited safety population); adverse reactions were assessed according to trial group and age cohort. The numbers and percentages of participants are summarized for those with solicited local and systemic adverse reactions that occurred within 7 days after each injection according to severity grade, as well as for those with unsolicited adverse events, serious adverse events, medically attended adverse events, severe adverse events, or adverse events leading to nonreceipt of the second injection or discontinuation from the trial or both. Descriptive summary statistics are reported for all other safety measures. Safety was also assessed according to baseline SARS-CoV-2 infection status at day 1 by means of virologic RT-PCR testing or serologic testing (Elecsys nucleocapsid protein serologic assay) or both.

To determine whether efficacy of the mRNA-1273 vaccine can be inferred (a primary objective), we compared the immunogenicity responses in each of two cohorts defined according to age group (children 2 to 5 years of age and children 6 to 23 months of age) in the per-protocol immunogenicity population with those among young adults (18 to 25 years of age) in the COVE trial. The per-protocol immunogenicity population included participants who had received the planned injections, were SARS-CoV-2–negative at baseline (day 1) according to both RT-PCR and serologic testing, had data available from antibody testing for day 1 and day 57, and had no major protocol deviations. Noninferiority, determined on the basis of neutralizing antibody geometric mean concentrations among children as compared with those among young adults at day 57, was indicated if the lower boundary of the 95% confidence interval for the geometric mean ratio was at least 0.67 and if the difference in the percentage of participants with a serologic response was −10 percentage points or more. We provide the geometric mean concentrations and geometric mean ratios (with 95% confidence intervals calculated according to the analysis of covariance model), the number and percentage of participants with a serologic response (with 95% confidence intervals calculated with the Clopper–Pearson method), and the between-group difference in serologic response (with 95% confidence intervals calculated with the Miettinen–Nurminen method) at day 57. The observed binding antibody levels against SARS-CoV-2 variants are also provided.

In part 2 of the trial, for the secondary efficacy objectives of determining the incidences of Covid-19 and SARS-CoV-2 infection, we evaluated all randomly assigned participants who did not have serologic or virologic evidence of SARS-CoV-2 infection at baseline and who received at least one injection of the correct dose (the modified intention-to-treat population) and participants who received both injections according to the schedule without a major protocol deviation (the per-protocol efficacy population). Incidence was calculated as the number of cases divided by the total number of person-years (defined as the total years from the first day of the analysis to the last day of trial participation, to censoring time, or to the efficacy data-cutoff date, whichever was earliest), and 95% confidence intervals were calculated with the exact method (Poisson distribution). Vaccine efficacy was estimated (1 minus the ratio of the incidence of Covid-19 or SARS-CoV-2 infection in the mRNA-1273 group as compared with the placebo group) and the 95% confidence intervals of the ratio were calculated with the exact method, conditional on the total number of cases and with adjustment for person-years. The interim results for the cohorts of children 6 to 23 months of age and children 2 to 5 years of age are provided through the data-cutoff date of February 21, 2022.

Results
TRIAL POPULATION
From April 2021 through June 2021, a total of 224 children 2 to 5 years of age and 150 children 6 to 23 months of age were enrolled in part 1 of the trial (Fig. S2). Among children 2 to 5 years of age, 75 were assigned to receive the 25-μg dose of mRNA-1273, and 149 were assigned to receive the 50-μg dose; all children 6 to 23 months of age (150 participants) were assigned to receive the 25-μg dose. All participants received both injections.

Figure 1.


Randomization of Participants 2 to 5 Years of Age and Participants 6 to 23 Months of Age in Part 2 of the Trial.

In part 2 of the trial, in the cohort of children 2 to 5 years of age, 3031 of 3040 participants (99.7%) in the mRNA-1273 group and 1007 of 1008 participants (99.9%) in the placebo group received the first injection; 2960 participants (97.4%) and 970 participants (96.2%), respectively, received the second injection (Figure 1). In the cohort of children 6 to 23 months of age, 1760 of 1762 participants (99.9%) assigned to the mRNA-1273 group and 590 of 593 participants (99.5%) assigned to the placebo group received the first injection; 1600 participants (90.8%) in the mRNA-1273 group and 529 (89.2%) in the placebo group received the second injection.

