As school officials debate whether to reopen this fall, physicians, teachers, and a prominent ethicist markedly disagreed on whether sending children back into the classroom is safe for their communities.
Some pediatricians are driving the push to reopen, while infectious disease specialists, family physicians, and teachers appear more wary, concerned that schools could become “new hotspots for the virus.”
At the heart of the debate are many unanswered questions, with arguably the most important being: How often are children infected, and how contagious are their infections?
The American Academy of Pediatrics (AAP) issued guidance in late June that strongly recommends children resume in-person classes in the fall.
While acknowledging that “many questions remain,” the AAP was confident in reopening given “the preponderance of evidence” that children “may be less likely to become infected and to spread infection,” as well as less likely to become symptomatic or develop severe illness when they do contract the virus.
However, NIAID Director Anthony Fauci, MD, has cautioned that there aren’t enough data to make a definitive statement about transmission in children. His colleague on the White House Coronavirus Task Force, Deborah Birx, MD, acknowledged on July 8 that children are the least tested population.
The AAP guidance does emphasize the importance of responding quickly to “new information,” but drives home its message that “all policy considerations for the coming school year should start with a goal of having students physically present in school.”
President Trump has made it clear he wants governors to reopen schools, even threatening to withhold funding from states that don’t force these reopenings.
His administration has leveraged the AAP’s own recommendations at every turn.
On July 8, during the Wednesday task force briefing, Education Secretary Betsy DeVos quoted from the academy’s guidance, stating that “keeping schools closed places children and adolescents at considerable risk of morbidity and in some cases mortality.”
At the same briefing, Vice President Mike Pence recommended that “every American” review the AAP’s guidance.
The White House has already shown its influence over these decisions. Following an angry Twitter storm from President Trump over CDC’s “very tough & expensive” recommendations for reopening schools, Pence said the agency would be releasing new guidance next week.
However, in an interview with Good Morning America on July 9, Redfield clarified that the basic CDC guidance would remain in place, but additional reference documents would be included.
The AAP’s statement makes clear it determined that the risk of viral transmission is the lesser danger compared with the social, emotional, and academic consequences of remaining home, and believes the evidence is on its side.
Danielle Dooley, MD, an AAP spokesperson and medical director of community affairs and population health at Children’s National Hospital in Washington, D.C., told MedPage Today that when schools closed in March, many experts assumed the virus would “behave like influenza” which spreads rapidly among children.
“But what we know now … three months later is that it doesn’t behave like influenza. Children do not appear to be ‘super-spreaders,'” Dooley said, noting that only “very limited cases” have shown children passing the virus to adults. A press representative was present during the phone interview with Dooley.
While “tens of thousands of children” of essential workers continued going to daycare centers and emergency childcare facilities throughout the pandemic, Dooley noted “there have not been cases of major outbreaks or spreading events in those areas.”
The YMCA and the New York City department of education cared for a total of 50,000 children during the pandemic, and both organizations told NPR in late June they had had no COVID-19 outbreaks.
The AAP also relied heavily on a May 15 policy brief from the Learning Policy Institute (whose funders include the Sandler Foundation and the Ford Foundation). The report summarized the experience of China, Denmark, Norway, and Singapore in reopening schools in late March or April and also includes the experience of Taiwan, which kept schools open nationally, while implementing mandatory and temporary closures in areas with high infection rates.
All five countries’ strategies were viewed by the policy brief’s authors as successful “to date” in avoiding the spread of COVID-19.
All instituted temperature checks and a range of physical distancing measures. Denmark and China reduced their class sizes and Norway instituted a maximum class size of 15 students for younger grades and 20 for older grades. The five countries also developed quarantine or school closure policies. Taiwan will suspend a particular class for 14 days if one case is discovered and will suspend school for 14 days if two or more cases are identified. In Denmark, anyone who’s sick is required to remain home for 48 hours.
The institute acknowledged that countries that reopened their schools “differ significantly from the experiences so far in the United States” with regard to their capacity “to test and track cases” and to “isolate individuals who have been exposed to infection,” all factors linked to their success in avoiding viral spread. The policy brief further stated that it “has not investigated the health implications of using any of these practices in the United States and does not endorse the safety or effectiveness of these practices or of any medical practices.”
