The New Mask Guidelines from CDC… and Kids

Last week, the CDC released new guidance on masks. The basic idea of the guidance is to help people think about what the safety of various activities, both inside and outside, depending on their vaccine status. The biggest take-away for most people was the idea that it isn’t necessary for fully vaccinated people to mask outside. A number of locations (for example: where I live in Rhode Island) have relaxed outdoor mask mandates as a result. Along with this, the CDC made a push for vaccines: get vaccinated! Move to the right side of the graphic! Look at all the great stuff you can do! But, among some parents, there was a palpable sense of frustration. My kids cannot be vaccinated yet! Do I have to wait forever for anything? This was exemplified for me by Savannah Guthrie interviewing Dr. Fauci. Their exchange is confusing — she’s confused, I think, and he doesn’t totally explain himself — but I feel her frustration coming through the screen. For many parents, I sense it feels like we’ve spent over a year holding our kids back even though the risks to them are small, so we can protect others. And now somehow even though they’re low risk, we have to hold them back even more. Our older parents are chillaxing with their friends on vacation in Florida drinking fruity cocktails at the swim up bar and we’re still supposed to make our three year olds wear masks at the playground. THIS FEELS VERY UNFAIR. Breathe. I wanted to try to cut through a little of the chaos today. First: What does this CDC thing mean, really, for kids? Second: Why don’t they explicitly call out kids separately, given that we know they are low risk for illness? Third: Is it just going to be like this until they get a vaccine? And when is that anyway? Before getting into this: I want to acknowledge that these CDC guidelines are just that — guidelines. They aren’t rules, and individual states and municipalities have their own statements. Whenever I write about this, I hear from people who live in areas — say, Texas or Florida or North Dakota — with many fewer mask restrictions and a looser set of guidelines in general. They are often very confused about why this is such a discussion. The explanations for this split are too lengthy for this newsletter, so let’s just leave it there. What Does This Mean? As Dr. Facui confusingly states in the interview, kids are unvaccinated and, therefore, the “unvaccinated” guidelines above apply to them. What this means, though, is that if you’re out walking around with your kids, with just your household, it is fine for them to be unmasked. In addition, if you have a gathering of fully vaccinated people and one household worth of unvaccinated kids are there, they can be unmasked. The CDC guidelines, if taken to the letter, also suggest both vaccinated and unvaccinated people should be masking for basically any indoor activities other than small gatherings (like with family) with only one unvaccinated household. Where masking in kids is still recommended are places like playgrounds or playdates, either indoor or outdoor. This is where I think people have come up against the inequities. If I meet a friend and their kids at a playground, in my house or in my backyard and the adults are fully vaccinated, the guidelines say adults unmasked and kids masked. This feels odd to a lot of people, but that’s what the CDC says. Why Aren’t Kids Separated Out? Why not discuss kids separately, especially little kids, since we know their illness risks are low? This is a question not just for this particular set of mandates, but one that comes up in general. The CDC and other public health bodies have been reluctant to talk about more freedoms for younger groups. The reason for this lies in the goal of this messaging. When they send health messages, public health officials have two goals. One is to help people protect themselves. The other is to protect the broader health of the public. Sometimes, the first part is the really key goal — when we give diet advice, it’s mostly about how to be healthy for yourself. And for that part of the advice, it really makes sense to distinguish between risk levels. But when it comes to COVID-19, public health messaging at this point is still very focused on lowering spread; we are still seeing around 50,000 infections per day. Kids are lower risk for COVID infection in general, but the risk differences are much less extreme than for serious illness. According to the CDC, kids 5 to 17 are only slightly less likely to have COVID at all relative to adults, even as they are much, much less likely to be seriously ill or die. The differences in guidance for vaccinated and unvaccinated people are really focused on their risk of spreading to others. And from this standpoint, kids are similar to adults and it doesn’t make sense to separate them out. (Some people have asked how to interpret some of the statements coming out of Michigan that younger people are more important in driving spread in the last wave. My read is this likely reflects the fact that they are a relatively larger share of cases, since older people are now vaccinated). So, is it going to be like this forever until kids get vaccinated? I do not have a crystal ball but, I think, no. Here’s the thing: these guidelines are specific to this moment in time when we are still seeing 50,000 cases a day. As these numbers go down — as we vaccinate more people and more people move from partial to full vaccination — this will make it possible to extend more flexibility to everyone. The situation can feel hard to predict, since vaccine hesitancy is real, but as we get to 50 or 60% of the population vaccinated, which I think is feasible, case rates will continue to drop. Herd immunity is a bit of a red herring, neither necessary nor sufficient, but the fact is that more vaccines less spread (ultimately) more ways to be safe even for unvaccinated people. The concern with extensive interactions