Table 1.


Demographic and Clinical Characteristics of the Participants in the Safety Population at Baseline (Part 2 of the Trial), Stratified According to Age Cohort and Trial-Group Assignment.

The baseline demographic and clinical characteristics of the children in the trial groups were generally balanced and were similar in part 1 (Tables S2 and S3) and part 2 (Table 1 and Table S4) of the trial. Overall, in part 2, the median age of the children in the 2-to-5-year-old cohort was 3.0 years (interquartile range, 2.0 to 4.0). A total of 76.5% of the participants in this cohort were White, 4.5% were Black, 6.0% were Asian, and 14.2% were Hispanic or Latinx. In the 6-to-23-month-old cohort, the median age was 16.0 months (interquartile range, 13.0 to 20.0). A total of 78.9% of the participants in this cohort were White, 3.1% were Black, 4.9% were Asian, and 13.2% were Hispanic or Latinx. The underrepresentation of Black participants is acknowledged. The median duration of follow-up in the 2-to-5-year-old cohort was 103 days (interquartile range, 83 to 113) after the first injection and 71 days (interquartile range, 49 to 83) after the second injection, and in the 6-to-23-month-old cohort, the corresponding values were 98 days (interquartile range, 76 to 110) and 68 days (interquartile range, 42 to 78).

SAFETY
Safety data from part 1 of the trial are available in the Part 1 Results section in the Supplementary Appendix and in Tables S5 through S13. In part 2, the incidence of solicited local adverse reactions was higher with mRNA-1273 than with placebo in both age cohorts, and in the mRNA-1273 group, the incidence was higher after the second injection than after the first injection (Figure 2 and Tables S14 through S17). Most local adverse reactions were of grade 1 or 2 and lasted for 1 to 3 days. Grade 3 events were rare overall but were more frequent after the second injection; the most common grade 3 events were erythema, swelling, and pain among children 2 to 5 years of age and erythema and swelling among children 6 to 23 months of age.
Figure 2.

Solicited Local and Systemic Adverse Reactions in the Cohorts of Children 2 to 5 Years and 6 to 23 Months of Age in Part 2 of the Trial.

Systemic adverse reactions after either injection were more common in the mRNA-1273 group than in the placebo group (Figure 2 and Tables S18 and S19). The most common systemic adverse reaction among children 37 months to 5 years of age was fatigue; among children 6 to 36 months of age, the most common reactions were irritability or crying, sleepiness, and loss of appetite. The majority of systemic adverse reactions in both groups were of grade 1 or 2, and grade 3 adverse reactions were infrequent. The most common grade 3 systemic adverse reactions were fatigue and fever (temperature, ≥39.0°C) among children 37 months to 5 years of age and irritability or crying and fever of at least 39.6°C among children 6 to 36 months of age in the mRNA-1273 and placebo groups. Most systemic adverse reactions in the mRNA-1273 group occurred within 2 days after either injection and persisted for a median of 2 to 3 days. Overall, the incidences of solicited adverse reactions were similar regardless of baseline SARS-CoV-2 infection status, except for somewhat higher incidences of fever after either injection among participants who were SARS-CoV-2–positive at baseline (Figs. S3 and S4).

In the mRNA-1273 group, fever (temperature, ≥38.0°C) occurred more frequently after the second injection than after the first injection, and the median duration was 1 to 2 days after either injection in both age cohorts. The majority of fevers ranged in temperature from 38.0 to 38.9°C (Figs. S5 and S6). In the cohort of children 2 to 5 years of age, a confirmed grade 4 fever (temperature, >40°C) was noted in three participants in the mRNA-1273 group after the first injection, in five participants in the mRNA-1273 group after the second injection, and in two participants in the placebo group after the first injection. In the cohort of children 6 to 23 months of age, a confirmed grade 4 fever occurred in one participant in the mRNA-1273 group after the first injection, in three participants in the mRNA-1273 group after the second injection, and in one participant in the placebo group after the first injection. Among the participants with confirmed grade 4 fever, five in the mRNA-1273 group and one in the placebo group had concurrent adverse events suggestive of viral infections (Table S20).

