Planning ahead

Making decisions when adults are vaccinated and children not.

Here in NYC it's freezing and snowy increasing barriers to the outdoor time and exercise I find so rejuvenating. While we are grateful to have access to in person school, my children are missing their friends - the playdates, the birthday parties, and the activities. We as parents are missing the adult social time and the travel. All of this has me looking ahead and day-dreaming about the future. 

We are at a frankly weird place in the pandemic. Many of my physician colleagues have been championing hope, which is a message I would love to echo and embrace. Vaccines are here in a very real way with nearly 1.5 million Americans getting vaccinated daily and the goal that by April any adult who wants a vaccine should be able to get it. Hopefully, the allocation has also prioritized the individuals who are most likely to experience severe covid requiring hospitalization so we should see these improve before then. This is a game changer!

But in the same breath we can’t ignore the very real issue of these variants. What’s happened in the UK was by all reports rather startling. We know these variants B.1.1.7 (UK), P1 (Brazil) and B.1.351 (South Africa) are likely to be more transmissible. For what it’s worth I am against referring to strains by location of origin given risk of bias against individuals, but I also acknowledge most people don’t have brain space for the numbers.

More transmissible variants mean a faster spread of COVID-19 and another peak of cases this spring. There is no evidence these variants cause worse disease, but more disease is still bad news. Long-term there are concerns about the vaccines being less protective against new variants, though from the beginning we’ve always anticipated this challenge. In the short term, I think the vaccines available in the US are likely to be helpful, even if less effective than the numbers from the original trial.

There are two reasons I’m not panicking about these variants. First, it’s highly likely the same protective measures we are taking now, masking and distancing will slow the spread and protect us even if incompletely. It’s not as if we are burying our heads in the sand and ignoring the possibility of another peak. Many of us are still living a fully mitigated lifestyle doing things like outdoor dining in sub-freezing temperatures.

Secondly, we will have early warning signals. The US has less than ideal viral sequencing program, but it’s expanding rapidly. The CDC’s variant tracking dashboard is informative and shows Florida leading the way, but most states have cases by now. The CDC recommends upgrading your mask, but even if you don’t now, you’ll want to be ready. 

The big warning sign that it’s time to “up your mask game” will be when cases start to increase again after coming down from the holiday peak. A “Super Bowl” surge may complicate this, but increasing cases would be a sign that variants are increasing the spread of COVID in your community. If you have a higher exposure lifestyle it may be worth upgrading your mask now prophylactically. Since everyone asks, my recommendation for a mask upgrade is a KF94 from a reliable vendor such as this one (not affiliated with them, but know they are selling legitimate masks) and for children either disposable surgical masks or Rafi Nova cloth masks are my favorite. Even when upgrading, please keep in mind the importance of fit and purchasing from a reputable vendor.

Many people have asked me to predict the future, but it’s very difficult. A lot of what school year 2021-2022 will look like depends on human behavior. What percentage of people will opt out of vaccination? How high is the surge of cases this spring? I remember the palpable priority during the summer of 2020, “let’s all flatten the curve so our kids can return to school”. I’d like to bend that message to “let’s all get vaccinated so our children’s lives can return to normal sooner!” 

As I mentioned in the prior post, our individual choices matter a lot with regard to vaccination. If adults embrace whatever vaccine they are offered as soon as possible, we’ll be that much closer to the herd immunity that will enable us to relax our precautions and allow our children to resume a more normal life.

This week I shared my understanding of the COVID vaccine timeline, and I do think there is some hope that children twelve and up could be vaccinated before school starts next September, but it seems less likely for the younger children. What I’m concerned about is how we decide to handle our children when our adults are all protected or at least have the option to be protected. So as we imagine what next school year, the fall of 2021, will be like, there are three ways we could choose to handle this.

Extremely Conservative - When children are unvaccinated, groups will have the potential to spread COVID-19. So we could keep most children locked down and fully mitigated until they can be vaccinated. Schools with hybrid models, some students electing remote, masking, with decreased sports. Realistically for my 3 year old this would mean no birthday parties or indoor playdates from the time she was 2-4, but children have done it this long so some would say why not continue until they can all be vaccinated.