Dooley also cited a systematic review in The Lancet, published in April, which cited data from the 2003 SARS outbreak in mainland China, Hong Kong, and Singapore indicating that closing schools “did not contribute to the control of the epidemic” while recent modelling studies of COVID-19 estimate that closing schools alone “would prevent only 2%-4% of deaths.”
AAP also cited an editorial published in The BMJ in May that leans on studies of widespread community testing in Iceland and South Korea which found children were “significantly underrepresented” in positive cases. The authors also cited a case study of a cluster in the French Alps in which one child with COVID-19 failed to transmit the virus to anyone “despite exposure to more than a hundred children in different schools and a ski resort.”
The AAP recommends that older children in elementary and secondary schools wear face coverings, social distance, and space their desks 3-6 feet apart when feasible. They also suggested that schools eliminate lockers, and transition to a block schedule for older students (where classes run longer each day, but terms are shorter) and when possible, rotate teachers for each new class rather than crowd hallways with students transferring place to place.
For children in pre-kindergarten, the academy did not suggest face-masking and physical distancing, believing both too difficult to implement in that age group. Instead it advocated separating kids into cohorts, using outdoor spaces whenever possible, and limiting unnecessary visitors.
The AAP recommended that students use alternatives to buses when possible, and assign seats in cohorts for those who do take the bus. The guidance also suggested one-way hallways, limiting the number of children on a playground at once, and potentially using classrooms or outdoor spaces for meals.
When asked about children as vectors of the virus, NIAID director Anthony Fauci, MD, said on Thursday during a press conference at the virtual International AIDS Conference that there’s “an assumption that we know for sure that children are poor transmitters when as a matter of fact, we don’t have enough data to make a definitive statement in that regard.”
He noted that there are “some suggestions that they are poor transmitters” and have less chance of an adverse outcome, but the research on transmission is ongoing.
“Right now, we are doing a natural history study on 6,000 families in the United States to determine definitively whether that suggestion … is actually based in actual scientific data,” Fauci said.
At the coronavirus task force briefing on Wednesday, Birx said current infection data are “skewed” to older adults, in part because initial testing protocols sought people with symptoms.
In recent weeks, case counts in children and teens 17 years of age and younger have been creeping up, nationally now at 5.9%, versus less than 2% as of April 2. In California, infection rates in this age group have more than doubled from 3.4% two months ago to 8.2% this week.
In a statement on Friday, the Infectious Diseases Society of America and the HIV Medicine Association suggested that school systems should be concerned about “instances in which children have fallen seriously ill … and in which children have died,” given that dynamics of the virus are unknown, and that teachers and other adults may be vulnerable to disease and death. The groups called for policies on symptom screening of students and staff as well as testing, and a recognition that a substantial proportion may be asymptomatic yet capable of transmitting.
On July 10, the AAP in coordination with the American Federation of Teachers (AFT), National Education Association (NEA) and AASA, The School Superintendents Association, issued a joint statement that looked like a reaction to statements from the White House calling for all schools to reopen.
While continuing to stress that “children learn best when physically present in the classroom” the new statement warned that public health agencies should base their recommendations on “evidence not politics.”
The four stakeholder groups also emphasized that local school leaders, public health experts, teachers and parents should drive decisions regarding “how and when to reopen schools, taking into account the spread of COVID-19 in their communities and the capacities of school districts to adapt safety protocols to make in-person learning safe and feasible.”
The groups also pointedly stated that “schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts.”
Schools’ Role, Beyond Educating Kids
Dooley said evidence has shown that online learning is “not sufficient to meet children’s academic needs.”
“We’re already looking at children being now months behind in their school curricula,” she said.
At a June 10 hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee, ranking member Patty Murray (D-Wash.) said she worried school closures could exacerbate inequities in education.
Researchers project that “Black children could lose over 10 months of learning, Latino students could lose over 9 months of learning, compared to white students who are projected to lose 6 months of learning,” she said.
She also cited the story of a mother in Yakima, Washington, whose children are sharing one iPhone for distance learning and who’s not certain she can continue to pay the phone bill.
Despite these challenges, Murray underscored the importance of school districts following the advice of public health officials and letting “science drive decision-making.”
Dimitri Christakis, MD, MPH, a pediatrician at Seattle Children’s and editor-in-chief of JAMA Pediatrics, agreed that distance learning for young children simply doesn’t work.
