Editor’s Note: Dr. Lawrence C. Kleinman, a pediatrician, is a professor and vice chair of the Department of Pediatrics at Rutgers Robert Wood Johnson Medical School, where he is founding director of Division of Population Health, Quality, and Implementation Sciences (PopQuIS). Kleinman is also professor of global urban public health at the Rutgers School of Public Health. The views expressed here are his own. View more opinion articles on CNN.
We are compounding an important public health policy mistake.
As the US Centers for Disease Control and Prevention, states and elected leaders declare an end to pandemic restrictions, paving the way back to “normal,” there’s a presumption that vaccinated adults can safely be around one another with neither masks nor social distancing. But, based on all we know, this behavior could put children at risk.
While vaccinated people are much safer than those who are not, they may still contract and spread the virus. We have only a hint about how often this might occur. A recent study published in The New England Journal of Medicine followed 417 fully vaccinated employees of Rockefeller University for eight weeks and found two infections. Extend the follow up time and account for the small size of the study and these findings are consistent with 3% or more becoming infected in the six-month window after vaccination.
While infections post-vaccination are uncommon, they do happen and prove that the virus can still spread, as we are reminded when learning of infections in eight vaccinated members of the New York Yankees organization. Failing to account for this possibility in our public health response puts children in harm’s way and is an unnecessary risk.
To keep children safe, public policy should require both masks and distancing for individuals, such as teachers and caregivers, who interact with unvaccinated children. Recent CDC guidance allowed fully vaccinated individuals to congregate among one another in small gatherings without masks. It explicitly allowed individuals who are vaccinated to interact without masks with “low risk” families with children. This guidance correctly indicated that these vaccinated individuals are generally safe. But it also underemphasized the risk to unvaccinated children. And the recent guidance that calls for the end of mask use by vaccinated individuals compounds their prior error and is insufficiently mitigated by Saturday’s update calling upon schools to continue to “prioritize universal and correct use of masks and physical distancing.”
In other words, it fails to protect this group, which depends upon adult behavior to keep them safe. To help address social needs, it is my view that we should continue to feel comfortable interacting unmasked and in close contact with those in our “pod” – a small number of family and friends who explicitly agree to a similar level of mitigating behaviors, such as always wearing masks and maintaining physical distance, around those outside the pod.
Messaging from health authorities, including the CDC, offers tantalizing incentives for individuals to be inoculated. As a pediatrician, I appreciate and share the importance of incentivizing vaccination. However, I am concerned that this particular carrot puts children who can’t yet get vaccinated at risk and is therefore bad public policy. While vaccines are newly available for adolescents, they are not yet available to younger children who consequently are at higher risk of infection.
We began this pandemic with the erroneous conclusion, until things began to change in April, that children were spared the ravages of Covid-19. But over the course of the crisis we have come to understand that children infrequently get very sick and rarely die. As shown in a study published in the medical journal JAMA Pediatrics in May 2020, while children with at least one identifiable pre-existing condition (including being obese) make up a majority of Covid-19 patients in US and Canadian pediatric ICUs, about 17% of these children had no pre-existing conditions.
Moreover, research published in June 2020 in The New England Journal of Medicine describes the link between Covid-19 and Multisystem Inflammatory Syndrome in Children (MIS-C) as an uncommon but severe and potentially fatal condition that can cause the heart and other organs to fail. MIS-C typically comes from out of the blue, several weeks after an initial Covid-19 infection, which may have presented without any symptoms and thus may have gone undetected. While researchers are working on it, right now we do not know what puts a child at increased risk.
The American Academy of Pediatrics reports that, as of May 6, more than 3.85 million children in the US have tested positive for Covid-19 – more than 72,000 new cases that week. These numbers are lower bounds as many children with Covid-19 are never tested. Even if only one half of 1% of these children develop a serious illness, that would be 360 children harmed in a single week. The impact of children on the pandemic and the pandemic on children should not be ignored.
There are simply too many unknowns, including the longer-term impact of the virus on children, to risk contagion. Children are on a journey towards their developing maturity. Their experiences before the pandemic influence their health and well-being today, and their experiences today impact their future. We know that, as for adults, Covid-19 can affect children’s brains; we do not yet know the long-term implications on their brains or on the development of younger children or adolescents. Neither do we know what physical consequences may lie ahead following infection. Even young patients, for example, may discover a lack of stamina or concentration even after they have seemingly recovered from Covid-19. Researchers are working to learn the range and frequency of long-term affects.
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We know that masking and physical distancing reduce the risk of transmitting the virus. We also know vaccines reduce both infections and death. When the virus is circulating in your community, congregating in groups increases risk. Thus, public health messaging should encourage widespread immunization and mitigation behaviors, such as wearing masks and maintaining distance to protect children who have not yet been vaccinated.
Like most of us, I yearn for normality. I, too, am tired of limiting my interactions, maintaining distance and wearing a mask. But for my 4-year-old daughter and her generation, I continue to do so when I am around others outside my pod, even among those who are vaccinated. I hope you will too.