among unvaccinated people is that someone will bring the virus, and others will be infected. But as case rates lower and more high-risk people are vaccinated, it both becomes less likely that anyone shows up with the virus, and less problematic if they do. CDC guidelines aren’t set in stone; they change. As case rates decline, it will be reasonable for them to relax more. And it may start being reasonable for them to focus messaging more on individual choices and to distinguish among unvaccinated people by risk level. As David Leonhardt has helpfully pointed out, there will be more than one reasonable way to behave with your children once all adults have had the option to be vaccinated. I don’t know when any of this will happen, but when I get frustrated and impatient, I try to remember that things look very different right now than a month or two months ago. If we keep pushing to vaccinate more, they can look even more different in a month. What about camp? Are we going to be masking at camp? And school next year? ARGH. Why? I get a lot of mask questions about camp and school. CDC camp guidelines are angering a lot of people, likely due to the somewhat extreme approach to masking and other mitigation. Last summer, my kids went to tennis camp and there was no masking except at drop off and pickup (there were no COVID cases). The current guidelines are considerably more stringent than this. This seems to many people kind of backward, since at this point all the counselors will be vaccinated, case rates are likely to be a lot lower, kids are low risk and outdoor activities are very safe. David Zweig has a skeptical piece on this which I agree with. Yesterday, Dr. Fauci expressed some skepticism and suggested updates might come. I think that would be appropriate. As for schools… the fall is hard to predict. We do have some opportunity to learn about the value of masks in these situations from — for example — the experience of schools in this latter part of the spring in states which relaxed their masking rules (e.g. Texas). Whether data like this will matter to these decisions, I’m not sure. In some ways, I find this frustrating and I worry about not seeing a way out. Are we going to make kindergarteners wear masks at school until no one has COVID anywhere? I would support this if we thought it mattered a lot for transmission, but it’s not clear it does especially when adults are vaccinated. I think we are also missing some of the significant costs for students with disabilities, who may struggle more with these restrictions in various way. Having said this: if the tradeoff in the fall is masks or no school, my strong sense is that masks are better than no school. Many kids have worn masks all year without issue. As economists say: it’s not the first best, but it’s maybe the second best. With no in person school as a distant third. I do want to name here that I’d like to see more clarity from the CDC about younger kids. It’s hard to get a 2 year old to wear a mask and I’m not sure what evidence we’d point to to suggest that it matters, especially when case rates are low. When will kids be vaccinated anyway? The FDA is reportedly set to extend the Emergency Use Authorization for the Pfizer vaccine to adolescents (12-15) next week. Realistically, this means in a couple of weeks we will start seeing that group vaccinated. Pfizer has said they’ll apply for an EUA for kids 2 to 11 in September. Moderna is in a similar space. So in principle we could have vaccines for this group in the late fall. This is a bit earlier than the January timeline that I’d seen predicted. So, this is when your child could be vaccinated. But will you? People sometimes ask me: will you get your kids vaccinated? I will, as soon as they can. If we had access, I would likely have enrolled them in a trial. However: I am expecting more vaccine anxiety and hesitancy around kids than there has been around adults, especially kids in the younger age groups. For a low risk 8 year old (for example) the individual benefit of the vaccine is low. Yes, kids can get severe COVID, so the vaccine benefit is not zero. But it’s much, much smaller than for (say) their 75 year old grandparent. The most significant benefits to childhood vaccines are to lowering spread to other people — these benefits are real! But, overall, the risk-benefit calculation is different in kids than older people. This comment, in Lancet Infectious Disease, is a more academic take on this questions. My bottom line is that I think it will be an uphill slog to getting high vaccine rates in kids, especially those under 12, until schools require them. And many schools in many places will not. Final Thoughts It is an amazing triumph of science that the COVID-19 vaccines are so effective. What it means — and this is reflected in the CDC guidelines and general rhetoric — is that people who are vaccinated can start to get back to normal. Like real normal. And a big part of that is not thinking through every f*ing activity to decide it if fits in today’s “risk budget” or whatever we are calling it. Want an eyebrow wax? Just get it. Forgot strawberries at Whole Foods? Just go back. I think many parents are experiencing, basically, decision-fatigue-induced-vaccine-jealousy. I just want to be able to make simple decisions about playdates and vacations and camp and extracurriculars without a calculator. (Yes, I like my calculator, but I wish I didn’t have to use it.) It seems like we are facing at least a few more months of these complicated decisions and it is frustrating and tiring. I have no real solution other than to name the feeling, to note that it will get easier, and to celebrate the small changes. Example: none of us will mask when we are hiking as a family this weekend and we will retire the front-of-line-there-is-someone-coming-mask-up-hand-signal my husband introduced a year ago. It’s a small thing, but it’s something.

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