“No one thinks you can teach a kindergartner, a first-grader, or second-grader entirely over Zoom,” he said.
In cases where it has worked, a parent has been present and helping, but that isn’t sustainable in the long-term, particularly for parents who work outside of their homes, Christakis said.
“I think we have to confront the reality that for primary school kids, not having the schools open means that a sizeable percentage of children are not learning at all,” he said.
If a child isn’t reading at grade level in the third grade, he or she is 3 to 4 times less likely to graduate high school, Christakis said, and even less likely if the student comes from a low-income family.
“We’re going to see the impact of this years from now, in terms of high school graduation rates,” he predicted.
But Dooley emphasized that beyond academics, schools are “absolutely critical” for children’s social and emotional well-being, providing free or reduced price meals and health services including mental health programs.
“Schools are also critically important for socialization for children,” she said.
The concern over the emergence of mental health challenges among kids is one factor driving Dooley’s support for reopening.
In her practice, she’s seeing children and families “every single week” struggling with anxiety and depression, as a result of not being in school, not having contact with peers, and being socially isolated.
She’s also seeing challenges with food insecurity — 30 million children receive free and reduced price lunch in schools — and children who’ve gained weight because they aren’t involved in physical education classes, she said.
Howard Taras, MD, a pediatrician at the University of California San Diego Center for Community Health and the district physician for the San Diego Unified School District, also sees the importance of in-person learning for children.
“At every stage of development, children learn how to make friends, and learn how to deal with bullies, and they learn how to test their personalities, and try different ones on,” Taras told MedPage Today. “There’s just all these things going on that are also part of the normal, natural education of children aside from formal education of children.”
That in-person contact with supportive adults is also important, Taras said.
“Abuse is often detected by school personnel,” and while child abuse rates appear to have plummeted, it’s possible that abuse has actually increased but simply isn’t being reported, he said in an email.
If the AAP is full throttle on reopening, the American Academy of Family Physicians is perhaps in first gear.
Gary LeRoy, MD, president of the AAFP, told MedPage Today in an email that family physicians “understand the importance of in-person learning for children.”
“They also understand the potential health risks of sending children back to school during a national pandemic,” he added.
Looking ahead to the 2020 school year, LeRoy stressed the need to carefully monitor COVID-19 cases in individual cities and communities “to help signal if and when the risks of attending school begin to outweigh the benefits.”
Any guidelines on returning to school should be “evidence-based and flexible” because the science concerning the spread of COVID-19 is still evolving and we “cannot predict where the next outbreak will appear.”
Asked whether the AAP’s own guidance would apply in states where cases are currently climbing, Dooley explained that the academy “would hope that even in areas that are seeing a surge in cases, that school systems are still working towards an opening of schools in some format, in-person for children, because this is really vital for their survival.”
Kris Bryant, MD, president of the Pediatric Infectious Diseases Society (PIDS), said it’s important to consider all sides of this discussion.
PIDS currently does not have an official position on schools reopening; she emphasized that she was giving her personal opinion.
Bryant echoed many of the concerns mentioned by other pediatricians around the danger of isolation for children’s development and mental health and the “variable” benefits of distance learning depending on how well-resourced a family is or isn’t.
While she described data from Iceland, for instance, showing no transmission among children as “encouraging,” she remained skeptical.
“When everything is said and done. I’m not convinced though that we will see zero transmission from children to adults or zero transmission from child to child,” Bryant said.
She stressed the need to “look at the experience of other countries that have already gone down this path … [and to] try to identify models that are similar to our situation in the U.S.”
Arthur Caplan, PhD, an ethicist and population health expert at NYU Langone Health, called the AAP’s guidance “optimistic.”
“I think we’re reopening schools just like in some ways Texas, Arizona, Florida reopened restaurants, bars, and beaches,” Caplan said. “And I don’t think it’s going to work any better.”
“I’m terrified that what’s going to happen is, kids will go back, they won’t have had their shots for measles, or mumps,” he continued. “The flu will come and COVID will stay, and we will have one viral, toxic stew that will lead to many hospitalizations and deaths, not just from COVID but from these other infectious diseases.”
