Children’s Hospitals Grapple With Wave of Mental Illness

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Krissy Williams, 15, had attempted suicide before, but never with pills.

The teen was diagnosed with schizophrenia when she was 9. People with this chronic mental health condition perceive reality differently and often experience hallucinations and delusions. She learned to manage these symptoms with a variety of services offered at home and at school.

But the pandemic upended those lifelines. She lost much of the support offered at school. She also lost regular contact with her peers. Her mother lost access to respite care — which allowed her to take a break.

On a Thursday in October, the isolation and sadness came to a head. As Krissy’s mother, Patricia Williams, called a mental crisis hotline for help, she said, Krissy stood on the deck of their Maryland home with a bottle of pain medication in one hand and water in the other.

Before Patricia could react, Krissy placed the pills in her mouth and swallowed.

Efforts to contain the spread of the novel coronavirus in the United States have led to drastic changes in the way children and teens learn, play and socialize. Tens of millions of students are attending school through some form of distance learning. Many extracurricular activities have been canceled. Playgrounds, zoos and other recreational spaces have closed. Kids like Krissy have struggled to cope and the toll is becoming evident.

Government figures show the proportion of children who arrived in emergency departments with mental health issues increased 24% from mid-March through mid-October, compared with the same period in 2019. Among preteens and adolescents, it rose by 31%. Anecdotally, some hospitals said they are seeing more cases of severe depression and suicidal thoughts among children, particularly attempts to overdose.

The increased demand for intensive mental health care that has accompanied the pandemic has worsened issues that have long plagued the system. In some hospitals, the number of children unable to immediately get a bed in the psychiatric unit rose. Others reduced the number of beds or closed psychiatric units altogether to reduce the spread of covid-19.

“It’s only a matter of time before a tsunami sort of reaches the shore of our service system, and it’s going to be overwhelmed with the mental health needs of kids,” said Jason Williams, a psychologist and director of operations of the Pediatric Mental Health Institute at Children’s Hospital Colorado.

“I think we’re just starting to see the tip of the iceberg, to be honest with you.”

Before covid, more than 8 million kids between ages 3 and 17 were diagnosed with a mental or behavioral health condition, according to the most recent National Survey of Children’s Health. A separate survey from the Centers for Disease Control and Prevention found 1 in 3 high school students in 2019 reported feeling persistently sad and hopeless — a 40% increase from 2009.

The coronavirus pandemic appears to be adding to these difficulties. A review of 80 studies found forced isolation and loneliness among children correlated with an increased risk of depression.

“We’re all social beings, but they’re [teenagers] at the point in their development where their peers are their reality,” said Terrie Andrews, a psychologist and administrator of behavioral health at Wolfson Children’s Hospital in Florida. “Their peers are their grounding mechanism.”

Children’s hospitals in New York, Colorado and Missouri all reported an uptick in the number of patients who thought about or attempted suicide. Clinicians also mentioned spikes in children with severe depression and those with autism who are acting out.

The number of overdose attempts among children has caught the attention of clinicians at two facilities. Andrews from Wolfson Children’s said the facility gives out lockboxes for weapons and medication to the public — including parents who come in after children attempted to take their life using medication.

Children’s National Hospital in Washington, D.C., also has experienced an uptick, said Dr. Colby Tyson, associate director of inpatient psychiatry. She’s seen children’s mental health deteriorate due to a likely increase in family conflict — often a consequence of the chaos caused by the pandemic. Without school, connections with peers or employment, families don’t have the opportunity to spend time away from one another and regroup, which can add stress to an already tense situation.

“That break is gone,” she said.

The higher demand for child mental health services caused by the pandemic has made finding a bed at an inpatient unit more difficult.

Now, some hospitals report running at full capacity and having more children “boarding,” or sleeping in emergency departments before being admitted to the psychiatric unit. Among them is the Pediatric Mental Health Institute at Children’s Hospital Colorado. Williams said the inpatient unit has been full since March. Some children now wait nearly two days for a bed, up from the eight to 10 hours common before the pandemic.

Cincinnati Children’s Hospital Medical Center in Ohio is also running at full capacity, said clinicians, and had several days in which the unit was above capacity and placed kids instead in the emergency department waiting to be admitted. In Florida, Andrews said, up to 25 children have been held on surgical floors at Wolfson Children’s while waiting for a spot to open in the inpatient psychiatric unit. Their wait could last as long as five days, she said.

Multiple hospitals said the usual summer slump in child psychiatric admissions was missing last year. “We never saw that during the pandemic,” said Andrews. “We stayed completely busy the entire time.”

Some facilities have decided to reduce the number of beds available to maintain physical distancing, further constricting supply. Children’s National in D.C. cut five beds from its unit to maintain single occupancy in every room, said Dr. Adelaide Robb, division chief of psychiatry and behavioral sciences.

The measures taken to curb the spread of covid have also affected the way hospitalized children receive mental health services. In addition to providers wearing protective equipment, some hospitals like Cincinnati Children’s rearranged furniture and placed cues on the floor as reminders to stay 6 feet apart. UPMC Western Psychiatric Hospital in Pittsburgh and other facilities encourage children to keep their masks on by offering rewards like extra computer time. Patients at Children’s National now eat in their rooms, a change from when they ate together.

Despite the need for distance, social interaction still represents an important part of mental health care for children, clinicians said. Facilities have come up with various ways to do so safely, including creating smaller pods for group therapy. Kids at Cincinnati Children’s can play with toys, but only with ones that can be wiped clean afterward. No cards or board games, said Dr. Suzanne Sampang, clinical medical director for child and adolescent psychiatry at the hospital.

“I think what’s different about psychiatric treatment is that, really, interaction is the treatment,” she said, “just as much as a medication.”

The added infection-control precautions pose challenges to forging therapeutic connections. Masks can complicate the ability to read a person’s face. Online meetings make it difficult to build trust between a patient and a therapist.

“There’s something about the real relationship in person that the best technology can’t give to you,” said Robb.

For now, Krissy is relying on virtual platforms to receive some of her mental health services. Despite being hospitalized and suffering brain damage due to the overdose, she is now at home and in good spirits. She enjoys geometry, dancing on TikTok and trying to beat her mother at Super Mario Bros. on the Wii. But being away from her friends, she said, has been a hard adjustment.

“When you’re used to something,” she said, “it’s not easy to change everything.”

If you have contemplated suicide or someone you know has talked about it, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Children’s Hospitals Are Partly to Blame as Superbugs Increasingly Attack Kids

COLUMBIA, Mo. — A memory haunts Christina Fuhrman: the image of her toddler Pearl lying pale and listless in a hospital bed, tethered to an IV to keep her hydrated as she struggled against a superbug infection.

“She survived by the grace of God,” Fuhrman said of the illness that struck her oldest child in this central Missouri city almost five years ago. “She could’ve gone septic fast. Her condition was near critical.”

Pearl was fighting Clostridium difficile, or C. diff, a type of antibiotic-resistant bacteria known as a superbug. A growing body of research shows that overuse and misuse of antibiotics in children’s hospitals — which health experts and patients say should know better — helps fuel these dangerous bacteria that attack adults and, increasingly, children. Doctors worry that the covid pandemic will only lead to more overprescribing.

