Hina Talib felt she had an understanding of Covid—or at least as much as any one doctor could have. She was accustomed to seeing it: She is a pediatrician, and an attending physician who directs a postdoctoral fellowship at the Children's Hospital at Montefiore in the Bronx. She is an associate professor at the Albert Einstein College of Medicine. She has abundant experience talking about Covid: She is a spokesperson for the American Academy of Pediatrics and a public health influencer with 53,000 followers, a position that brought her to the White House in November to discuss child vaccination with Jill Biden.
And she is a mom, parenting two kids in Manhattan with her husband—which gave her a whole new perspective when her preschooler daughter, who had just turned 4, developed a fever, and tested positive for Covid. It was two weeks after the Omicron variant was identified and just a few days before the holidays began. Talib and her husband were vaccinated and boosted, and their 5-year-old son had recently gotten his second shot. Still, “a tsunami of Omicron hit our household,” she says. She and both kids ended up getting sick. (Her husband showed no symptoms, she says, and his rapid tests were negative.)
Weeks later, all three have recovered from what the Centers for Disease Control and Prevention would consider mild cases—which is to say no one needed to visit an ER or had breathing problems that required hospitalization. Nevertheless, their lives were disrupted: As first one and then another positive test retriggered the 10-day countdown to safety, their family isolation period stretched to a month. The more lasting disruption, Talib says, is to her own sense of certainty and control. “I had been so cautious,” she says ruefully. “I'm a frontline pediatrician; I take care of people with Covid. I take the subway. I live in dense New York City. Yet I’d been able to keep Covid out of my home. And then all of a sudden it’s parading around my bedroom and sneezing and jumping on my bed.”
Talib and her family were not vulnerable because their luck ran out, nor merely because Omicron is so transmissible that it turns epidemic curves into lines that go straight up. The gap in their family’s armor was their daughter being one year too young to be vaccinated. Like millions of other US families, they balanced the benefit of her going to preschool against the risk of her becoming infected, knowing the tool that protected the rest of the household was not yet available for her. And, like millions of other families with very young kids, they were distressed they could not do more.
“As each age cohort of children were able to get these vaccines that are so amazing, their parents were able to make a different risk-benefit decision and feel in control,” Talib says. “But the parents of littles have been left out. The risk thinking has been really hard for parents who would have otherwise vaccinated but didn't have that option.”
Children have long been considered the population least vulnerable to severe Covid illness, but Omicron has changed the game. The American Academy of Pediatrics, which publishes regular analyses of Covid data, said last week that cases among US kids “are increasing exponentially” and have tripled since Christmas. Almost 8.5 million people younger than 18 have tested positive since the pandemic began, the organization said, but more than 10 percent of those cases occurred in the past two weeks.
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“Pediatric hospitalizations are at the highest rate compared to any prior point in the pandemic,” CDC director Rochelle Walensky said Friday in her first solo media briefing in months. In kids too young to be vaccinated, according to data from the US Department of Health and Human Services, the rate of hospitalization went from 2.5 per 100,000 to more than 4 per 100,000 since mid-December, compared to a steady 0.6 per 100,000 in 5- to 11-year-olds.
In kids 5 years old and up, the narrative that Covid—and especially Omicron—produces mild illness may have undermined demand for the vaccine. As of January 7, according to the CDC, just over half of 12- to 17-year-olds are fully vaccinated, and 16 percent of 5- to 11-year-olds are. Those low rates may be responsible for Omicron’s increasing burden on kids overall: The highly-contagious virus finds a home in the unvaccinated and doesn’t discriminate between “not vaccinated yet” and “not allowed to be.”
The option of vaccinating the youngest kids won’t be available for a few months more. In December, Pfizer—the only manufacturer whose vaccine has been approved for children and teens—announced that the regimen tested in clinical trials for kids younger than 5 appeared inadequate. The initial two-dose regimen, each containing a tiny amount of antigen (3 micrograms, one-tenth the dose adults receive), produced an adequate immune response in children 6 to 23 months old but not in children 2 to 4 years old. Following an external review, company officials said they would study the effect of a third dose, administered two months after the second one.
The addition of that third shot would make the vaccine for the youngest children more like the regimens given to everyone else: effectively a three-dose series, two plus a booster. (The FDA and CDC approved adding a routine booster for 12- to 17-year-olds last week.) But the need to test that third dose will push authorization of the youngest kids’ vaccine back down the calendar. Principal investigators in the Pfizer trial sites estimate that it can’t come before April. If a three-dose series is authorized, the youngest kids might not be fully protected until summer vacation starts.