The CDC identified a year-over-year drop in orders for noninfluenza childhood vaccines and for measles-containing vaccines funded through the Vaccine for Children Program (VFC) from early January through mid-April 2020 compared with roughly the same period in 2019. (The program provides federally purchased vaccines to roughly half of all children 18 or younger in the U.S.)
What About Teachers?
Lily Eskelsen García, president of the National Education Association, told CNN’s Erin Burnett on Tuesday that she worries what school reopenings will mean for teachers.
“I had 39 sixth graders one year in my tiny little classroom with one window,” she said. “My classroom was a germ factory.”
Every year she knew one of her students would pass a cold onto her, García said, adding: “This is different. This is a virus that kills people.”
She acknowledged the argument by pediatricians that “‘we have to consider the mental health of children’ – of course we do – but they didn’t say at the expense of their physical health, and they didn’t say that you should do it under all circumstances. They said when it’s safe and where it’s safe.”
Gov. Greg Abbott (R-Texas) announced last week that public schools in his state will reopen this fall, but without a state-level requirement for testing or masking.
In response, Zeph Capo, president of the state’s AFT affiliate, called on the governor to consider students’ and teachers’ safety.
“We want to see kids return to school in some way, but prudence requires that there be a health and safety plan in place to reduce the chances of spreading the deadly virus,” Capo said in a statement, suggesting that the state require every school district to develop a plan for a safe reopening and submit it to the Texas Education Agency.
National AFT President Randi Weingarten said all schools need plans to ensure they don’t become the “new hot spots of transmission.”
“A no-mask, no-testing, no-worries attitude is exactly what will spread the virus,” Weingarten said.
Bryant said she tells parents asking about their children returning to school that there is no “one-size-fits-all” answer. It depends on the individual child’s health, the school’s protocols, and the level of transmission in the community, she said.
While it isn’t feasible to keep schools closed until the virus “goes away, because that’s likely to be a long time,” Bryant expects a rocky transition.
“[T]here will be cases,” she said. “We need a plan for what to do when cases occur.”
Parents are accustomed to sending a child with a mild illness or a cold to school, she noted, but in this context that decision could have serious consequences: from now on, “sick children need to stay home.”
The Experiment Continues
While a recent Gallup poll suggests 56% of parents of children in grades K-12 support their children returning to school full-time, that leaves another 44% who have qualms.
The Clark County, Indiana school district near Bryant is offering a three-tiered model: all in-person, a hybrid of in-person and online, and an entirely virtual option.
Bryant said the model recognizes that some children may be at risk for infection, have an underlying condition, or live with someone who’s immunocompromised and need that at-home option.
“[W]hen school systems have the capability to do that and transmission in the community suggests that bringing everybody back and resuming school as usual is not the best choice, it’s great,” Bryant said. Her colleagues are also currently developing a white paper focused specifically on schooling challenges for immunocompromised students.
The AAP’s guidelines also emphasize the importance of being flexible and practical, Dooley noted.
“We may have to revise plans as we go along, and as we’re learning what works best … both from our country, but also the experiences of other countries, ” Dooley said.
She also underscored the need for robust research to monitor the return to school and to identify best practices for “mitigating the spread and the risk of the virus.”
Still, Dooley emphasized the need to “start from that starting point of having children physically present in school and then working together between our health system, our public health department, [and] our education system on how we can do that as safely as possible.”
Originally published in MedPage Today.
By Shannon Firth, Washington Correspondent, and Cheryl Clark, Contributing Writer, MedPage Today, with contributions from Associate Editor Molly Walker
More than a dozen registered nurses at Blake Medical Center in Bradenton, Florida, protested outside the hospital Friday, the third such protest since the pandemic began, saying hospital owner HCA Healthcare won’t give them N95 masks unless they are working with known COVID-19 patients, and doesn’t tell them when their patients later test positive.
As case counts in Manatee County climb, many patients have been admitted to the 383-bed hospital for other reasons, but later turn out to have COVID-19, said Candice Cordero, a telemetry nurse who works with stroke and cardiac patients in a step-down unit.
“We’re seeing more random patients test positive, and some have symptoms, but some don’t, or some are admitted for one thing, and start having (COVID) symptoms a few days later,” she told MedPage Today.
“We’re having a problem with the hospital being transparent with their numbers, and letting staff know when they’ve been exposed.”
