But What about the Kids? Flying?

(Lots of stuff going on tomorrow about schools — stay tuned — so I’m a bit early this week and there might even be a bonus on Friday…) On Monday, the CDC issued guidance about post-vaccine behavior. This was long-awaited and, basically, well-received. The CDC is walking a fine line here. On the one hand, until more people are vaccinated, they do not want to give the impression it’s cool to have giant parties. On the other, they seem to be recognizing that if you tell people nothing changes with the vaccine, then they will wonder what the point is. The three big takeaways from this round of advice are: Vaccinated people can get together unmasked with other vaccinated people in groups, but try to keep them small. Vaccinated people can hang out indoors with one other household of unvaccinated people, provided the latter group is low risk. Vaccinated people should still wear masks and distance in public. Number 2 above is clearly targeted at this newsletters favorite topic: grandparents-parents-kids interactions. And what it says is if grandparents are vaccinated, it’s cool to hang out inside without masks as long as parents and kids are low risk. Yay! There are people who suggested that the CDC should have gone further, to get more towards the idea that vaccination means you can behave “normally” — more travel, for example. I suspect they will update in this direction as vaccination rates continue to increase and cases go down. But certainly this is a good direction. However, many people seem to be freaking out about kids. They will not be vaccinated. Parents are f*ing tired. Based on my email, a lot of you are reading this as, basically, this summer all the vaccinated people will be frolicking on the beach while you are stuck in your house with your unvaccinated kids and not traveling anywhere. “Can I travel before kids are vaccinated?” “What about playdates?” “When can my kids friends’ come over?” “Can we vacation with my brother and his family once all the adults are vaccinated?” This is the big hole in the CDC guidance in my view. There are at least two others. The first is the issue of travel. It’s great to know I can see grandpa when he’s an hour drive away, but what about if he has to fly? And, second, what do you mean when you say “the unvaccinated people are low risk”? What if there is a higher risk unvaccinated person? Let’s dive in. What About Kids? I want you to cast your mind back to January 2018. During one week in late January of that year, the CDC reported flu hospitalization rates of 7.3 per 100,000 for children aged 0-4 and 1.4 per 100,000 for kids 5-17. This means that of 100,000 children aged 0 to 4, 7.3 of them were hospitalized with flu complications that week. Kids get the flu from a lot of sources. School, child care, their parents, travel, indoor trampoline parks, etc, etc. And flu can be very serious; there were almost 200 pediatric flu deaths during that 2017 - 2018 flu season. But I would venture in that time frame most of you were not making choices about your activities based on flu risk. The peak week of the COVID-19 pandemic for hospitalization for children 0 to 4 was mid-December (data here). During this week, the hospitalization rate for this group was 2.3 per 100,000. For children 5 to 17, the peak was the first week of January, with hospitalization rate of 1.3 per 100,000. In the most recent week of reported data, the week ending February 27th, these rates were 0.3 per 100,000 for children aged 0 to 4 and 0.6 per 100,000 for children 5 to 17. Bottom line here: hospitalization rates even at the peek COVID week were below that week in January 2018. Let me add onto this another set of facts, based on the graph below (original paper here). This graph shows non-COVID death rates for children in two age groups (based on 2018 data) versus COVID-19 death risks over the period from March through October 2020. Deaths in these age groups from any cause are really, really rare so I’m not trying to freak you out. But I am trying to convey that death rates from COVID-19 in these age groups over this period are less than a typical year of suicide, homicide or cancer. They are an order of magnitude less than car accidents. Infants are not in this chart, but the same logic flows. COVID death rates are higher in absolute numbers but lower in ratios. The SIDS death rate for infants under 1 in this comparison period is eighty times higher than the death rate for COVID-19. The you from 2018 was not thinking about these non-COVID risks. Yes, in the back of your mind you probably worried about your kids getting the flu and had some sense of the idea that cars are dangerous. But you were planning travel and playdates and everything else in spite of these risks because they are small. And for kids, the COVID-19 risks are even smaller. This isn’t true for adults. But it is true for kids. This doesn’t mean kids do not get COVID. They do get it (although probably at lower rates). Just like they can get flus, and colds, and other viral illnesses. But they are simply very, very unlikely to get extremely sick. Look forward, now, to the summer. You’re vaccinated, your parents are, your brother is. Barring some surprise, COVID-19 rates are expected to be even lower than they are now. Not zero, but lower. This makes COVID-19 even less of a threat to kids. They are extremely unlikely to be infected. And