Pfizer’s reevaluation is aimed at achieving the best result for the youngest children: doses that are small enough to avoid side effects and cumulatively produce a durable immune response. Investigators agree that’s the goal. But many of them have children of their own, and they feel the anguish of parents who want to better protect their kids right now.
“I have actually been fielding a lot of calls from really desperate families who are at their wits’ end,” says Yvonne Maldonado, a pediatrician and professor of epidemiology and population health at the Stanford University School of Medicine, and principal investigator of the Pfizer vaccine trial there. “I don’t have great answers. It’s frustrating and it is frightening.”
It’s some comfort, she points out, that so far Omicron appears to produce mild symptoms in many kids—though whether the variant is truly mild in all individuals or only blunted in population-level studies by more widespread immunity remains to be untangled. “The likelihood that a child will be hospitalized is well under 1 percent,” Maldonado says. “But still, it's not zero. Where we work, we’ve seen lots of children come into the hospital with respiratory failure or, at the very least, respiratory distress where they need to be on oxygen. That can be really distressing to families. And we don't know what the long-term consequences of having Covid are going to be in adults or kids.”The rise in kids’ case numbers has also made it harder to manage the return to school for the spring semester. “Our school district set a metric of 5 percent positivity, and in one day back almost all the schools reached that metric,” says Kawsar Rasmy Talaat, a physician and associate professor of international health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, where she leads a trial of the Pfizer vaccine for kids 12 and under. “Just because of the sheer numbers of people getting infected with Omicron, we're seeing a huge increase in the number of children also being affected and hospitalized.”
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Nationwide, the school picture is chaotic. In the week beginning January 2, 5,409 US schools switched to remote learning on at least one day, according to the tracker Burbio, which aggregates more than 80,000 K–12 calendars. Schools in Atlanta and five Georgia counties returned to classrooms Monday after a delayed start to the year, while ones in the Twin Cities and suburbs went remote to protect students. In New York City on Tuesday, students staged a citywide walkout to protest for social distancing and remote options, and in Chicago, the teachers’ union agreed to end a five-day walkout over safety concerns. In northern Virginia, parents reported receiving pleas to stand in as substitutes, and in Michigan, a teacher tweeted about schools missing entire grade levels of staff.
Parents constantly think about risk, whether that’s when introducing their kid to solid food, letting them climb a stepladder, or deciding whether to send them to school during a bad flu season. But thinking through the risks of Covid is uniquely challenging, because official advice has seemed to shift so often—and because, in addition to the vaccine, new treatments like antiviral pills and monoclonal antibodies aren’t yet available to younger kids.
“The common cold and flu and RSV are known entities,” says Jennifer Shu, an Atlanta pediatrician in private practice and medical editor of the American Academy of Pediatrics’ parent advice site. “We have some remedies, including antivirals approved for the flu. Whereas for Covid, even though there are multiple medicines, many of these are not approved under the age of 12. So they're not even an option for children.”
And if children cannot be vaccinated, the only option left is to create a protective bubble around them. “I would make sure that everyone around your child is vaccinated and boosted, if possible: Parents, older siblings if they are eligible. Teachers, other adults, day care providers,” Talaat says. “It requires the stuff that we have been doing for almost two years now. Though it’s getting a little old, I am sure.”
But what happens if, despite everyone’s best efforts, your pre-K kid gets infected? In the early days after her daughter tested positive, when she was trying to prevent transmission to the rest of the family, Talib was shocked to discover how far the official advice on managing Covid infections at home diverged from what was actually possible with such a young child. The family wore masks during the day, but it wasn’t practical to sleep in them, and the daughter would sneak into her parents’ room at night. Talib could try separating the kids and staggering their mealtimes, but with the whole family isolating, the kids were each other’s only playmates. And though she could hide in her bedroom once her own symptoms started, letting her husband manage the kids, “you cannot isolate a 4-year-old,” Talib says. “The guidance we have right now does not speak well to the situation of having a 0- to 4-year-old and ongoing household exposure.”
It may be the last, longest frustration of the pandemic: The cohort that we feel the greatest evolutionary impulse to shield turns out to be the one that takes the longest to protect.
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