A study published in the journal Clinical Infectious Diseases in January found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately — the wrong types, or for too long, or when they’re not necessary.

Dr. Jason Newland, a pediatrics professor at Washington University in St. Louis who co-authored the study, said that’s likely an underestimate because the research involved 32 children’s hospitals already working together on proper antibiotic use. Newland said the nation’s 250-plus children’s hospitals need to do better.

“It’s irresponsible,” Fuhrman added. Coupled with parents begging for antibiotics in pediatricians’ offices, it’s “just creating a monster.”

Using antibiotics when they’re not needed is a long-standing problem, and the pandemic “has thrown a little bit of gas on the fire,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School.

Although fears of covid-19 mean fewer parents are taking their children to doctors’ offices and some have skipped routine visits for their kids, children are still getting antibiotics through telemedicine visits that don’t allow for in-person exams. And research shows more than 5,000 children infected with the coronavirus were hospitalized between late May and late September. If symptoms point toward a bacterial infection on top of the coronavirus, Schleiss said, doctors sometimes prescribe antibiotics, which don’t work on viruses, until tests rule out bacteria.

At the same time, Newland said, the demands of caring for covid patients take time away from what are known as “stewardship” programs aimed at measuring and improving how antibiotics are prescribed. Often such efforts involve continuing education courses for health care professionals on how to use antibiotics safely, but the pandemic has made those more difficult to host.

“There’s no doubt: We’ve seen some extra use of antibiotics,” Newland said. “The impact of the pandemic on antibiotic use will be significant.”

Habits Drive Superbug Growth

Antibiotic resistance occurs through random mutation and natural selection. Those bacteria most susceptible to an antibiotic die quickly, but surviving germs can pass on resistant features, then spread. The process is driven by prescribing habits that lead to high levels of antibiotic use.

A March study in the journal Infection Control & Hospital Epidemiology found that the rates of antibiotic use on patients at 51 children’s hospitals ranged from 22% to 52%. Some of those medications treated actual bacterial infections, but others were given in hopes of preventing infections or when doctors didn’t know what was causing a problem.

“I hear a lot about antibiotic use for the ‘just in case’ scenarios,” said Dr. Joshua Watson, director of the antimicrobial stewardship program at Nationwide Children’s Hospital in Ohio. “We underestimate the downsides.”

Newland said each specialty in medicine has its own culture around antibiotic use. Many surgeons, for example, routinely use antibiotics to prevent infection after operations.

Outside of hospitals, doctors have long been criticized for prescribing antibiotics too often for ailments such as ear infections, which can sometimes go away on their own or can be caused by viruses that antibiotics won’t counter.

Dr. Shannon Ross, an associate professor of pediatrics and microbiology at the University of Alabama at Birmingham, said not all doctors have been taught how to use antibiotics correctly.

“Many of us don’t realize we’re doing it,” she said of overuse. “It’s sort of not knowing what you’re doing until someone tells you.”

All this drives the growth of numerous superbugs in the very population served by these hospitals. Numerous studies, including one published in the Journal of Pediatrics in March, cite the rise among kids of C. diff, which causes gastrointestinal problems. A 2017 study in the Journal of the Pediatric Infectious Diseases Society found that cases of a certain type of multidrug-resistant Enterobacteriaceae rose 700% in American children in just eight years. And a steady stream of research points to the stubborn prevalence in kids of the better-known MRSA, or methicillin-resistant Staphylococcus aureus.

Superbug infections can be extremely difficult — and sometimes impossible — to treat. Doctors often must turn to strong medicines with side effects or give drugs intravenously.

“It’s getting more and more worrisome,” Ross said. “We have had patients we have not been able to treat because we’ve had no antibiotics available” that could kill the germs.

Doctors say the world is nearing a “post-antibiotic era,” when antibiotics no longer work and common infections can kill.

A Monster Unleashed

Superbugs spawned by antibiotic overuse put everyone at risk.

Like her daughter, Fuhrman also suffered through a C. diff infection, getting sick after taking antibiotics following a root canal in 2012. While killing harmful germs, antibiotics can also destroy those that protect against infection. Fuhrman cycled in and out of the hospital for months. When she finally got better, she tried to avoid using antibiotics and never gave them to her daughter.

That’s because antibiotics affect your microbiome by wiping out bad germs and the good germs that protect your body against infections.

Pearl’s first symptoms of C. diff arose about three years later, at around 20 months old. Fuhrman noticed her daughter was having lots of bowel movements. The mom eventually found pus and blood in her daughter’s stools. One day, Pearl was so pale and weak that Fuhrman took her to the emergency room. She was discharged, then spiked a fever and returned to the hospital.

Doctors treated Pearl with Flagyl, a broad-spectrum antibiotic. But two days after the last dose, she went downhill. The infection had returned. She recovered only after going to the Mayo Clinic in Rochester, Minnesota, for a fecal microbiota transplantation, in which she received healthy donor stool from her dad through a colonoscopy.

Since her family’s ordeal, Fuhrman has been trying to raise awareness of superbugs and antibiotic overuse. She serves on the board of the Peggy Lillis Foundation, a C. diff education and advocacy organization, and has testified before a presidential advisory committee in Washington, D.C., about superbugs and antibiotic stewardship.

In March, the Centers for Medicare & Medicaid Services began requiring all hospitals to document that they have antibiotic stewardship programs.

One approach, Schleiss said, is to restrict antibiotics by “saving our most magic bullets for the most desperate situations.” Another is to stop antibiotics at, say, 72 hours, after reassessing whether patients need them. Meanwhile, doctors are calling for more research into antibiotic use in children.

Fuhrman said hospitals must do all they can to stop superbug infections. The stakes are enormous, she said, pointing toward Pearl, now a 7-year-old first grader who likes to wear a pink hair bow and paint her tiny fingernails a rainbow of pastel colors.

“Antibiotics are great, but they have to be used wisely,” Fuhrman said. “The problem of superbugs is here. It’s in our backyard now, and it’s just getting worse.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Health Officials Fear Pandemic-Related Suicide Spike Among Native Youth

WOLF POINT, Mont. — Fallen pine cones covered 16-year-old Leslie Keiser’s fresh grave at the edge of Wolf Point, a small community on the Fort Peck Indian Reservation on the eastern Montana plains.

Leslie, whose father is a member of the Fort Peck Assiniboine and Sioux Tribes, is one of at least two teenagers on the reservation who died by suicide this summer. A third teen’s death is under investigation, authorities said.

Leslie’s mother, Natalie Keiser, was standing beside the grave recently when she received a text with a photo of the headstone she had ordered.

She looked at her phone and then back at the grave of the girl who took her own life in September.

“I wish she would have reached out and let us know what was wrong,” she said.

In a typical year, Native American youth die by suicide at nearly twice the rate of their white peers in the U.S. Mental health experts worry that the isolation and shutdowns caused by the COVID-19 pandemic could make things worse.

“It has put a really heavy spirit on them, being isolated and depressed and at home with nothing to do,” said Carrie Manning, a project coordinator at the Fort Peck Tribes’ Spotted Bull Recovery Resource Center.

It’s not clear what connection the pandemic has to the youth suicides on the Fort Peck reservation. Leslie had attempted suicide once before several years ago, but she had been in counseling and seemed to be feeling better, her mother said.

