Sure, Go on Vacation with Your Unvaccinated Kids — Away from Unvaccinated People
Your unvaccinated child is nothing like a vaccinated grandma.
We all have mental lists of the things we’ve missed most during the pandemic, and we’re eager to get back to some semblance of normalcy that seems promised by the vaccines. While the CDC has affirmed that vaccinated adults can safely get together, parents still have to consider what gatherings and travel mean without the ability to vaccinate their children for many months to come. It’s been suggested that children’s mostly mild infections and low susceptibility to severe outcomes eases this decision-making because parents can think of their unvaccinated child’s risk of the worst outcomes — hospitalization and death — as less than the risk faced by vaccinated older adults. In terms of direct risk to most children, based on the (very incomplete) evidence we have to date, that much is true.
But making the leap from that fact to the idea that parents can blissfully tote along their unvaccinated children to whatever vacations or gatherings they want, as a recent article in The Atlantic proposed, is faulty — and dangerous — logic. Let’s examine why. And then we’ll get to what parents can do with their kids without increasing kids’ risks or endangering public health.
Let’s first examine the argument that the kids will be all right. It’s true that children ages 5–17 have the lowest death rates from Covid — though it’s unclear where the 99.9% protected statistic in the Atlantic article comes from when the CDC link provided only shows comparisons of rates between age groups. It’s also “absurd,” as Tara Smith, PhD, a Kent State University epidemiologist, put it, to phrase risk of death from Covid for kids in terms of vaccine efficacy.
Regardless, typical children have extraordinarily low rates of hospitalization and death from Covid, and that’s reassuring.
But note that I said “typical” children. That’s because our data in children is still woefully inadequate, and we can’t necessarily extrapolate that data to all children when many children have underlying conditions — recognized or not — that increase their risk. Further, it’s well established that Black and Latinx people have substantially higher risks of severe illness and death, and Black and Latinx children similarly have disproportionately higher risks of Multisystem Inflammatory Syndrome in Children (MIS-C), a risk increase not specific to the US. Meanwhile, children with disabilities may also have increased risk of poor outcomes from Covid, and that population could include up to 17% of all children.
“It’s irresponsible to reduce risk to kids into a single number,” wrote “Dr. Molly Malacostraca” (pseudonym) on Twitter. “Health risk is incredibly unequally distributed in our society. Let’s be honest here. You were talking about upper middle class white kids with easy access to health care and no disabilities.”
The bottom line is that we don’t really know what will happen if infections increase substantially in children, given how well protected many children have been throughout the pandemic.
“Hypothetically, if we let all the kids out and everybody have free rein because they’re ‘less affected’, you’re going to find a lot of these kids who have been particularly sheltered are the most vulnerable ones, and the picture could look really different,” Dominique Heinke, ScD, a postdoctoral researcher and Harvard-trained epidemiologist, said. “You find all of these vulnerabilities that you didn’t know existed. That’s part of where it’s particularly dangerous.” Children’s infections have been undercounted from the start because so many have mild or asymptomatic illness, so there’s a lot we still don’t know. That’s especially true when we consider how little we know about Covid and obesity in children.
According to the CDC, nearly 1 in 5 children (18.5%) between the ages of 2–19 have obesity, with slightly higher rates for Black (22%) and Latinx children (26%). A small case series of 50 pediatric Covid patients from early in the pandemic found that obesity was the most common underlying condition, and six of the nine patients with obesity required mechanical ventilation. This case series is too small, and from too early in the pandemic (before we learned more about appropriate clinical management), to extrapolate to the larger population, but not much else has been published. It therefore raises questions about what we don’t know until we see children more exposed to the virus. Children have remained relatively protected throughout the pandemic, at least among parents following recommendations, and those in school are most often protected by masking, distancing and cleaning interventions at the school. (Some — but not nearly enough — also receive protection from improved ventilation.)
“One of the things we’ve done by limiting kids’ exposures with school interventions — including remote schooling— is remove them from part of that equation,” Heinke said. “They’re taken out of that system of transmission mostly.”
But that’s likely to change soon, even before the summertime. As Heinke wrote in a Twitter thread, “As more schools go in-person, kids will have more contact with each other, both in classrooms and in sports, play dates, etc., so the infection rate is also likely to increase in this group.” With more interactions, risk of transmission increases, and not all schools have the resources needed to implement all the recommended mitigation measures.
Then there are the non-death outcomes in kids. It’s true that long Covid appears to occur more often in older age groups, though, again, that’s based on the limited data we have without high prevalence of disease in kids. But what we still don’t know is what long, long-term effects might show up years from now in children who even had asymptomatic infections. That certainly doesn’t mean we have to lock our kids up for years until we have those answers, but neither can we just leap into normalcy assuming that all will be fine. There are shades of gray between those extremes.