Incidences of unsolicited adverse events that occurred within 28 days after any injection were similar in the mRNA-1273 group and the placebo group in both age cohorts (Tables S21 through S24). The incidence of adverse events considered by the investigator to be related to mRNA-1273 or placebo was higher in the mRNA-1273 group (9% among 2-to-5-year-olds and 17% among 6-to-23-month-olds) than in the placebo group (8% among 2-to-5-year-olds and 12% among 6-to-23-month-olds); the events were mainly attributed to reactogenicity events.

The incidence of serious adverse events was low overall and was similar in the mRNA-1273 group and the placebo group in the cohort of children 2 to 5 years of age. In the cohort of children 6 to 23 months of age, eight serious adverse events occurred in the mRNA-1273 group, and none occurred in the placebo group. No serious adverse events related to mRNA-1273 or placebo were reported in 2-to-5-year-olds within 28 days after either injection. One participant in the mRNA-1273 group in the 6-to-23-month-old cohort had fever and febrile seizure that was categorized as a serious adverse event 2 days after the first injection, and a maculopapular rash developed in the participant 2 days later, suggesting a concomitant viral infection (Table S25); the participant subsequently received the second injection without recurrence.

Adverse events of special interest that were considered to be related to the trial regimen occurred in two participants in the mRNA-1273 group in the 2-to-5-year-old cohort, in two participants in the mRNA-1273 group in the 6-to-23-month-old cohort, and in one participant in the placebo group in the 2-to-5-year-old cohort (Table S26). During the entire trial period, one participant in the mRNA-1273 group and no participants in the placebo group had nonreceipt of the second injection because of adverse events that were considered to be related to the trial regimen. No deaths or cases of myocarditis or pericarditis or MIS-C occurred before the data-cutoff date.

IMMUNOGENICITY
In the per-protocol immunogenicity population in part 2, the neutralizing antibody geometric mean concentrations at day 57 were 1410 (95% confidence interval [CI], 1272 to 1563) among 2-to-5-year-olds (assessed in 264 participants) and 1781 (95% CI, 1616 to 1962) among 6-to-23-month-olds (assessed in 230 participants), as compared with 1391 (95% CI, 1263 to 1531) among the young adults in the COVE trial (Table 2, Table S27, and Fig. S7). In comparisons of the two age cohorts in the current trial with the young adults in the COVE trial, the geometric mean ratios (1.0 [95% CI, 0.9 to 1.2] among 2-to-5-year-olds and 1.3 [95% CI, 1.1 to 1.5] among 6-to-23-month-olds) as well as the differences in the percentages of participants with a serologic response (−0.4 percentage points [95% CI, −2.7 to 1.5] among 2-to-5-year-olds and 0.7 percentage points [95% CI, −1.0 to 2.5] among 6-to-23-month-olds) met the criteria for noninferiority with respect to the primary immunogenicity objective.

Table 2.

Immunogenicity of the mRNA-1273 Vaccine in Part 2 of the Trial.

In both age cohorts, the neutralizing antibody geometric mean concentrations at day 57 were higher among participants who were SARS-CoV-2–positive at baseline than among those who were negative (Fig. S8). Regardless of age, the two-injection primary series of mRNA-1273 elicited robust binding antibody responses to the ancestral strain and the B.1.351 (beta), B.1.617.2 (delta), and omicron variants (Fig. S9).

EFFICACY
In the 2-to-5-year-old cohort, there were 119 cases of Covid-19 among 2594 participants (4.6%) in the mRNA-1273 group and 61 cases among 858 participants (7.1%) in the placebo group that met the CDC definition; the estimated vaccine efficacy at 14 or more days after the second injection in the per-protocol population was 36.8% (95% CI, 12.5 to 54.0). With respect to cases that met the definition of Covid-19 from the COVE trial, there were 71 cases among 2594 participants (2.7%) in the mRNA-1273 group and 43 cases among 858 participants (5.0%) in the placebo group; the estimated vaccine efficacy was 46.4% (95% CI, 19.8 to 63.8) (Figure 3, Table S28, and Fig. S10). In the 6-to-23-month-old cohort, there were 51 cases among 1511 participants (3.4%) in the mRNA-1273 group and 34 cases among 513 participants (6.6%) in the placebo group that met the CDC definition; the vaccine efficacy was 50.6% (95% CI, 21.4 to 68.6). With respect to cases that met the definition of Covid-19 from the COVE trial, there were 37 cases among 1511 participants (2.4%) in the mRNA-1273 group and 18 cases among 513 participants (3.5%) in the placebo group; the vaccine efficacy was 31.5% (95% CI, −27.7 to 62.0). Vaccine efficacy was also shown against any SARS-CoV-2 infection regardless of symptoms and against asymptomatic infection in both age cohorts. The efficacy findings in the modified intention-to-treat population were similar to those in the per-protocol population (Figure 3 and Table S29).

