Grading of Recommendations, Assessment, Development, and Evaluation (GRADE): Moderna COVID-19 Vaccine for Children Aged 6–11 Years
A Grading of Recommendations, Assessment, Development and Evaluation (GRADE) review of the evidence for benefits and harms for Moderna coronavirus disease 2019 (COVID-19) vaccine for children aged 6–11 years was presented to the Advisory Committee for Immunization Practices (ACIP) on June 23, 2022. GRADE evidence type indicates the certainty in estimates from the available body of evidence. Evidence certainty ranges from type 1 (high certainty) to type 4 (very low certainty) .
The policy question was, “Should vaccination with Moderna COVID-19 vaccine (2 doses, 50 µg) be recommended for children 6–11 years of age during an Emergency Use Authorization?” The potential benefits pre-specified by the ACIP COVID-19 Vaccines Work Group included prevention of symptomatic laboratory-confirmed COVID-19 (critical), hospitalization due to COVID-19 (important), multisystem inflammatory syndrome in children (MIS-C) (important), and asymptomatic SARS-CoV-2 infection (important). The two pre-specified harms were serious adverse events (SAEs) (critical) and reactogenicity grade ≥3 (important).
A systematic review of evidence on the efficacy and safety of a two-dose regimen of Moderna COVID-19 vaccine among children aged 6–11 years was conducted. The quality of evidence from one Phase II/III randomized controlled trial was assessed using a modified GRADE approach .
Symptomatic COVID-19 was less common among the vaccine group compared with the placebo group (RR: 0.19; 95% CI: 0.05, 0.81; evidence type 2). A non-inferior geometric mean ratio (GMR) for antibodies in the 6–11-year-olds was observed with vaccination compared to the 18–25-year-olds (GMR 1.2, 95% confidence interval [CI]: 1.1, 1.4; evidence type 2). A lower risk of asymptomatic SARS-CoV-2 infection also seen in the vaccine group compared with the placebo group (Relative Risk [RR]: 0.29; 95% CI: 0.12, 0.71; evidence type 3). The available data indicated that SAEs were balanced between the vaccine and placebo arms, but certainty in the estimate was very low (RR 0.99; 95% CI: 0.20, 4.91; evidence type 4); none of these SAEs were assessed by the Food and Drug Administration (FDA) as related to study intervention. Reactogenicity grade ≥3 was associated with vaccination (RR 5.2; 95% CI: 3.6, 7.3; evidence type 1). About 17% of vaccine recipients and 3% of placebo recipients reported any grade ≥3 local or systemic reactions following either dose 1 or dose 2.
On June 17, 2022, the FDA updated the Emergency Use Authorization (EUA) for Moderna (mRNA-1273) vaccine for prevention of symptomatic COVID-19 to include children aged 6–11 years . As part of the process employed by the ACIP, a systematic review and GRADE evaluation of the evidence for Moderna COVID-19 vaccine was conducted and presented to ACIP. The ACIP adopted a modified GRADE approach in 2010 as the framework for evaluating the scientific evidence that informs recommendations for vaccine use. Evidence of benefits and harms were reviewed based on the GRADE approach .
The policy question was, “Should vaccination with Moderna COVID-19 vaccine (2 doses, 50 µg) be recommended for persons 6–11 years of age during an Emergency Use Authorization?” (Table 1).
We conducted a systematic review of evidence on the efficacy and safety of a two-dose regimen (50 µg per dose) of Moderna COVID-19 vaccine. We assessed outcomes and evaluated the quality of evidence using the GRADE approach.
During Work Group calls, members were asked to pre-specify and rate the importance of relevant patient-important outcomes (including benefits and harms) before the GRADE assessment. No conflicts of interest were reported by CDC and ACIP COVID-19 Vaccines Work Group members involved in the GRADE analysis. Outcomes of interest included individual benefits and harms (Table 2). The critical benefit of interest was prevention of symptomatic laboratory-confirmed COVID-19. Other important outcomes included prevention of hospitalization due to COVID-19, prevention of MIS-C, and prevention of asymptomatic SARS-CoV-2 infection. The critical harm of interest was serious adverse events, including death; reactogenicity grade ≥3 was deemed an important harm. Hospitalization, and MIS-C were not included in the evidence profile because no data were available.