Some argue that MIS-C, the most commonly reported complication in children, is rare and therefore less of a concern. But “rare” is relative. The CDC reports 2,617 cases through March 1, including 33 deaths, and those figures represent the numbers without uncontrolled Covid spread in children, as we’d be likely to see in a summer free-for-all. (More on that in a moment.) More than 2,500 cases is certainly rare compared to the hospitalizations and deaths among adults, but recall the panicked fear that swept the US a few years ago when mysterious cases of polio-like acute flaccid myelitis began appearing. There have been only 650 cases since 2014, but that didn’t stop parents from worrying when we were still learning about the condition. (Interestingly, social distancing in 2020 probably reduced cases last year.) It’s easy to dismiss 2,500+ cases — probably underreported — in one year as rare compared to the looming death figures the US has seen in the past year, but it doesn’t feel rare for the 2,500+ families who spent several weeks with their child in the hospital. And we’re still figuring out how to track these children long-term and learn whether they will experience long-term effects as well.
Kids Aren’t the Only Ones to Worry About
But, some argue, these are only things to worry about if kids get infected. Instead, high immunization rates will lead to herd immunity that reduces spread of the virus and protects children from infections, they argue. It’s true that as vaccine coverage increases, virus circulation should decrease. But the idea that we’ll reach herd immunity by summer isn’t just wishful thinking — it’s mathematically impossible. Herd immunity is incredibly complex, but experts initially estimated it would take at least 70% of the population to be immune to reach herd immunity. That number has since inched upward toward 90% — and youth under 18 make up nearly a quarter of the US population. Even if we assume most teens will get vaccinated, the US has 60.5 million children ages 14 and younger, about 18% of the population. With every eligible adult vaccinated — an unlikely feat to say the least — we will fall well, well short of anything close to herd immunity. Only 13% of the US is vaccinated right now — about a quarter have received their first dose — and we’re just a few months away from summer. The Bloomberg Vaccine Tracker estimates it will take 5 months to vaccinate 75% of the population. NPR’s estimate based on CDC data is 85% coverage by January 2022.
So what happens if we’re not at herd immunity and parents bring their kids to Disney parks, airports, family gatherings with a mixture of vaccinated and unvaccinated adults, and similar places? Kids will pick up infections. Herd immunity won’t protect them. Instead, the virus will find susceptible hosts, and kids will be prime pickings. Even if the rate of infection in children — which we still have poor evidence on — remains constant, kids will still gradually make up a greater and greater percentage of the infected population. So traveling or socializing this summer means it’s extremely unlikely that you’ll be in a “low-disease environment with the equivalent of your vaccinated older parent” unless you’re in small groups with vaccinated friends and family.
That means more MIS-C cases, more questions about long-term effects, and more transmission, including transmission to unvaccinated adults and adults for whom the vaccine cannot protect them because of immuno-compromising conditions or other reasons. (We have extremely sparse evidence on how well any of the vaccines protect adults with autoimmune disease, cancer, a history of organ transplants, or conditions requiring immunosuppressive medication.)
“Children can be silent spreaders and infect those around them,” said infection prevention specialist Eli Perencevich, MD, a professor of medicine and epidemiology at the University of Iowa’s College of Medicine. “Many high-risk adults are still unvaccinated. High-risk adults aren’t easily identifiable, so just letting kids roam as if vaccinated, could potentially put these high-risk adults at risk.”
And that leads to the biggest problems with the idea that traveling anywhere with your unvaccinated children this summer is no big deal or that you can think of your unvaccinated child as a “vaccinated grandma.” “We are starting to get evidence that vaccinated individuals are less likely to transmit Covid, whereas kids absolutely can and do transmit the virus,” Heinke tweeted. “Thus, unvaccinated kids cannot be treated as vaccinated adults,” unless they’ve recovered from a documented Covid infection, she added in an interview.
It’s an incredibly privileged and self-centered perspective to focuses only on risk to children without regard to the impact on public health or the potential for new variants to arise as infections travel through the pediatric population.
“I was blown away by the inability to acknowledge that your kids might pose a risk to other people, and while you might think they’re safer and lower risk, they’re not lower risk to everybody else,” said Saskia Popescu, PhD, an epidemiologist at the University of Arizona in Phoenix. “The article was only concerned about the kids being sick. It negated all the people coming into contact with them. It was just an inconsiderate take, and the ideas it promotes are reckless and inaccurate — in a way that is particularly upsetting right now as we work so hard to avoid another surge and distribute vaccines.”
Popescu pointed out that it’s a very privileged, Western-centric view to assume you can travel wherever you want and not worry about the support staff or other travelers you’ll come into contact with. If you decide it’s okay to travel internationally, you’re not accounting for risk to the residents of the country you visit.