Figure 3.

Secondary Efficacy End Points.

The results of the sensitivity analysis in which the incidence of Covid-19 was evaluated on the basis of any positive Covid-19 test, including home tests, were similar to those in which the incidences of Covid-19 were evaluated on the basis of confirmed positive RT-PCR assays (Table S30). The estimated efficacy against Covid-19 as defined by the CDC was 28.5% (95% CI, 5.9 to 45.3) among children 2 to 5 years of age and 53.5% (95% CI, 32.4 to 67.8) among children 6 to 23 months of age, and the estimated efficacies against Covid-19 as defined in the COVE trial were 37.5% (95% CI, 11.8 to 55.3) and 43.7% (95% CI, 8.5 to 64.8), respectively; the lower boundaries of the 95% confidence intervals were greater than 0 in each of these estimations. Among the Covid-19 cases in the per-protocol population that met the CDC definition and had available sequence information (December 2021 through February 2022), 78 of 79 cases in the 2-to-5-year-old cohort and 44 of 44 cases in the 6-to-23-month-old cohort were of omicron BA.1 and BA.1.1 lineages.

Discussion
In children 6 months to 5 years of age, a two-injection primary series of mRNA-1273 at a dose of 25 μg had an acceptable safety profile and elicited immune responses that were consistent with those observed in clinical trials that involved higher doses of this vaccine in older children, adolescents, and adults. In addition, vaccine efficacy against Covid-19 was shown, albeit at a lower values than those observed in previous mRNA-1273 trials involving older age cohorts that were conducted before the emergence of omicron — a finding consistent with reduced vaccine effectiveness against omicron observed among adults and adolescents.

The 25-μg mRNA-1273 dose, established in part 1 of the trial, elicited mild-to-moderate, transient reactogenicity in both age cohorts in part 2. No trial pause rules were met, and no safety concerns were identified. Apart from fevers, the reactogenicity in these young children was generally lower than that observed for mRNA-1273 in adults, adolescents, and older children (6 to 11 years of age). The incidence of fever after either mRNA-1273 injection in both age cohorts was similar (22 to 23%) to that previously reported (24%) among 6-to-11-year-olds who received 50-μg of mRNA-1273 in this trial14 and to that after other routinely recommended vaccinations. Few grade 4 fevers (temperature, >40.0°C) were reported in the mRNA-1273 and placebo groups. No myocarditis, pericarditis, or MIS-C and no deaths occurred through the analysis-cutoff date. No safety issues were identified in participants who had SARS-CoV-2 infection before or during the trial; however, longer-term safety monitoring will continue.

The efficacy of mRNA-1273 was inferred on the basis of having met prespecified criteria for immunobridging, the approach used for authorization and approval in Covid-19 vaccine studies involving adolescents and older children. Two-injections of 25 μg of mRNA-1273 in these younger children elicited neutralizing antibody concentrations similar to those in 18-to-25-year-olds who received two 100-μg injections in the COVE trial. These data suggest that the benefits of mRNA-1273 vaccination in the prevention of Covid-19 also extend to children and infants as young as 6 months of age.

