March 31, 2021
Dear Members of the Baylor College of Medicine Community,
One of benefits I have enjoyed from writing these weekly updates on our pandemic experience is the feedback I receive from readers.
Like all of us, I see the real-time events before us through the lens of my own experience. On many occasions, feedback from readers – praise and criticism, agreement and discordance – has helped me reshape my lens and hopefully broaden my perspective. I have learned elements of this crisis has been a universally shared experience. However, often the impact has been intensely personal and unique to individual circumstances.
Two bits of feedback this week helped to shift my thinking. The first was from a friend who sent me a splash page screenshot of a major national news outlet with side-by-side links to two stories. The first, an interview with Dr. Rochelle Walensky:
CDC chief warns U.S. headed for 'impending doom' as Covid cases rise again: 'Right now I'm scared.' The second, adjacent interview, was from former FDA director Dr. Scott Gottlieb: U.S. COVID vaccinations at 'tipping point' of helping turn the tide in pandemic. A few weeks ago, I wrote a piece on how to pick your pundit. Walensky and Gottlieb clearly check all the boxes as credible sources of information – truly accomplished leaders in their fields, interviewed by a hard news outlet. Although the full interviews were more nuanced than the headlines, the overall tone and messaging could not have been more different. Is it any wonder the lay general public has difficulty knowing what to think?
The second message I received this week was not from a lay person, but a highly educated and scientifically sophisticated Baylor faculty member, in response to last week's message: Back to Normal? As I wrote this, the vision of normal I carried in my head was the elimination of masking and distancing requirements in the workplace, relaxation of travel restrictions and return to non-distanced dining and entertainment. My conclusion was that now is not the time to make major return-to-normal steps, but we will likely get there soon – I think by this summer. In response to that e-mail, our faculty member wrote to me the following:
"… I am writing you as the mother of two young children who will not have access to vaccine anytime in the near future. I am curious what message you would share with those of us with young kids … yes, the vaccine is becoming more widely available to adults, and hopefully we will see widespread community vaccination. However, our children still remain at risk. While the morbidity and mortality in pediatrics has not been close to what we see in the adult population, disease in children is certainly not without consequence."
This is an important question, and to be honest, when I was writing about "return to normal" – through my grown-children-and-preschool-grandchildren frame of reference – one I did not consider. This week I would like to remedy this by reflecting on the timing of return to normal for children. When should you return to a normal classroom environment, if it is available? What about extracurricular activities? Social events? Sleepovers? Going out for family Sunday brunch?
Unfortunately, if you are looking for a credible authority figure to blow the "all clear" whistle to resume our normal lives, you will be waiting a very long time. The decision to ease back into normalcy for children will be made by parents and based on balancing the benefits of resuming normal activities against the risk of becoming seriously ill.
First, I think it is important to think deeply about the benefits of resuming activities for your child, as every situation is different. Is your child thriving in the virtual learning environment or – as many are – struggling? What teacher-mentorship relationships have been lost in virtual learning? What is the impact of sustained restrictions on their mental health and well-being? How concerned are you about lack of socialization and development? How important are extracurriculars to your child? What major social milestones are they missing (e.g., dances, proms, senior year events). In caring for a child at home, how disruptive has this been to your family's ability to go to work and earn a living? It is very important to acknowledge these are critical, non-trivial questions that will have different answers for every child and family and must be included in any risk-benefit analysis.
Second, the risk to children is far, far lower than in adults, but it is not zero. Children, particularly young children, are less likely to become infected, less likely to be symptomatic if infected, and far less likely to develop severe symptoms. Spend some time studying the following chart that stratifies new cases and deaths by age: COVID-19 Weekly Cases and Deaths per 100,000 Population by Age, Race/Ethnicity, and Sex.
Week to week, the rate of new cases and deaths in children on a per 100,000 population basis, carried out to two decimal places, often rounds to zero. To be sure, it is not zero. Children do develop severe COVID-19 infections, they can become critically ill and they can have severe outcomes. There are currently children in Houston area ICUs due to COVID-19 infections. As children reach their teen years, their risk steadily increases until it reaches young adult levels. On a statistical basis it is highly unlikely that your child will become critically ill. As a parent, I know every time your child walks out the door you think about all the terrible things that might happen – accidents, acts of violence. Thankfully, they rarely happen, but you do accept that risk as a necessary part of living in the world.
Third, we are still in a relatively high-prevalence viral environment. After a few weeks of decline, we have actually seen the national new case rate move up, largely driven by states in the northeast. In Houston, our daily case rate is in a month-long plateau, while hospitalizations continue to drift downward, likely due to our success in vaccinating people at-risk. The test positivity rate for Harris County is 8.6%. In a truly low prevalence environment, when we are at or approaching herd immunity, we should see new case rates drop sharply. Case positivity rates should drop well below 5%. You will start to see news stories about hospitals discharging their last COVID-19 patient. We are not yet in a low prevalence environment.
Fourth, when will your child be able to get vaccinated? Currently you can receive the Pfizer vaccine if you are 16 or older, Moderna at 18 or above. Clinical trials are underway in children and adolescents for all the available vaccines, and Pfizer just announced (via press release, not peer-reviewed publication) that their initial results in adolescents show the vaccine is highly effective. It may be possible we have an adolescent vaccine by the fall, but we will not see broad availability of child and adolescent vaccines until sometime in 2022.
In light of the above (continuing to hunker down has real cost, COVID-19 risk to children is very low but not zero, we remain in a relatively high prevalence state, and we do not currently have a vaccine for children), how do you make a decision as a parent?
Let us first acknowledge that this is hard, and a decision no parent wants to be forced to make. Parents should not feel guilt about making the wrong decision, as I honestly do not think there is a right or wrong answer at this point. The reality is the overwhelming majority of children and adolescents will come through the pandemic and be fine.
This analogy will be lost on many younger than me, but I remember going with my dad to buy tools at Sears. If we needed a hammer, we could choose between "good, better and best." The good version was perfectly serviceable, the best was $10 more expensive with a titanium re-enforced handle. No wrong choice. In terms of making a decision about your children, I think it we should consider "safe, safer and safest."
Start to relax restrictions on your child's activities. Based on the fact they are statistically less likely to develop severe illness, do not overly obsess on micromanaging the safety and design of every place they will be. Continue to encourage masking and distancing, as we all should at this point. Emphasize with them the importance of personal responsibility. In the current environment this is not a wrong decision. In my own personal risk-benefit analysis – as I look at my grandchildren – for me it is a little aggressive.
Actively promote a cautious return to activities (school, extracurriculars, community activities, social activities). Spend some time with your child listing the activities they need to resume and develop a means of prioritization. Return to face-to-face school and childcare seems to be high on the list. How important are after school activities? Sports? Face-to-face contact with friends?
Once you have your list, spend some time thinking about the safe design of the environment. Is there evidence that they (school, daycare, coach, family down the street) are taking the pandemic seriously, and putting reasonable safety measures in place? Has all the adult staff been vaccinated? Gradually reintroduce activities. This is where I land today in my personal decision-making process.
Continue to restrict activities and face-to-face interactions until we reach a low prevalence environment, and vaccines are available for children. This is clearly the safest option to prevent infection with COVID-19, but comes with significant, real cost. The titanium-handled hammer may be the "best," but there is a limit to what I am willing to pay. For most parents, I suspect the prospect of an additional six months or more of tightly restricted activity will be unstainable and come at an unacceptable price.
I truly wish this was a simpler process, but few things in the past year have been simple. Parents have been unsung heroes through the pandemic, working to preserve and protect the next generation. We owe you all a profound debt of gratitude.
James T McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs
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