if they were, they would be extremely unlikely to get very sick and they wouldn’t spread it to older people because those people are vaccinated. What’s going to happen if your family and your brother’s family and your parents rent a beach house together with all the cousins for a weekend? Let me tell you based on personal experience. Monday after you return home one of the children in one of the families will be vomiting, and the other family will recall one of their children complaining about a stomach issue which they didn’t think to mention. What if you fly with your kids to a vacation? They might get sick on the airplane and ruin your first two days in England complaining about their sore throat. My point is: kids get viruses. You cannot avoid the possibility they might get sick on vacation. But the presence of COVID-19 in a world of vaccinated adults does not change the risk of this very much at all. The challenge of this summer, I think, is going to be figuring out how we can consciously move towards normalcy despite lack of full vaccination for kids and despite the fact that COVID-19 will always be with us. It is going to require putting our minds to it. Booking that summer trip might be the first step. What about masks at camp and school? Earlier this week my 5 year old, Finn, asked when he could stop wearing a mask. I told him I would address it in this week’s newsletter. Here you go, Finn! You know how I feel about camp and school in general. We should have it. Schools (in some places) have been operating safely all year. Camps operated safely last summer. The situation this summer, barring some bad change, will be much better. Camps should be on. I am shipping my older one to sleep away camp. But: when we talk about a lot of unvaccinated kids interacting together, we do need to talk about precautions. A lot of the precautions we are taking with schools will continue — hand washing, maybe some cohorts. And, probably, masks. On the one hand, I think based on what I’ve said above, there is probably an argument for lightening up on the kid masks once all adults are vaccinated. On the other, I think it will be difficult to dial this back and given how well most kids have adapted to masks, the pressure may not be there. Eventually, we are going to need to remove the masks. Will it be this summer at camp? I’m betting no. Sorry, Finn. What if I am High Risk? The CDC guidelines specify in-house visits if the visitee (that’s a word, right?) is low-risk. But what if someone unvaccinated in the house is “high risk”? This likely depends on what you mean by high risk. If you have a seriously immune compromised adult or child, it is a good idea to be much more cautious. This would be true with any illness exposure. Maybe you can visit vaccinated grandparents outside, or enforce a stricter pre-visit quarantine even for vaccinated visitors. But if what you mean by high-risk is you fall into one of the millions of high-risk categories that one or another state has put on their list, we are in little more of a grey area. To the person who wrote to me to ask whether her post-partum BMI of 30.1 makes visits a no-no, or the person with well-controlled asthma who asked a similar question, the elevation in risk is extremely small. Given the low risk of transmission from vaccinated adults, I think this is an overly cautious interpretation of the CDC guidelines. (And healthy infants past the first couple of months are also not high risk. See discussion above.) Flying to Visit! It’s fine to have the grandparents visit unmasked inside, but what if they have to fly? This really comes down to: is flying a risky activity? The answer is, basically, no. I pulled the quote below from the linked Economist article, and this lines up with much of what we see in other reports. The number of infections on planes is really, really small. This may relate to their filtration systems, or the fact that people are wearing masks, or just really careful. In October data collected by IATA found that only 44 out of 1.2bn passengers since the start of 2020 were known or thought to have contracted covid-19 on a plane. iata’s medical adviser notes that, even if 90% of cases went unreported, that implies just one infection for 2.7m passengers. Triangulating the CDC guidance to this particular question is a little complicated. On the one hand, the CDC says even vaccinated people still shouldn’t do “nonessential travel”. But: they also say that vaccinated people do not need to quarantine after an exposure to COVID unless they are symptomatic. This is a disconnect. If you travel, the concern is that you’ll be exposed to someone with COVID-19. But if vaccinated people do not have to quarantine even after a known exposure to an infected person, why would they need to quarantine after travel, when exposure is basically the worst case scenario? My sense is that this is place where the CDC has still gone for an excess of caution, in the hopes that they can hold off the free-for-all travel for another month or so. But in practice, if this is what it takes to see grandparents, I can’t see a strong argument not to do it. If you do travel, I think the CDC advice is still good: test a day or two before leaving (even if vaccinated), wear a good quality mask in airport and on the plane, frequent hand washing and so on. And then enjoy your grandkids.

This Post Is for Paid Readers Only