Incidences of SARS-CoV-2 infections and Covid-19 were assessed as secondary end points in the trial during a period when omicron was the predominant circulating variant, particularly among young children. Among participants with available sequencing data, nearly all had confirmed omicron (BA.1 and BA.1.1) sequences. Nonetheless, primary vaccination with two 25-μg doses of mRNA-1273 was protective against confirmed Covid-19, as defined by the CDC or in the COVE trial, in both age cohorts. The estimated vaccine efficacy was lower than that reported in previous mRNA-1273 trials conducted when other variants were predominant and similar to that reported in effectiveness studies of the two-dose mRNA-1273 series involving adults during circulation of the omicron variant. The vaccine also elicited robust binding antibody levels against a broad range of variants including previous variants of concern and the delta and omicron variants. In addition, primary vaccination offers protection against hospitalization and death. The previously authorized vaccine for 5-to-11-year-olds showed excellent effectiveness in preventing Covid-19–related hospitalizations and MIS-C, including during peak circulation of delta. Although declines in vaccine effectiveness against omicron infection have been observed, the vaccines remain effective in preventing hospitalizations.

Important limitations to this trial should be considered. Generally healthy children and children with stable medical conditions were enrolled. Additional work may be necessary to understand the effect of immunosuppressive conditions on vaccine immunogenicity in children. The trial was powered to detect rare adverse events (at approximately 0.1%); however, wider-scale use of the vaccine in children after authorization may identify other less frequent or more serious adverse events, and continued monitoring of safety after emergency use authorization is ongoing. The vaccine efficacy was shown on the basis of cases of Covid-19 and SARS-CoV-2 infection reported as of the data-cutoff date, and longer-term evaluation of the efficacy and durability of protection continues in the ongoing trial.

In children 6 months to 5 years of age, two 25-μg injections of the mRNA-1273 vaccine had acceptable reactogenicity, safety, and effectiveness during a period when omicron was the predominant circulating variant, a finding consistent with that observed previously in children 6 to 11 years of age, adolescents, and adults. Active and passive safety surveillance will continue during the postauthorization period in large global safety networks to detect any new safety signals. The longer-term effectiveness and durability of mRNA-1273 will also continue to be assessed in clinical trials and through its postauthorization use.

Supported by the Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority (contract number, 75A50120C00034), and the National Institute of Allergy and Infectious Diseases (grant numbers, UM1AI148576, UM1AI148452, UM1AI148689, UM1AI148450, UM1AI148372, and UM1AI148575).

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on October 19, 2022, at NEJM.org.

A data sharing statement provided by the authors is available with the full text of this article at NEJM.org.

We thank the trial participants and their families; the staff at the trial sites for implementing the protocol; members of the data and safety monitoring board (David Bernstein, M.D. [chair], Cincinnati Children’s Hospital Medical Center; Michael Polis, M.D., M.P.H., Medical Consulting; and Anne Chang, Ph.D., M.P.H.T.M., M.B., B.S., Children’s Health Queensland Hospital, Australia); David C. Montefiori, Ph.D., and the Immune Assay Team at Duke University Medical Center for performing the neutralization assays in part 1 of the trial; PPD Laboratories for performing the neutralization assays in part 2 of the trial and the Meso Scale Discovery multiplex binding antibody assays in parts 1 and 2 of the trial; and Frank Dutko, Ph.D. (a Moderna contractor), for editorial support with an earlier version of the manuscript.

Author Affiliations
From the Center for Childhood Infections and Vaccines, Children’s Healthcare of Atlanta, and the Department of Pediatrics, Emory University School of Medicine, Atlanta (E.J.A.), and IResearch Atlanta, Decatur (K.A.J.) — all in Georgia; the Vanderbilt Vaccine Research Program, Department of Pediatrics, Vanderbilt University Medical Center (C.B.C.), and Meharry Medical College (V.B.) — both in Nashville; OnSite Clinical Solutions, Charlotte, NC (A.P.); the Henry Ford Health System, Detroit (M.Z.); Pi-Coor Clinical Research, Burke, VA (F.G.); the Lynn Health Science Institute, Oklahoma City (C.G.); the Cyfair Clinical Research Center (K.P.) and the Texas Center for Drug Development (K.A.), Houston, and ACRC Trials, Frisco (M.A.) — all in Texas; Velocity Clinical Research, Meridian, ID (M.T.); Children’s Hospital of Philadelphia Clinical Research Partners, Philadelphia (J.G.); Clinical Research Partners, Richmond, VA (R.L.B.); Clinical Research Institute, Minneapolis (G.B.); the University of Rochester Medical Center, Rochester (J.N.), and Certified Research Associates, Cortland (C.A.S.) — both in New York; Pediatric, Infant, and Adolescent Medicine, Ventura, CA (C.C.); Velocity Clinical Research, West Jordan, UT (B.R.); Ann and Robert H. Lurie Children’s Hospital, Chicago (W.J.M.); the University of Kentucky, Lexington (G.F.); the Pennington Biomedical Research Center, Baton Rouge, LA (D.H.); and Moderna, Cambridge, MA (J.E.T., D.D., C.R., B.K., X.Z., W.D., H.Z., D.R.S., K.H., B.G., K.S., R.M., R.P., A.A., R.D., J.M.M., S.S.G.).