The hour-long protest was called by members of the Blake Medical Center’s bargaining unit of the National Nurses Organizing Committee-Florida, an affiliate of National Nurses United. NNOC said in a news release that it has filed complaints about unsafe conditions at the hospital with the Occupational Safety and Health Administration. The statement said that at least four RNs at Blake have tested positive since late May.
The union further alleged that Blake Medical Center management requires RNs who have been exposed to COVID to continue working until they have COVID symptoms, does not test all patients prior to a procedure or operation, fails to provide PPE replacements for broken masks, and threatens RNs with discipline for raising safety concerns.
Officials for Blake Medical Center eleased this statement in response to the protest:
“In the midst of a global shortage of personal protective equipment (PPE), Blake Medical Center has been doing everything in our power to protect our caregivers and patient care teams throughout the pandemic and equip them to provide safe, effective care to our patients by following or exceeding Centers for Disease Control and Prevention (CDC) protocols.
“We have provided appropriate PPE, including a universal masking policy requiring all caregivers in all areas to wear masks, including N95s, in line with CDC guidance. While we currently have adequate supplies of PPE, we continue to provide safeguards that are consistent with CDC guidelines and help ensure the protection of our colleagues, not only today, but into the future as the pandemic evolves. The NNU fails to recognize the reality all hospitals nationwide are facing, that this pandemic has strained the worldwide supply of PPE, including masks, face shields, and gowns.”
Cordero said that recently one patient “was not properly screened in the ER who should have been on a COVID unit. That potentially exposed several nurses and the other patient in that room.”
When she complained to human resources officials, she said, she “was reprimanded verbally for speaking up and was told that if I did it again, I would receive discipline.”
The hospital should be testing all of its frontline workers regularly, she said. “We’re much more at risk of being exposed while at work than many other jobs out there. We really should be screened better than we are.”
Kim Brooks, who works in an ICU step-down unit for trauma and cardiac patients, assumes all of her patients are infected with COVID-19 and because of that, she said, she has bought her own N95 masks since the hospital won’t buy them for her.
“We know some of the nurses who are on non-COVID units are getting exposed to positive patients and now [some] are getting sick because they didn’t have N95 masks,” she told MedPage Today.
At the very least, the hospital should inform frontline workers when patients ultimately test positive on our floor, “so we can take precautions with our family,” Brooks said.
“Once we find out someone is positive, we do move them to a COVID unit. But sometimes there’s been a situation where that patient has been rooming with a COVID patient, and that patient is sometimes left on our unit to see if they turn out to be positive.”
By Cheryl Clark, MedPage Today
Hundreds of registered nurses marched outside the 478-bed Riverside Community Hospital in California for eight hours Monday during the fourth day of a 10-day strike. They accuse their administrators of ordering staff reductions that have resulted in dangerously high nurse-to-patient ratios that put themselves and their patients at risk.
The nurses say they’re sometimes forced to work their 12-hour shifts without taking a break to eat, get a drink of water, or even use the bathroom.
It’s all the more troubling as COVID-19 case counts and deaths recently spiked in that Southern California county, they said.
“You have to sneak the break in, or you get to the end of the day and it dawns on you that you’re dehydrated and you haven’t been to the bathroom all day,” said Erik Andrews, RN, a rapid response team member at the hospital and vice president of the 1,200-member bargaining unit of Service Employees International Union (SEIU) Local 121RN. He said he’s held on for 10 hours without a bathroom break while wearing an airtight respiratory mask, feeling uncomfortable and dehydrated, yet without a backup if he steps away.
“Each nurse is entitled to three paid 15-minute breaks and a half an hour off the clock every day,” Andrews said. “If I could find a single member who got all those breaks every day, I would keel over from shock because it doesn’t happen. And now it’s expected and accepted; we’re just taking it … when it doesn’t need to be this way.”
“You can’t get away without a safe break,” said Monique Hernandez, RN, a Riverside Community Hospital telemetry nurse and a member of the mediation team for SEIU. “That means someone who says I’m going to watch your patients while you go and put your feet up, take your mask off, go eat something, clock out. You can’t do that legally if there’s no one that can watch for you, because if something happens, that’s on your license.”
Wearing purple shirts, several hundred strikers carried signs around the hospital block for the last four days starting at 7 a.m. Some of the signs said, “Imagine wearing N95 for 12 hours with no breaks,” “Caution, unsafe staffing ahead,” and “You call us heroes yet treat us like zeroes.”