We identified clinical trials through clinicaltrials.gov. Records of relevant Phase I, II, or III RCTs of COVID-19 vaccine were included if they 1) provided data on children aged 6–11 years vaccinated with mRNA-1273; 2) involved human subjects; 3) reported primary data; and 4) included data relevant to the efficacy and safety outcomes being measured. We identified relevant observational studies through an ongoing systematic review conducted by the International Vaccine Access Center (IVAC) and the World Health Organization (WHO) . Relevant observational studies were restricted to the defined population, intervention, comparison, and outcome outlined in the policy question, or related outcomes if direct data were not available. In addition, unpublished and other relevant data were obtained by hand-searching reference lists, and consulting with vaccine manufacturers and subject matter experts. The systematic review was limited to studies published from January 1, 2020 to April 29, 2022. Characteristics of all included studies are shown in Appendix 1 and evidence retrieval methods are found in Appendix 2.
Relative risks (RR) were calculated from numerators and denominators available in the body of evidence. Vaccine efficacy estimates were defined as 100% x (1-RR). Immunobridging data comparing geometric mean neutralizing antibody titers (GMTs) in 6–11-year-olds were compared to those in 18–25-year-olds in whom clinical efficacy was previously established.
The evidence certainty assessment addressed risk of bias, inconsistency, indirectness, imprecision, and other characteristics. The GRADE assessment across the body of evidence for each outcome was presented in an evidence profile; the evidence certainty of Type 1, 2, 3, or 4 corresponds to high, moderate, low, or very low certainty, respectively.
The results of the GRADE assessment were presented to ACIP on June 23, 2022. One study was reviewed that provided data on outcomes specified for GRADE (Appendix 1). Data were reviewed from one Phase II/III randomized controlled trial using data provided by the sponsor . Symptomatic, laboratory-confirmed COVID-19 was less common among the vaccine group compared with the placebo group (RR: 0.24; 95% CI: 0.05, 1.08) (Table 3a, Table 4); serious concern for imprecision was noted due to fragility in the estimate because there were only 8 events observed from a single RCT. The immune response to the Moderna COVID-19 vaccine among adolescents aged 6–11 years was non-inferior (GMR: 1.2; 95% CI: 1.1, 1.4) to the immune response among adults aged 18–25 years receiving the Moderna COVID-19 vaccine in whom clinical efficacy had been established (Table 3b). Serious concern for indirectness was noted because immunogenicity is an indirect measure of vaccine efficacy for the critical outcome of symptomatic, lab-confirmed COVID-19. A lower risk of asymptomatic SARS-CoV-2 infection was also seen in the vaccine group compared with the placebo group (RR: 0.29; 95% CI: 0.12, 0.71), based on an analysis of seronegative participants with SARS-CoV-2 positive PCR test results from nasopharyngeal swabs collected 28 days after the second vaccine dose and at unscheduled visits (Table 3c). Serious concern for indirectness was noted because the outcome of interest was asymptomatic infection assessed with serial PCR testing for SARS-CoV-2 or seroconversion to a non-spike protein and the available evidence represent SARS-CoV-2 testing of the full cohort at a single point in time. Additionally, serious concern for imprecision was noted due to fragility in the estimate because there were only 19 events observed from a single RCT.
For evaluation of potential harms, data were reviewed from the Phase II/III randomized controlled trial. Serious adverse events were balanced between the vaccine and placebo arms, but certainty in the estimate was very low (RR 0.99; 95% CI: 0.20, 4.91). There was serious concern of indirectness because the body of evidence does not provide certainty that rare serious adverse events were captured due to the short median follow-up of 51 days after dose 2. There was also very serious concern for imprecision, due to the width of the confidence interval. No SAEs were judged by FDA to be related to vaccination (Table 3d). There were no cases of vaccine-associated enhanced disease or deaths. Grade ≥3, or severe, local or systemic reactions within 7 days following either vaccination, were reported by 17.1% of vaccine recipients, and occurred more frequently in the vaccine than placebo group (Table 3e). No serious concerns impacted the certainty of the estimate of reactogenicity.