Keiser noted that Leslie’s therapist canceled her counseling sessions before the pandemic hit.

“Probably with the virus it would have been discontinued anyway,” Keiser said. “It seems like things that were important were kind of set to the wayside.”

Tribal members typically lean on one another in times of crisis, but this time is different. The reservation is a COVID hot spot. In remote Roosevelt County, which encompasses most of the reservation, more than 10% of the population has been infected with the coronavirus. The resulting social distancing has led tribal officials to worry the community will fail to see warning signs among at-risk youth.

So tribal officials are focusing their suicide prevention efforts on finding ways to help those kids remotely.

“Our people have been through hardships and they’re still here, and they’ll still be here after this one as well,” said Don Wetzel, tribal liaison for the Montana Office of Public Instruction and a member of the Blackfeet Nation. “I think if you want to look at resiliency in this country, you look at our Native Americans.”

Poverty, high rates of substance abuse, limited health care and crowded households elevate both physical and mental health risks for residents of reservations.

“It’s those conditions where things like suicide and pandemics like COVID are able to just decimate tribal people,” said Teresa Brockie, a public health researcher at Johns Hopkins University and a member of the White Clay Nation from Fort Belknap, Montana.

Montana has seen 231 suicides this year, with the highest rates occurring in rural counties. Those numbers aren’t much different from a typical year, said Karl Rosston, suicide prevention coordinator for the state’s Department of Public Health and Human Services. The state has had one of the highest suicide rates in the country each year for decades.

As physical distancing drags on, fatality numbers climb and the economic impacts of the pandemic start to take hold of families, Rosston said, and he expected to see more suicide attempts in December and January.

“We’re hoping we’re wrong in this, of course,” he said.

For rural teenagers, in particular, the isolation caused by school closures and curtailed or canceled sports seasons can tax their mental health.

“Peers are a huge factor for kids. If they’re cut off, they’re more at risk,” Rosston said.

Furthermore, teen suicides tend to cluster, especially in rural areas. Every suicide triples the risk that a surviving loved one will follow suit, Rosston said.

On average, every person who dies by suicide has six survivors. “When talking about small tribal communities, that jumps to 25 to 30,” he said.

Maria Vega, a 22-year-old member of the Fort Peck Tribes, knows this kind of contagious grief. In 2015, after finding the body of a close friend who had died by suicide, Vega attempted suicide as well. She is now a youth representative for a state-run suicide prevention committee that organizes conferences and other events for young people.

Vega is a nursing student who lives six hours away from her family, making it difficult to travel home. She contracted COVID-19 in October and was forced to isolate, increasing her sense of removal from family. While isolated, Vega was able to attend therapy sessions through a telehealth system set up by her university.

“I really do think therapy is something that would help people while they’re alone,” she said.

But Vega points out that this is not an option for many people on rural reservations who don’t have computers or reliable internet access. The therapists who offer telehealth services have long waitlists.

Other prevention programs are having difficulties operating during the pandemic. Brockie, who studies health delivery in disadvantaged populations, has twice had to delay the launch of an experimental training program for Native parents of young children. She hopes the program will lower the risk of substance abuse and suicide by teaching resiliency and parenting skills.

At Fort Peck, the reservation’s mental health center has had to scale down its youth events that teach leadership skills and traditional practices like horseback riding and archery, as well as workshops on topics like coping with grief. The events, which Manning said usually draw 200 people or more, are intended to take teenagers’ minds away from depression and allow them to have conversations about suicide, a taboo topic in many Native cultures. The few events that can go forward are limited now to a handful of people at a time.

Tribes, rural states and other organizations running youth suicide intervention and prevention initiatives are struggling to sustain the same level of services. Using money from the federal CARES Act and other sources, Montana’s Office of Public Instruction ramped up online prevention training for teachers, while Rosston’s office has beefed up counseling resources people can access by phone.

On the national level, the Center for Native American Youth in Washington, D.C., hosts biweekly webinars for young people to talk about their hopes and concerns. Executive Director Nikki Pitre said that on average around 10,000 young people log in each week. In the CARES Act, the federal government allocated $425 million for mental health programs, $15 million of which was set aside for Native health organizations.

Pitre hopes the pandemic will bring attention to the historical inequities that led to lack of health care and resources on reservations, and how they enable the twin epidemics of COVID-19 and suicide.

“This pandemic has really opened up those wounds,” she said. “We’re clinging even more to the resiliency of culture.”

In Wolf Point, Natalie Keiser experienced that resiliency and support firsthand. The Fort Peck community has come together to pay for Leslie’s funeral.

“That’s a miracle in itself,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pediatricians Want Kids to Be Part of COVID Vaccine Trials

If clinical trials for COVID-19 vaccines aren’t expanded soon to include children, it’s unlikely that even kids in their teens will be vaccinated in time for the next school year.

The hurdle is that COVID vaccine makers are only in the early stages of testing their products on children. The Pfizer vaccine authorized for use by the Food and Drug Administration on Friday was greenlighted only for people ages 16 and up. Moderna just started trials for 12- to 17-year-olds for its vaccine, likely to be authorized later this month.

It will take months to approve use of the vaccines for middle- and high school-aged kids, and months more to test them in younger children. But some pediatricians say that concerns about the safety of the front-runner vaccines make the wait worthwhile.

Although most pediatricians believe the eventual vaccination of children will be crucial to subduing the COVID virus, they’re split on how fast to move toward that, says Dr. James Campbell, professor of pediatrics at the University of Maryland School of Medicine’s Center for Vaccine Development and Global Health. Campbell and colleagues say it’s a matter of urgency to get the vaccines tested in kids, while others want to hold off on those trials until millions of adults have been safely vaccinated.

Much of the debate centers on two issues: the degree of harm COVID-19 causes children, and the extent to which children are spreading the virus to their friends, teachers, parents and grandparents.

COVID-19’s impact on children represents a tiny fraction of the suffering and death experienced by vulnerable adults. Yet it would qualify as a pretty serious childhood disease, having caused 154 deaths and more than 7,500 hospitalizations as of Dec. 3 among people 19 and younger in the United States. Those numbers rank it as worse than a typical year of influenza, and worse than diseases like mumps or hepatitis B in children before the vaccination era.

Studies thus far show that 1%-2% of children infected with the virus end up requiring intensive care, Dr. Stanley Plotkin, professor emeritus of pediatrics at the University of Pennsylvania, told a federal panel. That’s in line with the percentage who become gravely ill as result of infections like Haemophilus influenza type B, or Hib, for which doctors have vaccinated children since the 1980s, he pointed out.

Campbell, who with colleagues has developed a plan for how to run pediatric COVID vaccine trials, points out that “in a universe where COVID mainly affected children the way it’s affecting them now, and we had potential vaccines, people would be clamoring for them.”

The evidence that teens can transmit the disease is pretty clear, and transmission has been documented in children as young as 8. Fear of spread by children has been enough to close schools, and led the American Academy of Pediatrics to demand that children be quickly included in vaccine testing.