“I think we’re missing a lot of the infections in kids,” Heinke said. “That means we’re also missing the fact that they’re potentially transmitting it to each other and the adults around them.” She also pointed out in a Twitter thread an easily overlooked behavioral element: “As adults become less vulnerable thanks to vaccines, they’re going to lower their guard for themselves and probably their kids. And mitigation efforts will fall.” Plus, more and more states are opening up now. “This will be combined with loosening restrictions on businesses and activities, so infected kids (often asymptomatic) are more likely to be indoors together (restaurants, movie theaters, etc) or with unvaccinated adults, so transmission continues within these populations,” Heinke tweeted.
“It’s such a misleading piece,” Heinke told me. “There’s so many people who want it to be true that makes it really hard to correct it.”
Finally, the variants are a problem the Atlantic article dismissed almost out of hand. The problem with variants isn’t whether the UK variant or another existing one is riskier for kids. It’s true that it’s not and that the vaccines appear to protect well against it. The problem is that the more the virus spreads, the more opportunity it has to evolve.
“If we treat kids like they are vaccinated and let them, while unvaccinated, go back to full interactions as if they were vaccinated, we will likely increase spread among the unvaccinated, and spread is what leads to new variants,” said Matthew Fox, DSc, a Boston University epidemiologist. “That’s a slow process, so we don’t want to be overly alarmist, but we do want to continue to keep spread down. Treating the unvaccinated like they were vaccinated just because they are low-risk for serious complications won’t accomplish that. I’m not arguing at all for treating kids the same as we do now once most at high risk are vaccinated, but that’s not the same as saying treat them like they are vaccinated.”
It’s not impossible that new variants could cause more dangerous infections in kids than the currently circulating variants, nor is it impossible that new variants could arise that are not as well prevented by the current vaccines.
“What about the county public health workers who are flat out exhausted and are going to be spending their summers desperately trying to convince people to get vaccinated before the fall comes or some awful variant plunges a dagger into our best laid plans?” tweeted Whitney R. Robinson, PhD, an epidemiologist at the University of North Carolina.
What Can Families Do This Summer Then?
It’s not problematic to be optimistic about what we might be able to look forward to this summer. But that’s different from presuming we’ll be in the most optimistic scenario or drawing a comparison between unvaccinated children and vaccinated adults. In the most charitable interpretation of the Atlantic article, advice to parents that they can travel anywhere, meet with anyone, and do anything with their kids this summer is premature.
Jason Terk, MD, a pediatrician in Keller, Texas, and chair of the Texas Public Health Coalition, said it’s certainly likely unvaccinated low-risk children can mix with vaccinated adults depending on “what happens between the vaccine rollout versus the spread of the variants and what will our situation truly be.” Right now, it’s already low-risk for unvaccinated, masked kids to interact with vaccinated adults. But it depends on what parents want to do.
“If you’re in a closed-in, inside environment that is densely populated, then that’s not a great idea,” Terk said. “If you’re in a larger area that’s inside that’s not too densely packed and the rates of disease are not out of control and are heading in the right direction and are relatively low, then I think it is probably okay, but that’s a lot of ifs.”
“If we are sanguine about us reaching the reality the article imagines for the summertime, and we see cases continue to decrease, I would go along with these potential conditions,” Terk said. “But if we see our rates increasing as has happened in Europe — and ours tend to go up 4–6 weeks after Europe — then we will not be able to be as optimistic about our summertime as the article implies.”
But there are plenty of activities parents can do with their kids this summer.
“You can take trips with your kids. No one’s saying you can’t,” Popescu said. “But there are safer options. Where are you going, where are you coming from, and are you so focused on the vacation of your family that you’re neglecting to think about the impact on the place where you go?”
My own family spent Thanksgiving, when rates were climbing, in Amarillo so we could hike in Palo Duro Canyon State Park. We kept masks with us and put them on if we encountered anyone else on trails.
“With the weather improving over much of the US, any outdoor activity is going to be safer,” Perencevich said. “The CDC now suggests kids can meet indoors without masks if the adults are vaccinated. So they can meet with their aunts and uncles and grandparents.”
Smith described how her family will enjoy travel this summer: they’ll take the car, pay attention to the Covid situation at their destinations, wear masks anywhere indoors, and eat take-out or meals cooked in a hotel kitchenette. Her kids will have outdoor playdates with families she knows are following public health recommendations. But her family won’t be doing any flying or in-restaurant dining, and they’ll quarantine before travel.
“Get outside!” urged Boston University epidemiologist Ellie Murray, ScD. “Drive to a state park. Go hiking. Go camping. Go to the beach. Avoid air travel, indoor dining, hotels, and indoor activities like children’s museums.”
It’s fine for your unvaccinated kids to go on a road trip and hug their vaccinated grandmas. It’s just not okay to pretend your unvaccinated kids are vaccinated grandmas.