COVID Fear and COVID Shame

We are in something of a COVID wave, especially in the Northeast. Despite some difficulty with measuring cases reliably, we can see an increase in wastewater data. This wave is much smaller than with Omicron, and hasn’t so far resulted in an increase in hospitalization. But still, there are many new cases. What I feel like I have noticed — and I admit to having limited actual data here — is an uptick in cases among people who have been the most cautious over the last two years. I’ve done a few polls on Instagram over the past month, to a set of followers who are quite COVID-careful. In January, 22% of respondents reported COVID in their household in the past two weeks. Last week, it was 12%, despite the fact that it’s clear that cases overall are much lower than 50% of the Omicron wave. (I told my husband this and he started complaining about the data, so let me be clear that this isn’t a systematic set of facts.) If it were true that current cases are concentrated in the more careful portions of the population, it wouldn’t be very surprising. A fully vaccinated person who had Omicron in January has a risk of infection that is much lower than someone who is fully vaccinated but didn’t have it. The January infection is something of a fourth booster, and generally hybrid immunity has performed the best in terms of preventing illness. On average, people who have been more cautious with out-of-home activities were less likely to get it in January. As things have continued to open up, they are more at risk. As this has happened, I am getting anguished messages. Some of what comes through is just continued anger at the insane under-5 vaccination situation. (Latest information: probably June, as the FDA seems to want to wait for Pfizer’s submission so they can approve both Pfizer and Moderna together. I cannot believe it.) But beyond the anger, I hear two things clearly. One is fear and the other is shame. Data and perspective can help with both. I’m really afraid of the consequences of COVID for my child This fear is coming largely from people with children under 5, who remain unvaccinated. There are two forms of this fear. One is the fear of serious illness in the immediate moment. The second is the fear of long COVID. I have said before here that children are at low risk for serious illness. But it is worth revisiting concrete numbers. Our best recent data on serious illness in Omicron comes from a study in JAMA Pediatrics published in early April. The study used a large cohort of children to analyze the serious-illness risk during the Omicron wave and the Delta wave of COVID-19. In the Omicron wave, the researchers have about 22,000 COVID-positive children in the age group 0 to 4. Twenty percent of these children visited the emergency department, 1.7% were hospitalized, and 0.17% — or about 1 in 500 — were admitted to the ICU. These numbers will overstate the risks from any infection, since they focus on cases of detected infection. Notably, the risks to children of serious illness were substantially lower than the risks during the Delta wave of COVID, as seen in the figure below. Children infected during the Omicron wave were a third as likely to be admitted to the ICU. The current CDC-estimated hospitalization rates are also extremely low for young children. In mid-April, the figure for children 0-to-4 is estimated at 1 per 100,000. This would amount to about 160 COVID-positive hospitalized children in the U.S. Based on other data, perhaps half of them would be hospitalized for primary reasons other than COVID. Obviously, anytime a child is hospitalized, it’s incredibly scary for parents and caregivers, so this isn’t to downplay that fear. But we can put it in context: (1) the COVID-19 hospitalization rate in this group was 14.9 per 100,000 in January; (2) the current hospitalization rate for flu in this age group is about equal, at 1 per 100,000; (3) in February 2019 the flu hospitalization rate in this age group was estimated at 8.5 per 100,000. (Note: We are now dealing with a new Omicron subvariant, but there doesn’t appear to be any reason it would cause more serious illness.) I hope this data continues to reinforce the low short-term risk to most children. It is true that children who are seriously immunocompromised are more at risk from COVID, and other illnesses. This is an argument for taking seriously the protection of these individuals in general, not just from COVID, and I think this is something we’ll be grappling with long after the pandemic. I also hear fear about long COVID. Long COVID is certainly a complication in adults, especially (but not limited to) those who had more serious illness. There is much more we need to learn about this problem — how it manifests, what the common symptoms are, treatments, incidence, how much vaccines lower the risk, and so on. What we do know so far is that while children can have persistent COVID symptoms, long COVID appears to be much more rare. “Your Local Epidemiologist” did an excellent series on long COVID, with a good entry on children. One issue in evaluating this is that some studies, including those that say things like 10% or 30% of children have long COVID, lack a control group (that is, children who didn’t have a positive COVID test). Since many long COVID symptoms — fatigue, runny nose, headache — are common childhood complaints, we need a baseline comparison. Studies that do have such a control group tend to show much lower risks. There is, of course, a further step here — even if you accept a low risk of serious illness and of persistent respiratory illness, there are fears like brain shrinkage or a long-term disability that shows up in years or decades. For obvious reasons, it is difficult to rule this out. And certainly there is more we need to learn about COVID and the brain, and about all possible long-term COVID complications. But fundamentally this has to fall into the category of an uncertainty we have to live with, like others. You cannot rule out some impacts in the long term, nor do they seem likely given what we know about other childhood respiratory illnesses. Living with this uncertainty may be hard, but there is no alternative. I feel shame It’s not just fear. People also feel shame. Some of this is shame about putting our children at risk for reasons we think are selfish: We were so careful, and just because I wanted my son to see his grandparents/go to Disney/hike in Utah, we went on a plane and now he has COVID. “I’m a bad mom,” someone wrote to me. Let’s start here: this isn’t true. You aren’t a bad parent. That isn’t how we think about other illnesses. Pre-COVID, when your child got the norovirus, you didn’t think, “I’m a bad mom”; you thought, “Shit, I’m going to have this in 12 hours. How many meetings do I need to reschedule?” Some childhood illness is a fact of life, and even pre-COVID most of the choices we made involved some illness risk — choices like child care, seeing other people, play dates, grandparents, planes, trains, trampoline parks, and so on. Yes, as you do more things, there will be risks of illness — of COVID, and also of other illnesses. And it makes sense to take normal precautions around these things. Not having play dates if someone is sick, or washing your hands when you come into the house. But if your child does get sick, which will happen sometimes no matter what you do, it shouldn’t be a source of shame. And it may be useful to keep in mind that there is value to the things you do with your children. Socializing, seeing family, going to school — these are also valuable to their physical and mental health. It isn’t selfish to want to see their grandparents. I repeat: you’re not a bad parent. There is also shame about communities. “What if my child gets COVID and then they bring it to school? I do not want to be the cause of illness for others.” In this age group, an even bigger deal is classroom closure: if my child tests positive, that may mean all the other children in the classroom miss 10 days of school. To the extent that this motivates people to take sensible precautions — getting vaccinated and boosted if we’re eligible, not going out when we’re sick, wearing a mask in higher-risk situations, rapid testing when appropriate — that’s all to the good. And it is clearly true that some people are taking risks with the health of others that are not okay — going on planes or to events when they know they have COVID. This is unacceptable. But the reality is that even if you do everything “right,” you might get COVID. And even if you do everything right, you might spread it to someone. This is true of other illnesses too. If it happens, it shouldn’t be a source of shame. We can respect our responsibility to others while also accepting that illness will happen, and that it shouldn’t necessitate a shame spiral. However: the combination of the continued tendency to imbue the avoidance of COVID with virtue and the completely impossible child care quarantine rules reinforce COVID-shaming in ways that are unproductive and, I think, contribute to polarization and anger. The underlying issues causing child care quarantines — slow vaccine approval, confusing CDC guidelines — are intractable from an individual level. But what we can do as individuals is show grace, to both ourselves and others.

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