“The longer we take to start kids in trials, the longer it will take them to get vaccinated and to break the chains of transmission,” said Dr. Yvonne Maldonado, a professor of pediatrics at Stanford University who chairs the AAP’s infectious disease committee. “If you want kids to go back to school and not have the teachers union terrified, you have to make sure they aren’t a risk.”

Other pediatricians worry that early pediatric trials could backfire. Dr. Cody Meissner, chief of pediatric infectious diseases at Tufts Medical Center and a member of the FDA’s advisory committee on vaccines, is worried that whatever causes Multisystem Inflammatory Syndrome in Children, a rare but frightening COVID-related disorder, might also be triggered, however rarely, by vaccination.

Meissner abstained from the committee’s vote Thursday that supported, by a 17-4 vote, an emergency authorization of the Pfizer vaccine for people 16 and older.

“I have trouble justifying it for children so unlikely to get the disease,” he said during debate on the measure.

But panel member Dr. Ofer Levy, director of the Precision Vaccines Program at Boston Children’s Hospital, said the 16-and-up authorization would speed the vaccine’s testing in and approval for younger children. That is vital for the world’s protection from COVID-19, he said, since in the United States and most places “most vaccines are delivered early in life.”

While vaccines given to tens of thousands of people so far appear to be safe, the lack of understanding of the inflammatory syndrome means that children in any trials should be followed closely, said Dr. Emily Erbelding, director of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases.

Under a 2003 law, vaccine companies are required eventually to test all their products on children. By late last month, Pfizer had vaccinated approximately 100 children 12-15 years of age, said spokesperson Jerica Pitts.

Moderna has started enrolling 3,000 children 12 and over in another clinical trial, and other companies have similar plans. Assuming the trials show the vaccines are safe and provide a good immune response, future tests could include progressively younger children, moving to, say, 6- to 12-year-olds next, then 2- to 6-year-olds. Eventually, trials could include younger toddlers and infants.

Similar stepdown approaches were taken to test vaccines against human papillomavirus (HPV), influenza and other diseases in the past, Erbelding noted. Such trials are easiest to conduct when researchers know that a measurable immune response, like antibody levels in the blood, translates to effective protection against disease. Armed with such knowledge, they can see whether children were protected without them having to be exposed to the virus. Federal scientists hope to get that data from the Moderna and Pfizer adult vaccine trials, she said.

Vaccine trials geared to tweens or younger children may involve testing half-doses, which, if protective, would require less vaccine and might cause fewer incidents of sore arms and fevers that afflicted many who’ve received the Pfizer and Moderna vaccines, Campbell said.

But unless additional studies begin quickly, the window for having an FDA-authorized vaccine available before the next school yearwill be closed even for our oldest children,” said Dr. Evan Anderson, a pediatrics professor at Emory University. “Our younger children are almost certainly going into next school year without a vaccine option available for them.”

In the meantime, teachers are likely to be high on the priority list for vaccination. Protecting school staff could allow more schools to reopen even if most children can’t be vaccinated, Erbelding said.

Eventually, if the SARS-CoV-2 virus remains in circulation, governments may want to mandate childhood vaccination against the virus to protect them as they grow up and protect society as a whole, Plotkin said.

In the 1960s, Plotkin invented the rubella vaccine that has been given to hundreds of millions of children since. Like COVID-19, rubella, or German measles, is not usually a serious illness for children. But congenital rubella syndrome afflicted babies in the womb with blindness, deafness, developmental delays and autism. Immunizing toddlers, which, in turn, protects their pregnant mothers, has indirectly prevented hundreds of thousands of such cases.

“We don’t want to use children to protect everyone in the community,” said Campbell. “But when you can protect both children and their community, that’s important.”

And while a coronavirus infection may not be bad for most children, missed school, absent friends and distanced families have caused them immense suffering, he said.

“It’s a huge burden on a child to have their entire world flipped around,” Campbell said. “If vaccinating could help to flip it back, we should begin testing to see if that’s possible.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Feds Look to Pharmacists to Boost Childhood Immunization Rates

Torey Watson is trained as a pharmacist but aims to do more than simply fill prescriptions.

Pharmax Pharmacy — a small drugstore chain where Watson works as a clinical services coordinator, about an hour and 30 minutes southwest of St. Louis — will soon allow him to offer childhood vaccines to patients without a doctor’s prescription. This change came after the federal government expanded pharmacists’ ability to administer routine immunizations to children as young as 3.

As a father of two young boys, Watson, 30, understands how difficult it can be to give a child a shot. Many pharmacists are accustomed to administering vaccines to adults, he said. Doing the same for children requires extra skill.

“We’re going to have parents asking questions,” he said. His other thought: “Holy cow, I don’t think I can give a shot to a 3-year-old.”

Federal officials are banking on pharmacists like Watson to undergo additional training and help reverse the slump in child immunization rates caused by the coronavirus pandemic. Fears over COVID-19 have led parents to avoid the doctor’s office and pediatricians to curtail in-person care. As a result, many children are missing routine vaccinations.

Children who fall behind on vaccinations usually don’t pose a health risk if kids around them are immunized, said Dr. Sean O’Leary, vice chair of the American Academy of Pediatrics committee for infectious diseases. However, large groups of children are now behind, and highly contagious vaccine-preventable diseases circulating in other parts of the world are only a plane ride away, he said.

“That’s a big deal,” he said in an email.

In August, the Department of Health and Human Services took steps to override restrictions in many states that kept state-licensed pharmacists from immunizing children.

“Today’s action means easier access to lifesaving vaccines for our children, as we seek to ensure immunization rates remain high during the COVID-19 pandemic,” HHS Secretary Alex Azar said in announcing the policy change.

However, challenges remain in getting pharmacists fully integrated into the nation’s framework of childhood vaccinations, immunization experts said.

A key issue is that few pharmacists participate in the Vaccines for Children program, a federal initiative that purchases vaccines for the nation’s neediest kids. Half of children in the U.S. receive immunizations through the program, which purchases government-recommended vaccines for kids ages 0 to 18 who are low-income, uninsured or belong to an indigenous group. Compared with last year, VFC-funded orders for vaccines overall are down 9.6 million doses as of Nov. 9, said a spokesperson from the Centers for Disease Control and Prevention. Measles-containing vaccines are down an estimated 1.3 million doses.

Weekly orders of non-flu vaccines and measles-containing vaccines have begun to rebound to levels seen last year, though the volume could again be affected if current COVID surges have a chilling effect on doctors’ visits.

Without solving the issues that keep pharmacists from participating in the Vaccines for Children program, said Claire Hannan, executive director of the Association of Immunization Managers, the steps to give parents more access to immunizations through drugstores may ultimately help only Americans wealthy enough to use it.

“Yes, we have a situation with the pandemic that has caused a drop in routine vaccinations,” Hannan said. “But I don’t want to see us go to a solution that is only serving those who can pay.”

Drugstores serve as a convenient access point. Nearly 90% of Americans in 2018 lived within 5 miles of a community pharmacy. In contrast, about 5% of rural counties in 2019 had no family physicians, according to a report from researchers at the University of Washington. Thirty-five percent of rural counties had no pediatricians. Additionally, KFF found over 51% of children in 2017 did not have a medical home, meaning they do not have a primary care doctor that manages their care. (KHN is an editorially independent program of KFF.)