Riverside Community Hospital: “Misguided Tactic“
In a statement, Riverside Community Hospital officials called the nurses’ job action “a misguided tactic” that “create(s) conflict and spreads misinformation” and has “everything to do with contract negotiations.” The statement said that Riverside Community has “not laid off or furloughed a single caregiver due to COVID-19 and has spent $160 million to pay workers, some of whom are receiving 70% of their pay even when there has been no work.”
But labor officials insisted their strike has nothing to do with money and nothing to do with their current contract, which doesn’t expire until September. They are not in negotiations now.
From the labor union’s view, the problem is that when Gov. Gavin Newsom (D) ordered the state to shelter in place in mid-March, and routine hospital operations like elective surgeries came to a halt, Riverside Community Hospital’s administrators took traveler nurses, per-diem and part-time personnel off the schedule and limited hours for other workers. Union representatives estimated that they are between 200 and 400 people below where they need to be.
Hospital officials failed to realize that even though the census has been low, the workload and burden of methodically taking extra precautions — for example cleaning reusable PPE equipment in short supply — turn what were once quick, routine tasks into more complicated, step-by-step procedures, Andrews said.
“When you’re dealing with a disease that presumably is aerosolized, and very contagious, you need people to slow down and think carefully,” he said. But there is no staff available to serve as a spotter, “for when you’re donning and doffing your protective equipment.” Also, COVID-19 patients are not always housed in separate parts of the hospital, complicating safety considerations further, and nursing staff don’t always know a patient’s status.
Nurses as Housekeeping Staff
Kerry Cavazos, RN, the labor union’s chapter president and a labor and delivery unit nurse, said Riverside’s owners, the Hospital Corporation of America, told many members of the housekeeping staff, who are represented by a different labor union, not to come to work. That meant the nurses have to do housekeeping work.
Women about to give birth are brought into rooms that are still dirty from the last delivery, she said. “There was no housekeeper to clean it and there is still blood on the floor, so we have to clean it up. The woman needs to get in the bed because she’s having a baby.”
She and her fellow nurses are told to strip the beds, wipe the poles and the IV, and stock the rooms. “Those were never nurses’ tasks. And it’s not beyond us to do that but we have other things (to take care of patients) that we need to do,” Cavazos said.
Cavazos echoed the concerns expressed by Andrews. “I honestly do not believe this is safe for any patient for a nurse to not have any nutrition or any fluids for 12 hours. But we do it because that’s who we are,” she said.
California’s Staffing Ratio Rules
The issue of hospital nurse staffing is an important one in California, which two decades ago passed the nation’s first set of maximum patient-to-nurse staffing ratios in acute care hospitals. For example, one med-surge unit nurse should take care of no more than five patients at a time. In a telemetry unit, the nurse-to-patient ratio can be no more than one to four.
But according to Hernandez, there has been no financial penalty against the hospital for violating the ratio unless there was documentable harm to a patient that the staffing lapse could be blamed as the direct cause. A new law took effect early this year, imposing fines of $15,000 to $30,000 on hospitals that failed to uphold ratios. Labor officials said that while that is a welcome fix, state health officials have not yet begun to enforce it due to the pandemic.
The history of the issue at Riverside Community Hospital regarding staffing ratios goes back several years, as the SEIU unit tried to get administrators to take the staffing issue more seriously. The bargaining unit got a contract amendment last year that required the hospital to pay a nurse a “monetary penalty” if he or she had been required to absorb more patients than the ratio allowed, regardless of whether the ratio lapse caused harm.
“Everyone was happy and they kept their part,” Hernandez said, until a few months ago when that monetary penalty agreement expired and, sometime in late May, hospital officials declined to renew it. Days after that, which was the weekend of June 13 and 14, Hernandez said, at least one unit at the hospital failed to meet the ratio, “and it’s happened repeatedly” since the agreement ended.
by Cheryl Clark, Contributing Writer, MedPage Today
Overcoming vaccine hesitancy and access issues has become even more critical because of the COVID-19 pandemic, public health experts argued at a recent webinar hosted by the National Academies of Sciences, Engineering, and Medicine.