Dr. Schnyder Ghamloush can be contacted at sabine.schnyder.ghamloush@modernatx.com or at Moderna, 1 Hampshire St., Cambridge, MA 02139.

The members of the KidCOVE Study Group are listed in the Supplementary Appendix, available at NEJM.org.

References

Centers for Disease Control and Prevention. COVID data tracker. 2022
(https://covid.cdc.gov/covid-data-tracker/#demographicsovertime).

Elflein J. Total number of cases of COVID-19 in the United States as of August 30, 2022, by age group. New YorkStatistaAugust 312022
(https://www.statista.com/statistics/1254271/us-total-number-of-covid-cases-by-age-group/).

Chu VTYousaf ARChang K, et al. Household transmission of SARS-CoV-2 from children and adolescents. N Engl J Med 2021;385:954956.
Free Full Text    |    Web of Science   |   Medline

Bhatt MPlint ACTang K, et al. Household transmission of SARS-CoV-2 from unvaccinated asymptomatic and symptomatic household members with confirmed SARS-CoV-2 infection: an antibody-surveillance study. CMAJ Open 2022;10:E357E366.
Crossref   |   Medline

McLean HQGrijalva CGHanson KE, et al. Household transmission and clinical features of SARS-CoV-2 infections. Pediatrics 2022;149(3):e2021054178e2021054178.
Crossref   |   Medline

Rostad CAKamidani SAnderson EJ. Implications of SARS-CoV-2 viral load in children: getting back to school and normal. JAMA Pediatr 2021;175(10):e212022e212022.
Crossref   |   Web of Science   |   Medline

Delahoy MJUjamaa DTaylor CA, et al. Comparison of influenza and COVID-19-associated hospitalizations among children <18 years old in the United States-FluSurv-NET (October-April 2017-2021) and COVID-NET (October 2020-September 2021). Clin Infect Dis 2022 May 20 (Epub ahead of print).
Crossref   |   Web of Science   |   Medline

Centers for Disease Control and Prevention. lnfluenza-associated pediatric mortality. In: FluView interactive (https://gis.cdc.gov/grasp/fluview/pedfludeath.html).

Centers for Disease Control and Prevention. Provisional COVID-19 deaths: focus on ages 0-18 years (https://data.cdc.gov/NCHS/Provisional-COVID-19-Deaths-Focus-on-Ages-0-18-Yea/nr4s-juj3).

Anderson EJCampbell JDCreech CB, et al. Warp speed for coronavirus disease 2019 (COVID-19) vaccines: why are children stuck in neutral? Clin Infect Dis 2021;73:336340.
Crossref   |   Web of Science   |   Medline

Baden LREl Sahly HMEssink B, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med 2021;384:403416.
Free Full Text   |   Web of Science   |   Medline

El Sahly HMBaden LREssink B, et al. Efficacy of the mRNA-1273 SARS-CoV-2 vaccine at completion of blinded phase. N Engl J Med 2021;385:17741785.
Free Full Text   |   Web of Science   |   Medline

Ali KBerman GZhou H, et al. Evaluation of mRNA-1273 SARS-CoV-2 vaccine in adolescents. N Engl J Med 2021;385:22412251.
Free Full Text   |   Web of Science   |   Medline

Creech CBAnderson EBerthaud V, et al. Evaluation of mRNA-1273 Covid-19 vaccine in children 6 to 11 years of age. N Engl J Med 2022;386:20112023.
Free Full Text   |   Web of Science   |   Medline