“We need our pharmacists to be vaccinators” in order to catch children up on their immunizations, said L.J Tan, chief strategy officer at the Immunization Action Coalition, a national organization of physicians and health experts focused on vaccine education.

Congress established the Vaccines for Children program to remedy the immunization disparities uncovered by a measles epidemic in the early 1990s that killed hundreds of people. While doctors jumped on board, pharmacist engagement lags far behind.

This pattern continues. As of Oct. 6, out of nearly 38,000 participating providers, a CDC spokesperson said, about two-thirds work in private practices. Seventy-one are pharmacies.

Stephanie Wasserman, executive director of Immunize Colorado, an Aurora-based nonprofit organization, said boosting the number of pharmacists in VFC will be “a really critical piece” to the success of the federal authorization. However, “just because they can participate doesn’t mean they necessarily will jump on it” unless pharmacists think the program is well-supported and will help their business, she said.

Enrollees must adhere to strict storage and handling requirements that involve expensive thermometers and refrigerators used only for products delivered under the government program. And if there isn’t enough demand, said vaccine experts, the investment may not be worth it.

For rural pharmacies, said Michaela Newell, president of the Community Pharmacy Enhanced Services Network of Missouri, the cost of paying for the equipment and personnel needed to handle the administrative work may price them out before they apply.

“I guess it hasn’t been worth the squeeze,” said Hannan.

Added Newell: “I just think that the barriers right now are too high for the pharmacists to enter into it.”

On the flip side, state administrators have trouble keeping up with the demands of the program, too. One study from 2019 showed limited success in getting Michigan pharmacies to administer the human papillomavirus vaccine through the Vaccines for Children program because the state’s health department didn’t have the personnel to conduct on-site inspections.

The strain on state resources has only grown worse during the pandemic, said Hannan.

“You can’t call them out for not having the bandwidth,” said Rebecca Snead, executive vice president and chief executive officer of the National Alliance of State Pharmacy Associations. “They’ve been compromised.”

Payment also poses a challenge to recruit and maintain providers in the program, immunization experts said.

Medicaid, the government-sponsored health insurance program that offers health coverage for many of the children supported by the vaccine initiative, does not pay providers enough to cover expenses. Participating clinicians lose an average of $5 to $15 for every vaccine they administer through Vaccines for Children, according to a report from Immunize Colorado.

Pharmacists cannot deny a vaccine to eligible children if the family is unable to pay.

Some states run their Medicaid programs using a managed-care model, which may make it harder for pharmacists to get paid, the report said. Children enrolled in these programs are often required to obtain care from designated providers. If their local pharmacist is not on the list of approved providers, they may not get paid.

The possibility of little to no pay hasn’t stopped pharmacist and drugstore owner Tim Mitchell from offering vaccines at his three pharmacies in Neosho, Missouri, about 30 minutes from the Oklahoma state line. He said he’s been immunizing patients since the late 1990s after he realized children coming into his pharmacies were missing routine vaccinations.

“I saw it as a way to help my community,” he said, “but I also saw it as a business opportunity.”

Mitchell, 53, views offering vaccines as a way to stand out from his competitors and bring more customers to his pharmacies. He said he submitted the paperwork to enroll in Vaccines for Children.

Although he welcomes the federal authorization, he acknowledged that not all his peers can afford to offer the service.

“We can’t work for free,” said Mitchell.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Parents Complain That Pediatricians, Wary of COVID, Shift Sick Kids to Urgent Care

A mom of eight boys, Kim Gudgeon was at her wits’ end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.

He had been up at night and was disrupting his brothers’ e-learning during the day. “He was just miserable,” Gudgeon said. “And the older kids were like, ‘Mom, I can’t hear my teacher.’ There’s only so much room in the house when you have a crying baby.”

She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.

To Gudgeon’s surprise, that’s not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.

“We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces,” said Adam Schriedel, chief medical officer and a practicing internist with the group.

Gudgeon’s experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

That policy is troubling to Dr. Arthur “Tim” Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. “It’s a practice’s responsibility to take care of patients,” Garson said. He worries about patients who can’t do video visits if they don’t have a smartphone or access to the internet or simply aren’t comfortable using that technology.

Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.

Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive “to provide care for the same variety of visits that they provided prior to the public health emergency.”

The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.

“I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter,” said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.

Fear is not unfounded. More than 900 health care workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line health care workers lost to the coronavirus.

For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.

“We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need,” he said.

Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.

It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents’ online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don’t have a continuity of care.

Also, there’s the expense. Bryce’s case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. “They barely looked in his ears, and we went home to wait for the results,” she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.

Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.

“In urgent care, we’re seeing all comers, whether they are sick with COVID or not,” he said.

Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.

“You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern,” Sacchetti said. “We reassure them” that the precautions taken in hospitals will help keep them safe, he added.

Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another health care facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.

“I just wish he didn’t have to suffer for so long,” Gudgeon said.

Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the “Swiss cheese” approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.

Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.

“We can’t create this barrier to care for uncomplicated, acute illnesses,” Kressly said. “This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Poor and Minority Children With Food Allergies Overlooked and in Danger

As Emily Brown stood in a food pantry looking at her options, she felt alone. Up to that point, she had never struggled financially. But there she was, desperate to find safe food for her young daughter with food allergies. What she found was a jar of salsa and some potatoes.

“That was all that was available,” said Brown, who lives in Kansas City, Kansas. “It was just a desperate place.”

When she became a parent, Brown left her job for lack of child care that would accommodate her daughter’s allergies to peanuts, tree nuts, milk, eggs, wheat and soy. When she and her husband then turned to a federal food assistance program, they found few allowable allergy substitutions. The closest allergy support group she could find was an hour away. She was almost always the only Black parent, and the only poor parent, there.

Brown called national food allergy advocacy organizations to ask for guidance to help poor families find safe food and medical resources, but she said she was told that wasn’t their focus. Support groups, fundraising activities and advocacy efforts, plus clinical and research outreach, were targeted at wealthier — and white — families. Advertising rarely reflected families that looked like hers. She felt unseen.

“In many ways, food allergy is an invisible disease. The burden of the disease, the activities and energy it takes to avoid allergens, are mostly invisible to those not impacted,” Brown said. “Black and other minority patients often lack voice and visibility in the health care system. Add the additional burden of an invisible condition and you are in a really vulnerable position.”

An estimated 6 million children in the United States have food allergies, 40% of them with more than one. Though limited research has been done on race and class breakdowns, recent studies show that poor children and some groups of minority children not only have a higher incidence of food allergies than white kids, but their families also have more difficulty accessing appropriate child care, safe food, medical care and lifesaving medicine like epinephrine for them.

Black children are 7% more likely to have food allergies than white children, according to a 2020 study by Dr. Ruchi Gupta, at Northwestern University’s Feinberg School of Medicine. To be sure, the study shows that Asian children are 24% more likely than white children to have food allergies. But Black and Hispanic children are disproportionately more likely to live in poor communities, to have asthma, and to suffer from systemic racism in the delivery of medical care.

And finding allergen-free food to keep allergic kids safe can be costly — in both time and money.

