This week, my kids missed two days of camp with the dreaded summer cold. Normally, I would’ve written it off as annoying, but with the Delta COVID-19 variant on the rise, I kept them out of camp — it’s always fun to swallow the cost — and took them for tests. Both of them are negative, but I feel like so many of you right now: Is it only a matter of time before a new surge takes over and targets our unvaccinated kids? That, coupled with the alarming news that the J&J vaccine might not be as protective against the new variant, and I feel back at square one.
I talked to Dr. Kristin Moffitt, pediatric infectious disease specialist at Boston Children’s Hospital, for answers on Delta, J&J, unvaccinated kids, and more. For those of you in my shoes, wondering what’s next, here are some answers.
There’s news this week that J&J’s vaccine might not be as effective against the Delta variant. Should a parent who got J&J now seek out a Pfizer or Moderna booster to protect their under-12 kids?
Having had a chance to very briefly review the non-peer-reviewed study that I think the New York Times and other articles are based off of is that I think people need to understand that, when studies like that are referenced, first of all — not only have they not been peer-reviewed, but studies like the one referenced in the news are lab-based studies.
These studies have taken serum from individuals who received the J&J vaccine and use a petri dish to look at the effectiveness of vaccinated sera at neutralizing the virus and compare it to sera from people who got Pfizer or Moderna. It’s not always appropriate to assume that what is being detected in a petri dish is going to apply to our real-world experience with these vaccines. The trends are often similar, but it’s not safe to assume that you can directly translate from these lab-based studies what’s going to happen in real life in our population. I always start with that caveat.
I do think that we don’t have a ton of data yet on the effect of boosting with an mRNA vaccine.
If we were to reference the experience from studies of people who got a similar vaccine, like AstraZeneca, and then getting boosted with an mRNA vaccine, like the Pfizer vaccine, I think what we’re starting to get a better sense of — we still need a little bit more data — is that, indeed, that looks like it might be a valuable approach toward getting better protection against variants.
So should a parent who got J&J assume that they’re more likely to transmit Delta than a parent who got Moderna or Pfizer?
I think that what these data suggest is that they may be more likely to become infected with the Delta variant than someone who got Pfizer. It’s a little nuanced, and I think it gets missed in some of the coverage. But, yes, based on that possibility, I think a parent who got the J&J vaccine should be —frankly, I would say this about anybody living in a part of the country where cases are surging, regardless of what vaccine you got — taking some extra care if you have either immunocompromised or vulnerable people in your household, or people who have not yet been able to be vaccinated.
What does that look like?
For me, that includes having a stronger consideration for wearing a mask when you’re headed indoors and might not be able to socially distance from people you don’t know. If you’re headed indoors in a setting that might otherwise be crowded with people whose own vaccination status you don’t know, I would strongly consider a return to wearing a mask, even if you’re vaccinated, and that’s especially true in parts of the country that are seeing really concerning surges right now.
In case people are scared who got J&J: The vaccine still prevents you from getting seriously ill or dying, even if you get infected?
That’s exactly right. For all of the vaccines authorized in the United States, the data are still very clear that every one of them is very effective at keeping people from getting sick. So I think that is an important point.
How dangerous is Delta or other variants for kids under 12?
We don’t yet have clear data that Delta causes more severe disease, and that’s true across all age ranges. What makes it more dangerous is how unbelievably capable it is of transmission. Its ability to spread is what makes it more dangerous, because then it becomes a numbers game. If it can infect that many more people, even if the overall percentage of people who are going to get severe illness from that infection stays the same as it did with variants circulating last year, if it’s that much more transmissible, you’re going to see more people getting severely ill. There has been some not very well controlled data that suggested that people can get sicker from the Delta variant than other variants, but I think well-controlled data to demonstrate that are lacking so far.
The big question looming on every parent’s mind is schools reopening in the fall, and how safe it will be. There was some difference in guidance between the CDC and the American Academy of Pediatrics in terms of mask-wearing, with the AAP recommending it for everyone, even those who were vaccinated. It seems like there’s a lot of mixed messages. What safety measures should parents push for and expect from schools?
I can certainly appreciate that parents are feeling confused by what seem like different messages. But my take on the CDC guidelines, compared with the AAP guidelines, is that they’re actually similar in a number of ways. First and foremost, they both prioritize everyone being back in school full time, in person, come fall. Beyond that, the CDC’s recommendation was that vaccinated students and staff don’t need to wear masks while unvaccinated students and staff do. But the CDC emphasized that this recommendation should be modified based on what’s going on at a community level with transmission.
The AAP took that a step further. We have to remember that the CDC guidance came out a month ago. We were just starting to see Delta. The AAP guidance is going a step further in saying there’s enough variability across our country right now, in terms of rates of transmission and rates of hospitalization, and vaccine coverage. The safest approach to keeping kids in school and keeping them safe is to have everybody wear a mask regardless of vaccine status.
