Emily Oster

11 min Read Emily Oster

Emily Oster

Triangulating Evidence on Outbreaks in Kid Settings

Emily Oster

11 min Read

The school reopen debate continues. A number of large school districts have made decisions — mostly to move to a fully remote schedule — but some are still deciding (like New York) and smaller districts, as well as many private schools, have yet to make decisions.

I have maintained since the start of this, back in March and April, that summer camps and others child care settings are a source of information on what to expect school reopens. In the service of this, I (with some COVID-Explained team help) have been trying to aggregate information. Today, I want to talk through what I think we are seeing, triangulating from several sources.

Before getting into this, I want to be clear on what we are looking for in the data. From a decision-making standpoint, the central question is whether these settings are sources of outbreaks. That is: if we open schools will they contribute to spread, make it worse, raise the “R0” value we hear so much about?

This is different from the question of whether people in schools will have COVID-19. As I’ve written about recently elsewhere, when we open schools we should expect some cases. The rates in the school will mirror the community even if schools do not contribute to spread at all. This is a reason, in my view, to limit opening to places where the virus levels are lower (no, I do not have an exact cutoff, but here’s a link to some people who do). But it’s also a reason to focus in the data on looking for outbreaks, not single cases.

When we go to look for these outbreaks, we can start by asking about the ideal evidence. What would be ideal, from a data standpoint, is if every child care setting — camp, child care center, etc — were required to report their enrollment and any COVID-19 cases regularly (say, once a week). Perhaps they could also indicate any precautions they are taking. This could be coordinated by states or, better yet, the CDC. It would give us a complete picture of what is going on.

But there is nothing like this. So today I’m going to talk through three imperfect pieces of information and see how we can triangulate. Specifically, we’ll talk about:

  1. Information I’ve crowd-sourced from camps and child care settings
  2. Media reports on outbreaks
  3. State-reported data

I’ll sum up at the end, at least what I take from this. No TL;DR here since I think we should all draw our own conclusions.

Crowd-Sourced Information

A couple of months ago, fueled by coffee and frustration, I started an effort to collect information from open child care settings on outbreaks. A piece of this effort has involved tracking locations over time, looking at their enrollment and cases by week. (Big thanks to — among others — people at YMCA, the American Camp Association and Winnie.com for their help on recruitment).

Effectively, I’m attempting to generate a voluntary, crowd-sourced sample which would do what I describe as the “ideal” above. However, such an approach is far from the ideal. The problem is not so much that it is not universal — that’s an inevitable part of sampling — but that it’s not random. Places with COVID-19 outbreaks may be less likely to participate. More generally, the places that want to engage on an effort like this are likely those who are taking other precautions about COVID-19. For all of these reasons, the numbers generated by this approach are likely to understate what we’d see in a random sample.

You may ask (people have) what is the point of seeing these data given those issues. I can see a few reasons. The first is to match anecdote with anecdote. The media coverage (more on this below) can give one the impression that it is impossible to operate a child care setting without outbreaks. These data contradict this.

Second, by tracking the same place over time, we can see how common it is for a single case to turn into multiple cases. We can see whether the cases we observe turn into outbreaks. And, finally, this is an opportunity to see what methods these settings are using as prevention.

What are we seeing? First, if you want to access all the (de-identified) raw data, you can see it here. Enjoy!

For a quick topline, the case numbers are limited. Among over 11,500 students and 3,800 staff in the most recent week, there were 2 student and 1 staff case. The camps — at least some of which are large overnight camps — showed similarly low numbers. In the Google sheet, we can separate out places in hotspots and the rates are still low.

Again, I am not saying these are the average rates for all organizations. What we do see is that it is possible to run (for example) a large overnight camp in Texas without COVID-19. What we can also see is that there are places which have 1 or 2 COVID-19 cases in a week and then do not have cases the following week. Effectively, we see containment.

In the most recent week I asked locations what they are doing to prevent COVID-19. I asked about just a few specific things: are you doing temperature checks, symptom tracking or routine testing.