The initial GRADE evidence level was type 1 (high) for each outcome because the body of evidence was from randomized controlled trials. In terms of benefits, the available data indicated that the vaccine was efficacious for preventing symptomatic COVID-19; serious concern for imprecision was noted due to fragility in the estimate because there were only 8 events observed from a single RCT (type 2, moderate certainty). The available immunobridging data indicated that the immune response among 6–11-year-olds was non-inferior to that of 18–25-year-olds, a group in which efficacy has been established. This immunobridging outcome serves as an indirect measure of prevention of symptomatic COVID-19 (type 2, moderate certainty). A lower risk of asymptomatic SARS-CoV-2 infection also seen in the vaccine group compared with the placebo group and the certainty estimate was downgraded once for indirectness and once for imprecision (type 3, low certainty). The certainty in the estimate of the effect for serious adverse events was downgraded one point due to serious concern of indirectness related to the median 51-day follow-up and two points for imprecision due to the width of the 95% confidence interval (type 4, very low certainty). No serious concerns impacted the certainty in the estimate of reactogenicity (type 1, high certainty) (Table 4).
- Ahmed F. U.S. Advisory Committee on Immunization Practices (ACIP) Handbook for Developing Evidence-based Recommendations[52 pages].
- Moderna, 2022. Personal communication, March 22 – May 26, 2022.
- Food and Drug Administration. Moderna COVID-19 Vaccine Emergency Use Authorization. Moderna COVID-19 Vaccine EUA Letter of Authorization 03292022 (fda.gov). Accessed June 21, 2022.
- International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. VIEW-hub. www.view-hub.org. Accessed: 4/29/2022.
|Policy question:||Should vaccination with Moderna COVID-19 vaccine (2-doses, IM) be recommended for adolescents aged 6–11 years?|
|Population||Children aged 6–11 years|
|Intervention||Moderna COVID-19 vaccine mRNA-1273 (50 μg, 2 doses IM, 28 days apart)|
|Comparison||No Moderna COVID-19 vaccine|
|Outcomes||Symptomatic laboratory-confirmed COVID-19
Hospitalization due to COVID-19
Multisystem inflammatory syndrome in children (MIS-C)
Asymptomatic SARS-CoV-2 infection
Serious adverse events
Reactogenicity grade ≥3
Abbreviations: IM = intramuscular.
|Outcome||Importance||Included in evidence profile|
|Symptomatic laboratory-confirmed COVID-19||Critical||Yes|
|Hospitalization due to COVID-19||Important||Noa|
|Multisystem inflammatory syndrome in children (MIS-C)||Important||Noa|
|Asymptomatic SARS-CoV-2 infection||Important||Yes|
|Serious adverse events||Critical||Yes|
|Reactogenicity grade ≥3||Important||Yes|
aNo events were observed in study identified in the review of evidence.
|Authors last name, pub year||Age or other characteristic of importance||n/N intervention||n/N comparison||Comparator||Vaccine Efficacy (95% CI) [100 x (1-RR)]||Study limitations (Risk of Bias)|
|Moderna, 2022 a||SARS-CoV-2 RT-PCR-positive symptomatic illnessb, in seronegative or seropositive persons aged 6–11 years, ≥14 days post second dose||3/2980||5/966||Placebo||80.6% (18.8%, 95.3%)||Not serious|
Abbreviations: RT-PCR = real-time polymerase chain reaction; CI = confidence interval; RR = relative risk.
aBased on data cutoff November 10, 2021; participants had a median of almost 2 months of follow-up
bRT-PCR symptomatic illness defined as: a positive post-baseline PCR result, and one or more of the following symptoms: fever (temperature ≥38ºC), chills, cough, shortness of breath, difficulty breathing, fatigue, muscle aches, body aches, headache, new loss of taste or smell, sore throat, nasal congestion, rhinorrhea, nausea, vomiting, or diarrhea
Table 3b: Summary of Studies Reporting Symptomatic Laboratory-confirmed COVID-19 (assessed using immunobridging)
|Authors last name, pub year||Age or other characteristic of importance||n
|Met Noninferiority Objectived||Study limitations (Risk of Bias)|
|Moderna, 2022 a||Pseudovirus neutralizing antibody level by pseudovirus neutralizing assay (ID50) Pseudovirus neutralizing antibody level by pseudovirus neutralizing assay (ID50)b||319||295||1.2 (1.1, 1.4)||Yes||Not serious|
Abbreviations: GMR= geometric mean ratio; CI = confidence interval; LLOQ = lower limit of quantitation
aImmune response was measured at Day 57
bAmong participants immunologic or virologic evidence of prior COVID-19 (i.e., negative NP swab test at Day 1 and/or binding antibodies against SARS-CoV-2 nucleocapsid below limit of detection or lower limit of quantification) at Day 1 before the first dose of IP.
