Protect Kids From Delta
As I wrote last week, CDC’s messaging about the Provincetown outbreak and their updated guidance has (naturally) put parents of unvaccinated kids into a tailspin.
(Warning: this is a long post, so grab a drink and some snacks!)
The short story on the CDC’s guidance? The agency now recommends masks indoors for vaccinated people in areas where the risk of transmission is "substantial" or "high" due to the remote possibility of asymptomatic (non-sick) vaccinated people transmitting the virus to others. As a result of this change — plus the deluge of Delta news — parents and caregivers are understandably worried about unwittingly transmitting coronavirus to their unvaccinated kiddos.
To allay fears and add some perspective, let’s start with the facts.
We know that Delta is more contagious than other variants. As a result, more unvaccinated folks are getting COVID-19. Vaccinated people are getting breakthrough infections, though in general these cases are rare compared to people who are unvaccinated. Breakthrough cases also tend to be mild-to-moderate, and only a tiny percentage of vaccinated people who get COVID will land in the hospital.
So do vaccinated people now need booster shots to protect ourselves and our kids?
No. But the FDA and CDC are soon expected to approve a third vaccine dose for immunocompromised patients only. This is completely appropriate and will spare my patients who are on chemotherapy from the moral anguish over telling fibs to the pharmacist!
And just last week, the first study testing the real-world effectiveness of the J&J shot against Delta was released. It showed that a single-dose of J&J provides excellent protection against death and hospitalization from Delta — and that breakthrough infections produced mild symptoms in 96% of cases and resulted in severe disease or death in less than 0.05%. No booster shot needed. Amazing news!
What about viral transmission from vaccinated people?
We know that it’s possible for sick, vaccinated people to transmit the virus to other people. This is true for any virus: that sick people are contagious. It’s also possible — just unlikely — for vaccinated people without symptoms to transmit the virus in enough of an amount to significantly sicken other people. New data from Singapore shows us just how uncommon asymptomatic transmission from vaccinated people is. And if that does happen, it would likely be more common within households where viral transmission has always been more common (for COVID or for any other virus).
Transmission within households — where we’re up close and unmasked — is many parents’ biggest worry. However, transmission within a household is still not as high as you might imagine. Even with Delta, Public Health England estimates about 12% transmission to household members (versus 8.6% with the ancestral strain of coronavirus). Of course, this is an average and does not distinguish between vaccinated and unvaccinated, or between children.
A previous analysis (published when the original strain was circulating) found that asymptomatic transmission in a household was extremely low (0.7%). For anecdotal evidence, recall that no other McBride family member got sick — or even tested positive — from my husband's COVID infection back in November 2020. The upshot? If someone in your household gets sick — whether they are vaccinated or not — isolating them from others reduces the risk of forward transmission. If isolation within a home isn’t possible, masking a sick person and treating their cough can help.
The other upshot? Get everyone vaccinated who’s eligible. A more recent UK study (when the Alpha strain was predominant) found that vaccination with just one dose reduced household transmission by 40-50%.
What does Delta really mean for kids?
The truth is that Delta is highly contagious but (so far) not thought to be more severe. A robust study of nearly 260,000 children (1,700 with symptoms) in the UK, published last week, reminds us that for most kids, COVID-19 will manifest as the common cold. This study from July showed that approximately half of infected kids will have no symptoms at all.
This is not to dismiss the very real spikes in pediatric hospitalizations around the country — most notably in areas with low vaccine uptake. The impact on kids and families in this hot spots is enormous — not to mention the strain on hospital systems and workers.
The highest risk groups appear to be newborns through age 4 years. It’s important to note that pediatric hospitalizations are not only from COVID; we’re witnessing a resurgence of three other respiratory viruses that have spiked since the lifting of pandemic precautions. RSV, a common virus that presents as a cold for most people, can be particularly dangerous in young children (ages 0-4) and currently is driving much of the need for hospital care in this cohort. In the meantime, other age groups (ages 5-17) appear to have hospitalization rates which are remaining relatively steady.
What can we do to protect our kids?
Parents are understandably wondering what, if anything, they can do differently to protect children while allowing them to have a fairly normal end of summer. Many of us are in the middle of short summer vacations to see family after months of quarantine. What does all this mean for the unvaccinated and higher-risk loved ones?
First, kids need to be kids.
Kids need camps, sports, school, and other kids for their health and well-being. Families also need time together. Despite the concerning news about the Delta variant, we know well how to protect unvaccinated kids and others who may have high risk conditions in our households.
It’s the absence of regular social interaction — plus ongoing restrictions and fear — that have contributed to the emotional distress of many young people. This weekend, Professor Emily Oster and I together wrote about a letter we jointly received from an insightful and empathic director of an overnight camp and his concerns about the mental health toll of the pandemic on kids, families, and teachers as we approach the school year. It is excellent food for thought, and I hope you give it a read here.
Here is what I’m telling my patients with vaccine-ineligible kids under the age of 12:
The vast majority of children who are generally healthy will experience COVID-19 like a common cold. For most, unmasked interactions with other kids, even if unvaccinated, will be fine.