“Strengthening vaccine access and confidence today is more important than ever because … all across the globe we are dealing with the [COVID-19] pandemic,” Nancy Messonnier, MD, director for the CDC’s National Center for Immunization and Respiratory Diseases, said at last week’s event.
The pandemic has interrupted and delayed routine vaccinations for many people, including children, Messonnier noted.
Robin Nandy, MPH, principal adviser and chief of immunizations for UNICEF, added that a “substantial setback” in immunizations is expected. He highlighted a study from UNICEF, the World Health Organization, and others estimating that 80 million children across 68 countries were at risk for preventable diseases due to disruptions in care resulting from the pandemic.
Discussing the prospect of a COVID-19 vaccine, Messonnier said she hopes some will be available this fall, with more arriving in the winter, but expressed concern that a large number of Americans won’t be willing to be immunized.
One in four U.S. adults said they were not interested in getting a coronavirus vaccine, a recent Reuters/Ipsos poll found. Ongoing research suggests that, at a minimum, 70% of the U.S. population would need vaccine-based immunization, or infection with the virus itself, to achieve herd immunity.
In addition, vaccine confidence levels vary across different ethnic and socioeconomic groups, Messonnier noted.
“It’s very concerning to us that overall confidence in vaccines is lower in Hispanic and black communities, lower in those [of] lower income, and lower in those with lower education,” she said, citing research from the Pew Research Center.
These are also some of the same groups that are disproportionately impacted by COVID-19.
“Vaccinating With Confidence“
Messonnier noted that even parents who report that they are less confident in vaccines are more likely to get their children vaccinated when they have “easy access.”
To that end, the CDC and other public health experts are working on plans for the distribution of a coronavirus vaccine, to monitor the impact of such a vaccine, and on gaining a better understanding of public perceptions of the coronavirus vaccine in order to develop effective messaging.
The anti-vaccination movement is powerful. According to recent research, anti-vaxxers have greater influence on social media than pro-vaccine activists.
However, experts know that the impact of fear as a motivator “doesn’t last very long,” Messonnier said.
As a result, the CDC is pivoting toward a strategy of “vaccinating with confidence,” which involves identifying pockets of low vaccination, working to improve vaccine access, and taking steps to try to stop misinformation.
A child’s doctor is still the “most trusted source of information” for most parents, Messonnier said, adding that, in some cases, the reassurance of those doctors has been enough to get vaccine-hesitant parents to change their minds. Strengthening the conversation between parents and providers will be a critical part of the plan to increase vaccine uptake.
Vaccine Uptake and Access
Immunization rates among U.S. children are strong overall, with more than 90% of those under 2 years of age having received their “primary series,” Messonnier said. High rates are due in part to the Vaccines for Children (VFC) program, which has also reduced disparities in coverage and reduced incidence of vaccine-preventable diseases.
The program provides vaccines for more than half of the children in the U.S., many of whom are uninsured or underinsured, she noted, adding that despite the availability of the VFC program, children without access to health insurance are nine times more likely not to have received a vaccine by the time they’re 2 years of age.
Vaccine uptake among adolescents is a “mixed picture,” said Messonnier, with 86% receiving their Tdap (tetanus, diphtheria, and pertussis) immunization, but only 52% receiving a flu shot, and only 68% receiving one or more doses of the HPV vaccine.
Only about 60-64% of adults receive their routinely recommended vaccines, and somewhere between 35-68% of adults receive the annual flu vaccine.
There are also vaccination disparities related to race, ethnicity, and location. American Indian and Alaska Native children have the lowest MMR (measles, mumps, and rubella) vaccination rates for children under 2 years. Urban-dwelling children are more likely to receive one or more MMR doses versus those in rural areas, according to a 2019 Morbidity and Mortality Weekly Report.
While school vaccination requirements have helped to protect students from vaccine-preventable illnesses, “grace periods” that allow parents to enroll their children in school, with a pledge to visit the doctor for an immunization at a later date, have proven challenging.
The number of kids who fall into these grace periods across different states is anywhere from 0.2-6.7%. Some of these children do eventually get vaccinated, while others may be children of vaccine-hesitant parents who are taking advantage of this loophole in schools’ policies. Most counties and schools lack the staff and resources to follow up with families and determine which children ultimately did receive a vaccine.