We learned so much last year, with schools that either had a hybrid approach, or had some component of in-person learning, that transmission within schools really was able to be minimized when a layered approach to safety was taken. Probably one of the most important pieces to that approach was to mask at school, and that was when no vaccines were available.
What’s the rationale for the youngest kids in day care not needing to mask? Is that age group not as susceptible?
That may change. I think that every child-care center is thinking carefully about all of the dynamics involved that keep children and staff in their center safe. I think part of that rationale historically had been that we really weren’t seeing a lot of transmission in day-care centers. We were certainly seeing 2-, 3- and 4-year-olds get infected, but most of those infections were coming from household contacts. As long as staff and adults in day-care centers were masked, and again, this is all pre-vaccine availability, and as long as good health-screening measures were in place, we really were not seeing a lot of transmission.
You have to take on balance what a day in the life of day care looks like for a 2-year-old, who would be taking a mask off to eat, they’d be taking a mask off to nap, and they’d be spending as much time of their day unmasked as masked.
Even with Delta, can a vaccinated grandparent hang out inside, unmasked, with kids under 12? Or are you afraid of transmission?
The risk in that scenario would have a lot to do with geography and understanding what the grandparents’ exposures might be like. If it’s a grandparent who lives in a part of the country with very good vaccine coverage, and that grandparent is also taking regular safety measures to keep himself or herself protected, then I would still feel very comfortable with that.
What are those measures, for grandparents reading this? I hear from people who say, “My mom loves to hang out in casinos!”
Sitting for hours in a casino indoors, depending on the ventilation and surrounded by strangers, is not a low-risk scenario in my mind. I think it may involve some difficult conversations with family, but I think it’s about mitigating risks as much as possible and keeping your time unmasked indoors with strangers to a minimum. I think to take off your mask indoors to eat is reasonable, especially if you can still be distanced relatively well from other tables. Those are still relatively low-risk scenarios for vaccinated individuals.
Air travel with kids under 12: Are you leery of that right now?
We actually gained a lot of data throughout the course of the pandemic to suggest that when people are masked for the duration of their flight, transmission on airplanes actually was really reasonably controlled. And, again, that was before vaccines were available for anyone. Masks are still required in airports and appropriately required on airplanes. I would be keeping that in mind as a parent. If I had someone who was too young to be able to wear a mask or unable to wear a mask for the duration of a flight, I would be a bit more worried.
When are kids getting the vaccine?
Pfizer and Moderna both have clinical trials in those 12-and-under groups in similar phases of completion. But at least for Pfizer, we know that they plan on having data in 5- to 11-year-olds likely available initially in September, but now it’s looking maybe like October. I think they still have the goal of submitting for emergency-use authorization sometime early to mid-fall. Realistically, with what the FDA is going to be requesting and looking at in terms of safety data, authorization might be more likely to happen in late fall or early winter. It would be a little bit behind that for the 2- to 5-year-olds and then even some months behind that for 2 years down to 6 months.
Should parents just assume any symptom is COVID and go get a test — or when is a runny nose just a runny nose?
It’s really tricky, and what makes it tricky is that the symptoms have looked different in kids to some extent than they have in adults, and that’s throughout the duration of the pandemic regardless of what variant was circulating. But we certainly are getting more data with cases in children happening now that the majority are presenting with symptoms of an upper respiratory infection and often the absence of fever.
With the availability of testing being so markedly improved, compared with where we were at a year ago, that I would err on the side of testing for reassurance for that family.
The stock market is tanking. It seems like a new surge is looming. Any reassuring news on the horizon?
I would say the reassuring news is that we do know enough now about how to keep schools safe. And we do know enough now, and we’re still learning, how detrimental school closure, especially for prolonged periods of time, is to children. The reassuring news is that schools should, and can, remain open safely and that everyone seems aligned on that priority.
What that is going to look like is something that’s being determined community by community. But compared with where we were a year ago, we have vaccines that are so effective at keeping people from getting sick from COVID-19. I don’t know if our population at large appreciates how unbelievably fortunate we are to be in that position.
Last but not least, is it still the common thinking that kids in general are less likely to have severe outcomes from COVID?
That is still very much the thinking. But I would just offset that, because that gets into the argument about then, really, should we even be vaccinating our very young children? It leads to questions about risk tolerance, and what’s acceptable risk in children. We are all so grateful as pediatricians and parents that it has held true that children are much less likely to get severely ill from COVID-19 infections.
But as both a pediatrician and a parent, it does still worry me that tens of thousands of children required hospitalization for COVID-19 infection, and several hundred have died, and several thousand have been severely ill and required hospitalization and intensive treatment for MIS-C associated with COVID-19 infection. I take assurance in the risk of severe infection being so much lower in children, but those risks still to me are concerning.
This interview has been edited and condensed.