cGMRs and 2-sided 95% CIs were calculated by exponentiating the mean difference of the logarithms of the titers (Group 1 [6–11 years] – Group 2 [18–25 years]) and the corresponding CI (based on the Student t distribution).
dNoninferiority is declared if the lower bound of the 2-sided 95% CI for the GMR is greater than 0.67.
|Authors last name, pub year||Age or other characteristic of importance||n/N (%) intervention||n/N (%) comparison||Comparator||Vaccine Efficacy (95% CI) [100 x (1-RR)]||Study limitations (Risk of Bias)|
|Moderna, 2021 ||SARS-CoV-2 RT-PCR positive among asymptomatic persons 28 days after dose 2, or at unscheduled study visits, among participants with negative SARS-CoV-2 serology at baseline||9/2644||10/853||Placebo||71.0% (28.8%, 88.1%)||Not serious|
Abbreviations: RT-PCR = real-time polymerase chain reaction; CI = confidence interval; RR = relative risk
|Authors last name, pub year||Age or other characteristic of importance||nc/Nd (%) intervention||nc/Nd (%) comparison||Comparator||RR (95% CI)||Study limitations (Risk of Bias)|
|Moderna, 2022 ||Persons aged 6–11 years||6/3007 (0.2%)c||2/995 (0.2%)c||Placebo||0.99 (0.20, 4.91)||Not serious|
Abbreviations: RR = relative risk; CI = confidence interval; RCT = randomized controlled trial.
aDeath, life-threatening event, inpatient hospitalization or prolongation of existing hospitalization, persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions, medically important event, or congenital anomaly/birth defect
bSerious adverse events followed a median of 51 days after dose 2
cNumber of participants experiencing SAEs (participants may experience more than one SAE)
dIncluded all randomized participants who received at least 1 dose of vaccine.
|Authors last name, pub year||Age or other characteristic of importance||n/N (%) intervention||n/N (%) comparison||Comparator||RR (95% CI)||Study limitations (Risk of Bias)|
|Moderna, 2022 ||Persons aged 6–11 years||514/3006 (17.1%)||33/994 (3.3%)||Placebo||5.2 (3.6, 7.3)||Not serious|
Abbreviations: RR = relative risk; CI = confidence interval; RCT = randomized controlled trial.
aReactogenicity outcome includes local and systemic events, grade ≥3. Grade 3: prevents daily routine activity or requires use of a pain reliever. Grade 4: requires emergency room visit or hospitalization. One participant in the vaccine group reported grade 4 pyrexia (40.4 °C).
|Certainty assessment||№ of patients||Effect||Certainty||Importance|
|№ of studies||Study design||Risk of bias||Inconsistency||Indirectness||Imprecision||Other considerations||Moderna COVID-19 vaccine, 50 mcg, 2 doses 28 days apart||No vaccine||Relative (95% CI)||Absolute (95% CI)|
|Symptomatic laboratory-confirmed COVID-19|
|1||RCT||not seriousa||not serious||not serious||seriousb||none||3/2980 (0.1%)||5/966 (0.5%)||RR 0.19
(0.05 to 0.81)
|4 fewer per 1,000
(from 5 fewer to 1 fewer)
|Symptomatic laboratory-confirmed COVID-19 (assessed with immunobridging)|
|1||RCT||not seriousa||not serious||seriousc,d||not serious||none||-/319||-/295||Not estimablee||— per 1,000
(from — to –)f
|Asymptomatic SARS-CoV-2 infection|
|1||RCT||not seriousa||not serious||seriousc,g||not serioush||none||9/2644 (0.3%)||10/853 (0.9%)||RR 0.29
(0.12 to 0.71)
|832 fewer per 100,000
(from 1,032 fewer to 340 fewer)i
|Serious adverse events|
|1||RCT||not seriousa||not serious||seriousc,j||very seriousk||none||6/3007 (0.2%)||2/995 (0.2%)||RR 0.99
(0.20 to 4.91)
|2 fewer per 100,000
(from 161 fewer to 786 more)i
|Reactogenicity, grade ≥3|
|1||RCT||not serious||not serious||not seriousc||not serious||none||512/3006 (17.0%)||33/994 (3.3%)||RR 5.2
(3.6 to 7.3)
|13,944 more per 100,000
(from 8,632 more to 20,915 more)h
|Type 1 High||IMPORTANT|
Abbreviations: CI = confidence interval; RR = relative risk; COVID-19 = coronavirus disease 2019; RCT = randomized controlled trial.