Nearly all of the locations in these data — 95% — are doing at least one of these. 90% of them are doing routine temperature checks (note that many states require this) and 73% are doing symptom tracking (again, often required). More notable, about 15% of the sample is doing some routine testing of either staff or students. These high numbers reflect good compliance, and may be part of what has kept cases down.

Media Outbreak Reports

In a sense, the polar opposite of the crowd-source data is media reports on outbreaks. I say this because these focus only on settings with cases (stories of camps with no cases are not interesting). If the crowd-source data selects for places with few cases, media reports on outbreaks selects for places with lots.

Still, this provides a different kind of evidence. It tells us something about what can happen in the other direction, the bad direction.

It’s difficult to be comprehensive about outbreaks reported in the media. We sourced from Twitter, from online searches, from various threads. We did our best! (See a way to weigh in below if you have things to add). To make it easy to see, we put it in a table, with some key information added. (The table with sources is here).

An important note here is that we found additional media stories which report on a camp or child care closing due to one case among staff, or reporting the presence (or suspected presence) of a case. We did not include these in the table for the simple reason that this isn’t an outbreak. See longer discussion above. We focused this on cases where there were more than two cases noted.

Some of the outbreaks listed here are very small. Three or four cases in a setting, with limited details provided.

There are, however, several notable, larger outbreaks. Some of these seem inevitable. The first location listed — a camp at Allaso Ranch, in Texas — posted Instagram photos showing large, indoor gatherings with singing and no masks. Given the overall COVID-19 levels in Texas and what we know about indoor unmasked singing events, this is not surprising.

But there are other examples — for example, the Kanatuck camp or the Lake Grove KinderCare — where the outbreak seems less explicable. In the last case, there were a large number of cases in both staff and children and (based on some digging we did) it doesn’t seem like the location did anything objectively “wrong”. It would be helpful if we knew more about these situations, although I think it’s understandable that privacy concerns limit how much locations want to reveal.

State-Level Data

The last thing I’ve been looking at is the data that states have been putting out there. We’re doing this over at COVID-Explained, and you can see the whole messy disaster here. These data mostly focus on child care facilities, not camps, but it’s a bit of a hodge-podge.

A challenge with the data provided from many states it is that it provides no ability to look at outbreaks as distinct from cases. For example, California reports out cases linked to child care centers, but this includes all counts of children, staff and parents who are affected. They do not provide evidence on clustering of cases. You’d expect some base rate of cases in these settings, and without knowing if the cases are clustered, there’s not sufficient information. Texas data has a similar problem, as I discussed in an earlier newsletter (let it not be said that I do not repeat myself).

There are a few states which specifically focus on outbreak data. Colorado reports all clusters of two or more cases within 14 days as outbreaks; their data has 7 child care facility outbreaks since the start of the pandemic, mostly with very small case numbers. North Carolina reports ongoing clusters here and their most recent update includes 14 clusters, with case counts ranging from 5 to 14.

Oregon does a similar type of reporting and has two clusters identified, one of which is that larger Lake Grove KinderCare case we talked about above.

The random nature of this reporting, the fact that much of it must be dug out of newspaper articles, is not great. But more data is better, even if we cringe a bit at the quality.

Pulling it Together

Ultimately, the idea is to pull these data together and triangulate — at least a bit —what we might see in schools. I think there is both bad news and good news here.

On the bad news side, the fact that we see some outbreaks here tells me that it is not realistic to expect no school outbreaks at all. In some cases, the large outbreaks cited above seem clearly linked to behaviors we’d hope schools would avoid, but it is simply not realistic to expect no clusters of cases to emerge. Some of these could be large.

But on the positive side: many child care centers and camps, even large ones and even in high prevalence areas, are operating without significant outbreaks. They are dealing with cases without having them turn into clusters. We see this in the crowd-sourced data. We can also infer it, to some extent, from the media reports and state-level data. The number of clusters observed are simply very limited relative to the overall population.