“Many times, a mother is frank and says, ‘I have $20 to $40 to buy groceries for the week, and if I buy these foods that you are telling me to buy, I will not be able to feed my entire family,’” said Dr. Carla Davis, director of the food allergy program at Houston’s Texas Children’s Hospital.

“If you are diagnosed with a food allergy and you don’t have disposable income or disposable time, there is really no way that you will be able to alter your diet in a way that your child is going to stay away from their allergen.”

Fed up with the lack of support, Brown founded the Food Equality Initiative advocacy organization in 2014. It offers an online marketplace to income-eligible families in Kansas and Missouri who, with a doctor’s note about the allergy, can order free allergy-safe food to fit their needs.

Nationwide, though, families’ needs far outstrip what her group can offer — and the problem has gotten worse amid the economic squeeze of the COVID pandemic. Job losses and business closures have exacerbated the barriers to finding and affording nutritious food, according to a report from Feeding America, an association of food banks.

Brown said her organization more than doubled its clientele in March through August, compared with the same period in 2019. And though it currently serves only Missouri and Kansas, she said the organization has been fielding an increasing number of calls from across the country since the pandemic began.

For low-income minorities, who live disproportionately in food deserts, fresh and allergy-friendly foods can be especially expensive and difficult to find in the best of times.

Food assistance programs are heavily weighted to prepackaged and processed foods, which often include the very ingredients that are problematic. Black children are more likely to be allergic to wheat and soy than white kids, and both Black and Hispanic children are more likely to be allergic to corn, shellfish and fish, according to a 2016 study.

Some programs allow few allergy substitutions. For example, the federal Special Supplemental Nutrition Program for Women, Infants and Children allows only canned beans as a substitute for peanut butter. While nutritionally similar, beans are not as easy to pack for a kid’s lunch. Brown questions why WIC won’t allow a seed butter, such as sunflower butter, instead. She said they are nutritionally and functionally similar and are offered as allergy substitutions in other food programs.

Making matters worse, low-income households pay more than twice as much as higher-income families for the emergency medical care their children receive for their allergies, according to a 2016 study by Gupta. The kids often arrive at the hospital in more distress because they lack safe food and allergy medications — and because asthma, which disproportionately hits Black and Puerto Rican children and low-income communities, complicates allergic reactions.

“So, in these vulnerable populations, it’s like a double whammy, and we see that reflected in the data,” said Dr. Lakiea Wright-Bello, a medical director in specialty diagnostics at Thermo Fisher Scientific and an allergist at Brigham and Women’s Hospital in Boston.

Thomas and Dina Silvera, who are Black and Latinx, lived this horror firsthand. After their 3-year-old son, Elijah-Alavi, died as a result of a dairy allergy when fed a grilled cheese instead of his allergen-free food at his preschool, they launched the Elijah-Alavi Foundation to address the dearth of information about food allergies and the critical lack of culturally sensitive medical care in low-income communities.

“We started it for a cause, not because we wanted to, but because we had to,” said Thomas Silvera. “Our main focus is to bring to underserved communities — especially communities of color — this information at no cost to them.”

Recently, other advocacy groups, including Food Allergy Research & Education, a national advocacy organization, also have started to turn their attention to a lack of access and support in poor and minority communities. When Lisa Gable, who is white, took over at the group known as FARE in 2018, she began to diversify the organization internally and to make it more inclusive.

“There wasn’t a big tent when I walked in the door,” said Gable. “What we have been focused on doing is trying to find partners and relationships that will allow us to diversify those engaged in the community, because it has not been a diverse community.”

FARE has funded research into the cost of food allergies. It is also expanding its patient registry, which collects data for research, as well as its clinical network of medical institutions to include more diverse communities.

Gupta is now leading one of the first studies funded by the National Institutes of Health to investigate food allergy in children by race and ethnicity. It looks at all aspects of food allergies, including family life, management, access to care and genetics.

“That’s a big deal,” said Gupta. “Because if we really want to improve food allergy management, care and understanding, we really need to understand how it impacts different groups. And that hasn’t been done.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: A Little Good News and Some Bad on COVID-19

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For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.

Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
  • Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
  • California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
  • A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
  • Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
  • With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera

Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan

Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez

Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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One School, Two Choices: A Study in Classroom vs. Distance Learning

Cozbi Mazariegos stays in shape these days by running room to room inside her Marin City apartment to answer questions from her kids, ages 7, 10 and 12. They’re all working at home on laptops issued by their school, Bayside Martin Luther King Jr. Academy.

Meanwhile, Shannon Bynum’s son, Kamari, 10, and daughter, Keyari, 8, who live nearby, are back on the Bayside MLK campus. Bynum had warned them, however, that if he heard they weren’t wearing masks, they’d have to learn remotely, too.

The two households, less than 3 miles apart, have found different answers to one of the most perplexing questions this fall: Should parents send their children back to school for classes during an ongoing pandemic or keep them at home?

At Bayside MLK, a K-8 school serving the ethnically and economically diverse community of Marin City, 103 children are attending class in person, including the Bynum children. The Mazariegos kids are among 12 learning remotely.

In March, the coronavirus consigned nearly all of the nation’s 55 million schoolchildren to home schooling. One by one, school districts across the country are weighing the risks of reopening. Some that have reopened have seen a spike in coronavirus cases among students who returned to class.

Bayside MLK was one of 15 Marin County schools that received waivers from the local public health department to reopen full time on Sept. 8, but officials gave parents the choice whether to send their children to campus or keep them home.

The start of classes was delayed for a week when one school employee contracted the virus, said Principal David Finnane. Once they started, the challenges mounted.

“This is the most mind-numbing time I’ve ever had as an educator,” said Finnane, who’s been a school principal for two decades.

“These are crazy days of temperature checks, telling third grade Jenny she entered the second grade gate at the wrong time, telling Xavier to use sanitizer on his elbow after he sneezes, reminding students not to touch this thing or that thing. It’s a job this school has never had to do and now we’re doing it every day, all day long.”

Health and safety protocols enacted by the school include staggered arrival times for students (via parent drop-offs), smaller classes, spaced-out desks, routine temperature and health checks, and an intensified cleaning schedule.

Mazariegos, 52, spent a difficult summer deciding whether to send Emily, 12, Ezekiel Jr., 10, and 7-year-old Evelyn back to class if and when school reopened in the fall.

But her husband, Ezekiel, a 42-year-old construction worker, had made up his mind. “He said, ‘Are you crazy? We can’t send our kids back to school without a vaccine,’” she recalled. “‘How do we know they’d be safe?’”

Mazariegos, who was a schoolteacher in her native Guatemala but now stays at home with her kids, has juggled the roles of teacher, tech consultant and even hall monitor in recent weeks.

School hadn’t been back in session for a week before her home Wi-Fi connection crashed. The two eldest kids could not connect to their Zoom instruction sessions, so Mazariegos called the school for help. To make sure they didn’t resort to computer games in the interim, she gave them textbooks to read.

“The phone was ringing, the kids were all calling my name from different rooms,” she said. “It was crazy.”

Single father Bynum, on the other hand, chose to send his two kids back to school.

“Kids learn from other kids, not just teachers,” said the 29-year-old real estate developer. “In school, they know what’s expected of them. It’s the best place for them to be.”