The better question is should children have to? We can’t ignore the burden of covid-19 on young people, certainly some children get very sick and even more rarely die, but by and large most, even high risk pediatric patients seem to do fine. Emily Oster tackled this topic in her newsletter recently. While the data makes these comparisons complex and there are unknowns related to long-term consequences of COVID-19, I agree that the risk for most children is low. This analysis emphasizes that the primary reason we shut down the world was not to protect children rather to protect adults particularly those over age 50. 

We have to balance the cost of keeping our kids locked down with the secondary impact of the pandemic on our children - academic delays, physical inactivity, disordered eating, weight gain, anxiety, depression, suicidality, and child abuse are all big concerns. We are charged with weighing an unlikely potential consequence of COVID-19 in children (ie. Being a long-hauler, being one of 10,000 to suffer through MIS-C or having an unusually significant cardiac manifestation) with the likely consequences of continuing COVID-19 lockdowns after adults are vaccinated.

Blasé - What if fall 2021 we revert fully to pre-covid life, what would happen?

We can hope to get numbers really low by the end of summer, but if we return to crowded indoor activities unmasked there would be spread of COVID-19 among children which would cause some children to experience negative outcomes from COVID-19.

If adults are fully vaccinated, despite the spread among children, the overall spread would be unlikely to reach the exponential levels we have seen since on average each child would spread to fewer individuals.

However with vaccine hesitancy, if adults do not get vaccinated and gain protective immunity, the spread amongst children would result in significant community spread again.

More cases would result in more pressure for COVID-19 to infect adults with incomplete protection and to evolve to evade immunity from prior exposure or vaccination. Every family where the parents are vaccinated and the children get it will be an opportunity for the virus to “learn” a way to spread - potentially increasing the risk of a mutated form getting past the parent’s immunity. Children’s cases would “test” the effectiveness of the adult vaccines in a way that could cause harm, particularly if the vaccines are less effective with the new variants or if immunity wanes before boosters are available. More than the direct risk to children, this systemic risk is the one I worry about.

A middle ground - If you have followed me for a long time, you know I am all about the nuance, and this is a highly complex situation. As a pediatrician, at many times this pandemic I have felt frustrated. The political affiliation of states has driven policy instead of science. I know that some places like Texas, Florida, and Iowa for example are eager to resume regular life and in some ways have. Totally ignoring spread could backfire by allowing variants to emerge eluding our attempts at herd immunity. Other places like California, New York, and Illinois have been more aggressive about their precautions, but in doing so have asked children pay greater costs. 

The magnitude of difference is really staggering. I saw a discussion on Twitter that estimated children in red states are 3x more likely to have 5 day a week in person school (62% vs 20%)  as compared to blue states where 4x as many children are 100% remote (44% vs 12%). 

If I was in charge, I would try to navigate this middle ground and responsibly maximize children’s return to regular life. What this means will be different within communities and within families, but looking for opportunities to make things better for children when it’s reasonably safe. 

When rates of vaccination are up and disease spread are down, decreasing masking at young ages or within fixed cohorts, increasing in-person education and children’s sports and activities particularly in situations where we can use cohorting, testing and ventilation as adjunctive measures to mitigate risk. 

As a parent, the adults being vaccinated will be a huge relief. Once the grandparents, parents and caregivers are vaccinated (2 weeks after the second shot), they should be able to visit freely in small consistent groups without quarantining even if the children are unvaccinated. Spread is possible from vaccinated individuals particularly if the variants mentioned above be spreading in a big way, but it’s less likely. While at a population level we need to see sufficient improvements in community spread and higher numbers of vaccinated individuals to change our measures, within our households we can make these decisions with confidence. 

Overall I think in the pandemic, children’s wellbeing has been an afterthought and they deserve more. We have an opportunity to approach this very complex decision of how to treat unvaccinated children once vaccines are freely available for adults, and I think we should plan now to maximize children’s freedom and return to “regular life” next school year. I feel confident we can navigate a middle ground to do so responsibly.

Let me know what you think by leaving a comment!