It’s easy to forget the denominator, but estimates suggest in the range of 5000 summer camps are operating this summer, including perhaps 1500 overnight camps. The number of child care centers in the US is in the hundreds of thousands. Yes, it is concerning that there are 14 child care locations in North Carolina with clusters, but this is out of a total of about 6500 locations.

Again, this doesn’t mean that there aren’t individual cases at other centers — we know there are — but the cluster rate simply seems limited.

I will stop short of drawing any overall conclusions on schools here, since I think people may read this differently. Some will say it is not responsible to open schools if there is going to even one cluster. If we take that approach, this is not good news, and I think it would realistically say we need to stay closed.

A different approach would be to say that these data suggest the risk of a cluster is fairly small, and focus on opening with a key set of procedures in place for limiting spread when individual cases do crop up.

And everyone, cautious or not, should leave this conversation with the sinking feeling that our data isn’t good enough, and that it would be great if I were not the one collecting it.

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Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings
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Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone. 

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone.

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle
...

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster
...

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory
...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76. 

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76.

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife
...

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster
...

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy. 

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy.

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙
...

Exciting news! We have new, high-quality data that says it’s safe to take Tylenol during pregnancy and there is no link between Tylenol exposure and neurodevelopmental issues in kids. Comment “Link” for a DM to an article exploring this groundbreaking study.

While doctors have long said Tylenol was safe, confusing studies, panic headlines, and even a lawsuit have continually stoked fears in parents. As a result, many pregnant women have chosen not to take it, even if it would help them.

This is why good data is so important! When we can trust the data, we can trust our choices. And this study shows there is no blame to be placed on pregnant women here. So if you have a migraine or fever, please take your Tylenol.

#tylenol #pregnancy #pregnancyhealth #pregnancytips #parentdata #emilyoster

Exciting news! We have new, high-quality data that says it’s safe to take Tylenol during pregnancy and there is no link between Tylenol exposure and neurodevelopmental issues in kids. Comment “Link” for a DM to an article exploring this groundbreaking study.

While doctors have long said Tylenol was safe, confusing studies, panic headlines, and even a lawsuit have continually stoked fears in parents. As a result, many pregnant women have chosen not to take it, even if it would help them.

This is why good data is so important! When we can trust the data, we can trust our choices. And this study shows there is no blame to be placed on pregnant women here. So if you have a migraine or fever, please take your Tylenol.

#tylenol #pregnancy #pregnancyhealth #pregnancytips #parentdata #emilyoster
...

How many words should kids say — and when? Comment “Link” for a DM to an article about language development!

For this graph, researchers used a standardized measure of vocabulary size. Parents were given a survey and checked off all the words and sentences they have heard their child say.

They found that the average child—the 50th percentile line—at 24 months has about 300 words. A child at the 10th percentile—near the bottom of the distribution—has only about 50 words. On the other end, a child at the 90th percentile has close to 600 words. One main takeaway from these graphs is the explosion of language after fourteen or sixteen months. 

What’s valuable about this data is it can give us something beyond a general guideline about when to consider early intervention, and also provide reassurance that there is a significant range in this distribution at all young ages. 

#cribsheet #emilyoster #parentdata #languagedevelopment #firstwords

How many words should kids say — and when? Comment “Link” for a DM to an article about language development!

For this graph, researchers used a standardized measure of vocabulary size. Parents were given a survey and checked off all the words and sentences they have heard their child say.

They found that the average child—the 50th percentile line—at 24 months has about 300 words. A child at the 10th percentile—near the bottom of the distribution—has only about 50 words. On the other end, a child at the 90th percentile has close to 600 words. One main takeaway from these graphs is the explosion of language after fourteen or sixteen months.

What’s valuable about this data is it can give us something beyond a general guideline about when to consider early intervention, and also provide reassurance that there is a significant range in this distribution at all young ages.

#cribsheet #emilyoster #parentdata #languagedevelopment #firstwords
...