If all non-exempt children who fell into these grace periods went on to be vaccinated, most states would see a 95% MMR coverage rate, Messonnier said.
Vax “Drop Off“
Messonnier said she’s worried about the “dramatic drop off” seen in rates of healthcare providers ordering routine vaccinations after March 13, when the White House declared the novel coronavirus pandemic a national emergency. This was particularly true for routine measles vaccination across all ages, with kids under age 2 faring slightly better than other groups, she added.
Parents are worried about exposing their children to COVID-19, and haven’t been going to the doctor, which is an “appropriate concern,” Messonnier stated.
But the CDC and the American Academy of Pediatrics want parents to know that it’s safe to go back to the pediatrician’s office, and are urging healthcare providers to encourage “catch-up vaccinations” through outreach to parents.
Many practices are implementing special preventive measures to help reduce the risk of viral spread. For instance, some are having “well child” visits in the mornings and seeing sick children in the afternoon.
The CDC is also urging public health officials and clinicians to disseminate information regarding the VFC program as there may be more families who are eligible for the program given the increasing unemployment rates, Messonnier said.
As nationwide protests sparked by the death of George Floyd enter their fourth week, the American Thoracic Society is calling for a moratorium on the use of tear gas and other chemical agents to control demonstrators.
On Thursday, ATS officials issued a statement asking law enforcement groups to stop using tear gas agents such as 2-chlorobenzalmalononitrile (CS) and highly concentrated oleoresin capsicum (OC) pepper oil due to concerns about long-term lung injury.
Concerns about the use of tear gas and other agents on the spread and severity of COVID-19 were a factor in the move, said ATS President Juan Celedon, MD, in the statement.
“The use of chemical crowd control agents is outlawed in the time of war. They cause significant short-term and long-term respiratory health injury and likely propagate the spread of viral illnesses, including COVID-19,” Celedon said.
“Based on the lack of crucial research, the escalation of tear gas use by law enforcement, and the likelihood of compromising lung health and promoting the spread of COVID-19, the American Thoracic Society calls for a moratorium of CS tear gas and OC pepper weapons use,” he added.
The statement was issued on the same day President Trump — speaking at a roundtable discussion on policing and race — praised the use of tear gas and other aggressive tactics against demonstrators in Minneapolis early in the protests, calling it a “beautiful scene.”
Sven-Eric Jordt, PhD, of Duke University School of Medicine, Durham, North Carolina, has spent years researching the impact of chemical exposures — including tear gas — on the lungs.
He told MedPage Today that a study in military recruits linked tear gas exposure to chronic bronchitis, viral respiratory illness, compromised lung function and other acute and possibly chronic lung injuries.
The study, published in the journal Military Medicine in 2014, showed that recruits intentionally exposed to CS during basic training had more than twice the risk for an acute respiratory disease diagnosis after exposure compared to before exposure.
Jordt said recent technical advances in tear gas deployment allow the gas to be dispersed over much greater areas, and the clinical impact of this wider exposure has not been studied.
Likewise, in the U.S. protests and in other parts of the world where tear gas has been widely used to disperse crowds, police tactics have changed in ways that can make exposure more problematic, he added.
“What we are seeing and what we have seen is that police are using massive amounts of these agents,” he said. “In the recent protests in Hong Kong there were days when several thousands of cartridges were used.”
He added that in many recent protests within and outside the United States, tear gas and pepper spray were deployed as a first line measure, rather than a measure of last resort.
“In U.S. cities we have seen episodes where police are boxing in protesters and then using tear gas or pepper spray when the protesters have no way out,” Jordt said.
While there are, as yet, no studies directly examining the impact of tear gas exposure on COVID-19, Jordt and Celedon both said there is cause for concern that exposure may promote SARS-CoV-2 transmission.
Someone exposed to tear gas would be likely to quickly take off protective masks due to contamination, and maintaining a safe distance from other people would probably not be their main concern, Jordt told MedPage Today.
COVID-19 patients also often report loss of sense of smell, which could increase their risk of unknowingly inhaling dangerous levels of tear gas. And tear gas makes people cough, enhancing the virus’s spread if those individuals are currently infected.
“We have seen a dramatic escalation of (tear gas) use that I fear may become normalized,” Jordt said. “We have to reassess the safety of these agents with state-of-the-art toxicological techniques.”