- Risk of bias related to blinding of participants and personnel was present. Although participants and study staff were blinded to intervention assignments, they may have inferred receipt of vaccine or placebo based on reactogenicity. This was deemed unlikely to overestimate efficacy or underestimate risk of serious adverse events, therefore the risk of bias was rated as not serious.
- Serious concern of imprecision due to fragility in the estimate was present because there were only 8 events observed from a single RCT.
- The RCT excluded persons with prior COVID-19 diagnosis or a medical or psychiatric condition that, according to the investigator’s judgment, may pose additional risk as a result of participation, interfere with safety assessments, or interfere with interpretation of results. The population included in the RCT may not represent all persons aged 6-11 years.
- Indirectness noted because immunogenicity is an indirect measure of efficacy. Symptomatic COVID-19 was less common among the vaccine group compared with the placebo group (RR: 0.2; 95% CI: 0.05, 1.08), however this was not used as the formal GRADE outcome due to very serious concern for imprecision in the estimate.
- The immune response to vaccine was evaluated using the geometric mean titer ratio of adolescents to young adults. Non-inferiority criteria are met when the lower bound of the 95% confidence interval for the ratio comparing the geometric mean neutralizing antibody titer for the two groups is not less than a pre-set value, which for this study was 0.67. The immune response to vaccine in children aged 6-11 years (GMT: 1610.2 [1456.6, 1780.0]) was noninferior to that observed in young adults aged 18-25 years (GMT: 1299.9 [1171.2, 1442.7]), with a geometric mean ratio of 1.24 (1.07-1.43), based on SARS-CoV-2 neutralization titers at 1 month after dose 2, in participants without prior evidence of SARS-CoV-2 infection.
- Absolute effect not applicable for immunobridging outcome.
- Serious concern for indirectness was noted. The intended outcome was asymptomatic infection assessed with serial PCR testing for SARS-CoV-2 or seroconversion to a non-spike protein. Data are presented from an analysis of participants with SARS-CoV-2 positive PCR test results from nasopharyngeal swabs collected 28 days after the second vaccine dose or at unscheduled visits, among persons who were seronegative at baseline and did not report COVID-19 symptoms after dose 1. Additionally, seroconversion data are included on a subset of participants (n=510). The available evidence are indirect because they represent SARS-CoV-2 testing of the full cohort at a single point in time.
- Serious concern of imprecision due to fragility in the estimate was present because there were only 19 events observed from a single RCT.
- Absolute risk was calculated using the observed risk among placebo recipients in the available body of evidence. Absolute risk estimates should be interpreted in this context.
- Serious concern of indirectness was noted. The body of evidence does not provide certainty that rare serious adverse events were captured due to the median 51-day follow-up after dose 2.
- Very serious concern for imprecision was noted based on the confidence interval containing estimates for which different policy decisions might be considered and failure to meet minimum information requirements
|Last name first author, Publication year||Study design||Country (or more detail, if needed)||Population||Total population||N Intervention||N comparison||Outcomes||Funding source|
|Moderna, 2022 ||Phase II/III RCT||USA||Persons aged 6–11 years||
Abbreviations: RCT = randomized controlled trial; COVID-19 = coronavirus disease 2019.
|Clinicaltrails.gov||Inclusion: Relevant Phase 1, 2, or 3 randomized controlled trials of COVID-19 vaccine
Additional resources: Unpublished and other relevant data by consulting with vaccine manufacturers and subject matter experts
|International Vaccine Access Center (IVAC)||Inclusion criteria for IVAC systematic review:
Vaccine effectiveness estimate calculated comparing vaccinated to unvaccinated**
Additional criteria for GRADE review:
a. Most recent search conducted April 29, 2022.