Finnane, the principal, had hoped all 115 students would return to classrooms. “Many kids doing distance learning just don’t have the same support network,” he said. “They might not have the resources, a quiet place to work, a supportive adult right there who can mentor and encourage them.”

And then there are the technical issues. Students who have stayed at home have experienced internet failures, Zoom glitches and computer bandwidth problems — “or when a teacher gives out the wrong Zoom link, all of which has already happened,” Finnane said.

A recent study by the Economic Policy Institute on the educational challenges posed by the pandemic found that remote-learning programs are effective only if students have consistent access to the internet and computers and if teachers receive targeted training and support for online instruction.

While researchers acknowledged the risk of virus infection is greater at school, they found that students who have not returned to the classroom are falling behind.

“Children’s academic performance is deteriorating during the pandemic, along with their progress on other developmental skills,” the study said.

When Bayside MLK resorted to remote teaching for the entire school in the spring, officials identified 41 students who were demonstrably falling behind, Finnane said. Standardized tests given to students this academic year will provide a report card on students’ success, he added.

Over the summer, Bayside MLK teachers received one day of training to perform online classes in addition to their at-school duties.

“A full day of online-learning training helps, but when it comes to the constant challenges of teaching, especially those with special needs, I’m not sure that’s sufficient,” said Emma García, who co-authored the Economic Policy Institute study.

Mazariegos knows this all too well. Her daughter Emily has comprehension issues that have kept her back a grade.

A quiet girl who loves animals and science, and who one day wants to become a veterinarian, the sixth grader relies on her mother to spend extra time reviewing lessons.

“She has to touch and feel things, to have a lesson demonstrated before she can best understand,” her mother said. “She can’t just sit in front of a computer reading some concept over and over and over.”

Mazariegos understands her daughter may fall another year behind but says she’ll take that chance. “If we lose her to COVID-19, that year is nothing,” she said. “This is a hard decision for any mother. But Emily is so afraid of the virus that sending her back to school would just be traumatizing.”

Bynum, whose fourth grade son, Kamari, suffers from attention deficit disorder, believes the classroom is the best place for the restless child. In March, when the school was closed at the start of the pandemic, Bynum got a taste of the demanding task of being a teacher.

“With two kids in two different grades asking me questions, I struggled to explain things,” he said. “It would have been easy for me to just tell them the answer, but the object of a good instructor is to teach them to find it themselves. And I had to learn that.”

Bynum has developed his own protocol. He requires his children to shower the moment they return from school, and they get regular lectures about hand-washing and common sense.

“If I even suspect they’re not wearing their masks, I’ll say, ‘OK, it’s back to the house and your laptop,’ and they’ll say, ‘Oh yeah, Dad, I’m wearing my mask.’”

Mazariegos remains comfortable with her decision, especially when she reads about all the COVID-19 outbreaks at schools and colleges.

Her kids aren’t so sure.

Second grader Evelyn, an outgoing girl, recently joined a Zoom lesson that included classmates she hadn’t seen in person for months.

“She cried,” her mother said. “She wanted to be back at school to see her friends.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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DeSantis Says COVID Is a Lower Risk for School-Aged Kids Than Flu

Even as his state is a hotbed for COVID-19, Florida Gov. Ron DeSantis has been pushing schools to reopen so parents have the choice of sending children back to the classroom or keeping them home to learn virtually.

The Republican governor has said children without any underlying health conditions would benefit from in-person learning and the stimulation and companionship of being among other young people. He has also made clear that he thinks these benefits far outweigh what he considers to be minimal risks.

“The fact is, in terms of the risk to schoolkids, this is lower risk than seasonal influenza,” DeSantis said, during an Aug. 10 televised roundtable discussion on education.

DeSantis’ assertion got us wondering, so we asked the governor’s office what evidence it had to back up the claim.

Looking at the Numbers

A spokesperson responded with data from the Florida Department of Health showing the state’s COVID-19 mortality rate is 0.02% for people 24 and younger. That’s the same as the influenza mortality rate for this age group.

But for children 14 and younger, the spokesperson said, Florida’s COVID-19 mortality rate is 0.009%, far below the 0.01% for flu for that age group.

And the risk of death is not the only concern children face if infected by the COVID-19 virus. They can develop complications that require hospitalization.

“The risk of complications for healthy children is higher for flu compared to COVID-19,” according to the Centers for Disease Control and Prevention. “However, infants and children with underlying medical conditions are at increased risk for both flu and COVID-19.”

The CDC estimates there were 480 deaths among U.S. children due to flu in the 2018-19 season, including 136 cases in which the virus was confirmed by laboratory testing.

As of mid-August, 90 children died of COVID-19 in the United States, according to the American Academy of Pediatrics.

More than 46,000 children were hospitalized for flu in that 2018-19 period. The hospitalization rate among children 5 to 17 was 39.2 children per 100,000 children.

The hospitalization rate for COVID-19 is six per 100,000 children for those ages 5 to 17, according to the CDC.

The number and rate of COVID cases in children in the United States steadily increased from March to July. “The true incidence of SARS-CoV-2 infection in children is not known due to lack of widespread testing and the prioritization of testing for adults and those with severe illness,” the CDC wrote recently.

While children have lower rates of using a ventilator than adults, 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, the same rate as for adults, the CDC said.

Dr. Chad Vercio, chair of pediatrics at Riverside University Health System in California, said DeSantis’ statement is partly true, with many caveats. Children’s risk from COVID-19 “entirely depends on how widespread COVID is in any area,” he said.

Data Reflects a Snapshot in Time

U.S. hospitalization rates for children with COVID are lower than for those with flu, Vercio said. But that could be due to parents keeping children home and schools being closed since March, he added. “It is unknown if these COVID hospitalization rates would rise when we open schools,” he said.

About two-thirds of Florida school districts have opened in the past two weeks with the rest planning to resume by Aug. 31. Most districts are offering in-person classes while giving parents the option to keep students home for virtual learning. In South Florida, where the pandemic has hit hardest, districts are planning, at least initially, to offer only virtual teaching.

Hillsborough County, which includes Tampa, had initially planned to reopen classrooms but reversed itself after doctors warned that school closures were likely to ensue. The county revised its plan to limit classes to online-only instruction, but the state’s education commissioner rejected that approach, saying it denies parents the option of sending their children back to school. Fearing the loss of millions of dollars in state funding, the district now plans to begin virtual learning for all students on Aug. 24, and, on Aug. 31, begin offering students the option to return to the classroom.

“The direct impact of COVID-19 on children is currently small in comparison with other risks and … the main reason we are keeping children at home is to protect adults,” concluded a report in the British Medical Journal published in June. Still, health authorities say parents should make sure children practice good hygiene and limit playtime with other children.

Based on data from February through mid-May, the report found 44 deaths from COVID-19 for people 19 and younger in France, Germany, Italy, Korea, Spain, England and the United States. In a typical three-month period, there would be 308 deaths from lower respiratory tract infections, including flu, in those countries.

“At this stage of the pandemic, COVID appears to be less dangerous for children than influenza,” said Sunil Bhopal, a co-author of the report and an academic clinical lecturer at Newcastle University in England.

“We don’t need to wait for a whole season because, even at its peak in most countries, COVID killed a smaller number of children than estimated influenza deaths averaged from across a year,” Bhopal said.