Baden LREl Sahly HMEssink B, et al. Phase 3 trial of mRNA-1273 during the delta-variant surge. N Engl J Med 2021;385:24852487.
Free Full Text   |   Web of Science   |   Medline

Fowlkes AGaglani MGroover KThiese MSTyner HEllingson K. Effectiveness of COVID-19 vaccines in preventing SARS-CoV-2 infection among frontline workers before and during B.1.617.2 (Delta) variant predominance — eight U.S. locations, December 2020–August 2021. MMWR Morb Mortal Wkly Rep 2021;70:11671169.
Crossref   |   Web of Science   |   Medline

Price AMOlson SMNewhams MM, et al. BNT162b2 protection against the omicron variant in children and adolescents. N Engl J Med 2022;386:18991909.
Free Full Text   |   Web of Science   |   Medline

Tseng HFAckerson BKLuo Y, et al. Effectiveness of mRNA-1273 against SARS-CoV-2 Omicron and Delta variants. Nat Med 2022;28:10631071.
Crossref   |   Web of Science   |   Medline

PPD Laboratories. PPD Laboratories assays for COVID-19 trials (https://www.ppd.com/wp-content/uploads/2020/06/PPD-Laboratories-assays-for-COVID19.pdf. opens in new tab).

Bonhomme MEBonhomme CJStrelow L, et al. Robust validation and performance comparison of immunogenicity assays assessing IgG and neutralizing antibodies to SARS-CoV-2. PLoS One 2022;17(2):e0262922e0262922.
Crossref   |   Web of Science   |   Medline

Meso Scale Diagnostics. V-PLEX SARS-CoV-2 Panel 24 (IgG) kit. 2022 (https://www.mesoscale.com/products/v-plex-sars-cov-2-panel-24-igg-kit-k15575u/).

Prevnar prescribing information. PhiladelphiaPfizer2019 (https://labeling.pfizer.com/showlabeling.aspx?id=501#section-6.1).

ProQuad prescribing Information. Whitehouse Station, NJMerck2018 (https://www.fda.gov/media/75195/download).

Walter EBTalaat KRSabharwal C, et al. Evaluation of the BNT162b2 Covid-19 vaccine in children 5 to 11 years of age. N Engl J Med 2022;386:3546.
Free Full Text   |   Web of Science   |   Medline

Frenck RW JrKlein NPKitchin N, et al. Safety, immunogenicity, and efficacy of the BNT162b2 Covid-19 vaccine in adolescents. N Engl J Med 2021;385:239250.
Free Full Text   |   Web of Science   |   Medline

Food and Drug Administration. Emergency use authorization for vaccines to prevent COVID-19. Guidance for industry. March 312021 (https://www.fda.gov/media/142749/download).

Andrews NStowe JKirsebom F, et al. Covid-19 vaccine effectiveness against the omicron (B.1.1.529) variant. N Engl J Med 2022;386:15321546.
Free Full Text   |   Web of Science   |   Medline

Delahoy MJUjamaa DWhitaker M, et al. Hospitalizations associated with COVID-19 among children and adolescents — COVID-NET, 14 states, March 1, 2020–August 14, 2021. MMWR Morb Mortal Wkly Rep 2021;70:12551260.
Crossref   |   Web of Science   |   Medline

Olson SMNewhams MMHalasa NB, et al. Effectiveness of BNT162b2 vaccine against critical Covid-19 in adolescents. N Engl J Med 2022;386:713723.
Free Full Text   |   Web of Science   |   Medline

Zambrano LDNewhams MMOlson SM, et al. Effectiveness of BNT162b2 (Pfizer-BioNTech) mRNA vaccination against multisystem inflammatory syndrome in children among persons aged 12-18 years — United States, July–December 2021. MMWR Morb Mortal Wkly Rep 2022;71:5258.
Crossref   |   Web of Science   |   Medline

Straus WUrdaneta VEsposito DB, et al. Myocarditis after mRNA-1273 vaccination: a population-based analysis of 151 million vaccine recipients worldwide. November 122021 (https://www.medrxiv.org/content/10.1101/2021.11.11.21265536v1). preprint.

Read the full published article.