You may be tired of hearing from me this week! Don’t worry, next week it’s back to twice a week posting.
(And thanks for lots of helpful feedback on the decision tool yesterday. Look out for version 2.0…)
Panic in the Headlines
Early this week headlines proclaimed, “97,000 children tested positive for COVID-19 in the last two weeks in July.” Panic ensued in my inbox and Twitter feed.
“This means we cannot open schools!”
“Kids are actually the MOST likely to get it!”
“Help me! What does this mean?!”
The source of this fact is this (mostly) very helpful report the CDC put out, with all kinds of details. They are combining data from many states on pediatric cases, looking at case counts and hospitalization rates.
(Note: “children” is a broad definition here and varies by state. In most cases it is 0 to 17, although Alabama thinks of all people under 24 as children).
The top line number in the report is that, overall, based on positive tests we have so far, the COVID-19 rate in children is 447 cases per 100,000 children. This means that of every 100,000 children in the US, 447 of them have tested positive for COVID-19.
The report also includes a hospitalization rate, and a death rate. About 2% of cases are hospitalized, for a rate of 9 in 100,000 people. The death rate is 0.13 in 100,000.
The question is: what to make of all this? Here are some reactions, and some responses…
I thought kids didn’t get COVID-19, so this is really shocking.
Kids do get COVID-19. I think a number of policy-makers, including the President, have done a huge disservice by making claims that children do not get COVID-19. They can. But this isn’t news from this study.
I thought kids were less likely to get it
This is true, and not disproved by these data. If you dig into the CDC report you can see that in places which are doing a lot of testing (like New York), kids represent a small share of cases. This suggests they are less likely to get COVID-19 than older people.
But, honestly, these data are not the best way to learn these facts. We have lots of information out of Europe and elsewhere on kids and COVID-19 (check out this summary). The inconsistent testing, poor “child” definitions here, the fact that kids are often asymptomatic…all of this means that these numbers don’t really mean that much. The actual rate is probably higher for this whole age group (because we do not test enough asymptomatic people) and probably lower for younger kids. The data is just incomplete.
Can we learn anything?
For me, the most useful information out of this is the information on hospitalizations and deaths. Hospitalizations for COVID-19 are much better tracked than cases, and not nearly as subject to the testing issue. Looking at the hospitalization rate, we can say something about how likely children are to be seriously ill.
And, as I said above, the hospitalization rate is about 9 in 100,000 in these data. How can you contextualize that?
In the 2019-2020 flu season, the hospitalization rate for flu was 94 per 100,000 in children 0 to 4 and 24 in 100,000 in children 5 to 17. This averages to about 47 in 100,000 over the whole age range. This is about 5 times higher than COVID-19. This isn’t a hospitalization rate per case — it’s an overall rate, taking into account both likelihood of getting the disease and severity. Put simply: children were more than 5 times as likely to be hospitalized for flu over this period than for COVID-19.
The flu death rate for children per 100,000 is about twice as high as the COVID-19 death rate.
Kids may be more likely to get COVID-19 than the flu, but they are much less likely to become seriously ill from it. Not just less likely conditional on getting it, but less likely overall.
Okay, great, so that means that schools are fine? Or not fine? What?
In my view, these data are a nothing-burger in terms of schools. In a sense, they tell us things we already know: kids can get COVID-19 but it is typically not serious. But opening schools is about much more than this — it’s about transmission, adults transmitting to other adults, transit to school, etc. On top of the fact that there are benefits to school which are not (obviously) captured here.
Conclusion: please do not panic every time there is a scary headline. Breathe, read the context and think about what we learn.
Most Common Question: Pregnant with a Toddler
Many weeks ago, I wrote a very long piece on a decision process for many things in COVID-19, notably grandparents and child care. You can revisit it here, but to highlight there was a 5 point “decision framework”:
Frame the Question
I thought it might be useful to revisit this, briefly, today in the context of the question I get by far the most. It is a version of: “I am pregnant, due in October, and I’m trying to decide whether my two year old should go back to day care.”
Frame The Question
Should I sent my toddler back to day care or…what? In many cases, especially with a newborn at home, the alternative is to keep the toddler at home in whatever child care solution the newborn has. But your choice may be slightly different. If the newborn is planning to be in out of home child care, this probably changes the calculation.
Just two notes on risk mitigation. First, make sure the child care solution you choose has some simple symptom monitoring and case reporting. This will go a long way to lowering the risk of in-care transmission.
Second, totally independent of COVID-19, you should be careful about having your toddler interact with your infant before the have their first shots. Infants are more susceptible to (non-COVID) illnesses and they will need more intensive treatment if they, say, get a fever. So it’s always worth being careful of these interactions in the first month or two. (I talk about this some in Cribsheet, in the non-COVID world).
The key question I think people are grappling with here is how risky is this? This combines a few pieces: how likely is my toddler to get COVID-19 in child care, how likely are they to transmit to the family (either pregnant person or infant), and how likely is it that serious illness will result in anyone in this chain?
One piece of this relates to the prevalence around you, so I’d probably start everything by going to Johns Hopkins and checking out the situation in your area. There is no hard and fast rule about what is a “low” prevalence, but at least you can get some sense of the chance of exposure.
Of course, what you really want to know is the risk of your child getting infected at child care, and our data on that is poor. What we do have generally suggests pretty low risk — you can see some data from crowd-sourcing here, and all the data that we could find on state-level outbreaks here. There have been some cases in child care centers but the fact is that this risk is low.
You can refer above to the information on the chance of your child getting very sick. In terms of in-household transmission, the best evidence we have is probably from this South Korea study which showed very limited transmission from younger children within the household. So that is also reassuring.
What if you do get COVID-19? COVID-Explained has some resources here on COVID in pregnancy, most of which is very reassuring. A few weeks ago everyone panicked when the CDC said pregnant women were more likely to be hospitalized with COVID-19 than non-pregnant, but what most coverage failed to note is that this included hospitalizations to give birth. Sigh. Infants do seem to be at slightly higher risk than older children but, still, very low.
How do we aggregate all of this? There is a low probability of infection, and then a low chance of transmission and then a very low chance of serious infection. Small times small times small equals small.
It may actually be more helpful to refer to the flu information above. If you send your toddler to child care they are more likely to get seriously ill from the flu than from COVID-19. This flu would also be much more dangerous for you and your infant. The fact that you probably wouldn’t be having this conversation in flu season suggests something about your risk tolerance (not something bad! These risks are also small!). But I think it puts this all in some context.
You do not need me for this. What is the value to your family? How much do you think your toddler needs socialization? Are there other (less risky) social opportunities? How difficult would it be to have the toddler home during parental leave (if you have it)? Do you have other help?
Don’t ignore the mental health benefits here. I think we too frequently forget that parental happiness and sanity should be valued in these choices.
…and then move on. You’ll never really know if the decision was right ex ante. This is part of what makes this especially hard here. There is so much uncertainty, so much fear, that it is difficult to ever really feel “happy” with your choice. What you can feel happy about is the choice process. So make that the goal.
Keep the thoughts coming. I cannot write back to everyone but I do read all of your emails, I promise.
Where to Find Me