Unvaccinated kids who have underlying health conditions (like diabetes, heart conditions, obesity, etc), however, are indeed at higher risk. These children in particular deserve to feel safe and to be shielded with every proven mitigation measure, namely:
Surround kids with vaccinated or naturally immune adults. Those who have recovered from COVID-19 have natural immunity, but a single dose of vaccine for these folks will boost antibody levels and provide a head start against Delta’s impressive viral replication. (To me, schools are arguably the most logical place for an adult vaccine mandate in order to protect our most vulnerable kids from COVID-19.)
If under the weather, stay home until symptoms subside. In the past, many of us pushed through the common cold unless we had a fever. Society may revert to this workaholic habit again, but for now symptoms should be a warning sign that your body is fighting something, and it would be wise to keep the contagion away from schools, workplaces and loved ones.
Get a rapid antigen test to detect infectious levels of coronavirus. The rapid antigen tests (like the over-the-counter “Binax Now”) are excellent at picking up cases of COVID-19 in sick people during the stretch of time when we can infect other people. These tests look for the spike protein (antigen) in the nose and are 99% specific — which means that a negative test is a true negative. In short: in a sick person — vaccinated or not — a rapid antigen test can be considered a “COVID contagiousness” test. If negative, you can feel very good that the sniffles/cough are not from COVID. That said, be sure to always call the pediatrician!
Common sense strategies include ventilation and hand hygiene. When indoors, continue to use good basic hygiene and ventilation to promote dilution. Use a fan and open windows. Spend time outside whenever possible. The great outdoors are naturally ventilated and safe.
Masks? Again, it’s still unclear if and how much masks help to reduce infection and transmission, particularly with kids. It’s very difficult to prove that masking helps prevent viral spread from kids when:
so many kids (30-40% in this study; 50% in another) who are infected with coronavirus are asymptomatic,
asymptomatic transmission is half as likely as symptomatic transmission,
very few clusters of COVID seem to originate from a pediatric case, and
data from the UK shows that transmission among unmasked kids in school was < 2%.
That said, it’s certainly possible that masks help under certain conditions and if they’re well-fitted, but the reality is that most people — especially kids! — don’t wear masks terribly well.
Level-up your fitness to fight Delta. A British Journal of Sports Medicine study found that at least 150 minutes of activity each week was protective against severe COVID-19, even among those with comorbidities. This includes walking, jogging, high-intensity interval workouts, strength training, golf, tennis, ice hockey, boxing, swimming, foam-sword-fighting with a brave uncle, and just moving our bodies in any way possible!
Modify routine activities to be lower-risk. Dine outside, go to venues when they’re less busy, and wear a well-fitting 2- to 3-layer mask in crowds or when ventilation isn’t great. If your child has underlying health concerns, focus on keeping playmates to a small circle, and play outside to increase the dilution of any circulating virus.
Trust vaccines to reduce infection and transmission. Vaccines provide high levels of circulating antibodies which impede viral replication, making infection AND transmission less likely.
Women trying to conceive can protect their newborn by getting vaccinated now; this will provide protective antibodies through the placenta.
Pregnant women can get vaccinated any time during pregnancy to provide antibody protection via the placenta and after delivery via breastmilk.
For older adolescents, vaccination is recommended by the AAP, and I fully support parents engaging in an informed conversation about vaccination for their children. For older boys, among whom rare adverse cardiac events have been reported (myocarditis), the sweet spot may be spacing the two doses out by 8 weeks. To be clear, we have no data yet on whether this strategy reduces risk, but we do think it optimizes antibody protection while reducing the tiny risk of vaccine-related myocarditis.
Know that hope is alive. We can learn a lot from the UK where kids were unmasked and in school and where Delta has already spiked and is now coming down. I suspect we’re right behind them — and that we’ll see Delta peak and fall at the end of next month. I’ll mention again that a recent study out of the UK showed that in-school transmission is < 2%. Notably, this happened when kids were unmasked and Delta was surging. And last, here is a sobering yet reassuring Twitter thread from a pediatric infectious disease specialist in the UK about COVID and kids.
Without a doubt, this is a uniquely challenging time for parents and caregivers (not to mention for kids themselves). But we can’t lose sight of the facts or forget how far we’ve come since last year. With the accumulated knowledge about how to protect ourselves and our families from COVID — plus three stunningly effective vaccines that protect the recipient and others around them — there’s still light at the end of the tunnel.
Above all, it’s crucial to fact-check our internal narratives and to tailor our behaviors to our unique health circumstances. No child or household is alike. Similarly, risk mitigation will look different for each of us. To be our children’s best advocate is to understand their particular vulnerabilities, to partner with our trusted pediatricians, and to do the best we can without losing sight of our kids’ broad needs.
Programming note! Keep your eyes out this week for my latest article for the Atlantic about kids, COVID, and mitigating fear. I hope that you will share it widely.
I will see you next week. Until then, be well.