“While flu is likely to have caused more deaths than COVID, this may change as the pandemic progresses and major caution is necessary to ensure this doesn’t change,” said Bhopal, an honorary assistant professor at the London School of Hygiene and Tropical Medicine.

Dr. Sean O’Leary, professor of pediatrics at the University of Colorado Anschutz Medical Campus, said the growing number of U.S. deaths could be another reason to think about COVID-19 and children.

“We do know for sure that schoolchildren are major drivers of influenza epidemics in the community and, though that is not as much the case with COVID, it doesn’t mean they can’t spread it,” he said.

DeSantis also maintained that kids are less likely to spread COVID-19 than they are the influenza virus. However, experts cautioned that there’s still a lot that is unknown about children’s ability to transmit the virus to the people they interact with — parents, grandparents and even teachers. The perceived risk for teachers, for instance, is at the root of a lawsuit between the state’s largest teachers union and the DeSantis administration. The Florida Education Association wants a Leon County judge to stop the state’s order forcing school districts to open classrooms for in-person learning by the end of August.

Dr. Gabriela Andujar Vazquez, an infectious disease specialist at Tufts Medical Center in Boston, said children are more likely to have zero or mild symptoms from COVID-19 compared with adults.

“The bottom line is kids can get infected and they tend to have less severe disease,” she said. But the concern over reopening school is that children could spread the disease to others, including adults who are more likely to develop complications.

“Because schools are tied to the community — they are not in a bubble — and if community spread is not controlled in the community, it’s likely the school will reflect that,” she said. One factor that can determine if the disease is out of control is if positivity rates for people getting tested for COVID are over 5%. Many Florida counties have been well above that mark since June, although the rates have been dropping this month.

Back-to-school risks will be handicapped based on the ability of the school to adopt physical distancing measures and enforce wearing of face masks, said Dr. Andrew Pavia, a pediatric infectious disease specialist at the University of Utah Health and Intermountain Primary Children’s Hospital.

“This fall, we may see a lot of kids get infected as schools reopen, and those could be just the tip of the iceberg,” he said. “Even though most kids have mild or asymptomatic cases, what I worry about is just how big is the tip of the iceberg,” Pavia said.

He also noted there is a vaccine for flu — which about 50% to 70% of children receive. “The vaccine is not perfect but does reduce the impact of the disease, and with COVID everyone is at risk and susceptible,” Pavia said.

Dr. Vidya Mony, an infectious disease expert with Santa Clara Valley Medical Center in San Jose, California, said data suggests COVID-19 is not as bad for children as flu and that children are not the main driver of the pandemic. But, she said, there isn’t enough data yet to say indisputably that the COVID-19 risk is lower. “We are learning something every day with this.”

Our Ruling

DeSantis said that COVID-19 is a lower risk for schoolchildren than is seasonal influenza.

Studies show the numbers of COVID-related deaths and hospitalizations among children are lower than the average rates for flu. Still, it’s uncertain if these lower rates among children were partly because schools were closed since March and whether those rates will rise as classrooms reopen this fall. It’s also unclear whether opening schools — particularly in communities with a high number of people testing positive — will lead to more spread of the disease.

We rate the claim as Mostly True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What The Health?’: Democrats in Array (For Now)

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Democrats have shown a remarkably united front, including on health care, in their socially distant, made-for-TV convention this week. That’s likely due, at least in part, to the physical separation of party members who disagree on issues — this year they cannot chatter on live television — and to the party truly being united in its desire to defeat President Donald Trump in November.

Meanwhile, the coronavirus pandemic continues to complicate efforts around the country to get students back to school, from preschool to college. And the Trump administration’s effort to eliminate anti-discrimination protections in health care for transgender people is put on hold by a federal judge.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Shefali Luthra of The 19th.

Among the takeaways from this week’s podcast:

  • Democrats’ online convention has helped make the party seem unified. But on health policy, divisions remain even though Vice President Joe Biden has agreed to broaden some of his plans, such as lowering the eligibility age for Medicare and agreeing to have federal regulators run a public option plan he is advocating. Progressives in the party still hope to move the debate next year back to establishing a “Medicare for All” system.
  • The heated Democratic primary campaign put a good deal of focus on health policy, including whether to support a Medicare for All system and efforts to make health care more affordable. But the convention rhetoric on health hasn’t focused much attention on that and instead has played up issues surrounding the Trump administration’s response to the coronavirus pandemic.
  • The emphasis on COVID-19 in recent months has also pushed out much of the debate on the issues of high drug prices and surprise bills.
  • As the question of a mail slowdown has enveloped the country, concerns are being raised about mail delivery of prescription drugs, especially for seniors and veterans. Despite anecdotal reports of missed deliveries, most drug industry experts say problems haven’t been widespread.
  • The controversies about reopening schools — both K through 12 and colleges — point to difficulties with the country’s COVID testing program. It is too hard and too expensive for schools to be able to test enough students to guarantee that the virus isn’t spreading.
  • Schools may want to reconsider which age groups they target for returning to the classroom. Since there is little evidence that younger kids spread the virus widely and since they may need the in-classroom experience more, it could make sense to bring them back to school sooner than older students. Plus, older students generally can better handle online classes.
  • Federal health officials have recently warned that the pandemic is having an impact on mental health for many people, raising levels of depression and anxiety. The physical isolation and the economic stresses are fueling much of that.
  • The Trump administration’s rule overturning an Obama administration rule on transgender protections in the Affordable Care Act has been put on hold by a federal judge. But the Obama-era rule had also been put on hold by another judge. So the question is in limbo until higher courts — perhaps the Supreme Court — take up the case.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Washington Post’s “Can Dogs Detect the Novel Coronavirus? The Nose Knows,” by Frances Stead Sellers

Margot Sanger-Katz: The Atlantic’s “The Plan That Could Give Us Our Lives Back,” by Robinson Meyer and Alexis C. Madrigal

Paige Winfield Cunningham: Stat News’ “Seven Months Later, What We Know About Covid-19 – And the Pressing Questions That Remain,” by Andrew Joseph, Helen Branswell and Elizabeth Cooney.

Shefali Luthra: KHN’s “Back to the Future: Trump’s History of Promising a Health Plan That Never Comes,” by Victoria Knight

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Must-Reads of the Week

Hi, I’m back with a revamped Friday Breeze, tackling a few hot health care topics of the week and some news you may have missed. Here’s what the Breeze blew in this week, in these dog days of our COVID-constrained, socially distant summer:

Schools Reopen: No Easy Answers for Keeping Kids Healthy

It’s back-to-school time, which means pencils, books, hand sanitizers and, for some, a visit from Vice President Mike Pence. The vice president visited a campus of Thales Academy in Apex, North Carolina, saying, “We’ve got to open up America’s schools, and Thales Academy is literally in the forefront.” Unfortunately, a few days later, Thales suffered a setback when a fourth grader at its Wake Forest campus tested positive for COVID-19.

Things weren’t much better in other states, either. Groups of students and teachers in Indiana, Georgia, Mississippi, Louisiana and Tennessee have been forced into quarantine after being exposed to the virus. When a photo of a packed hallway at North Paulding High School north of Atlanta went viral this week, Superintendent Brian Otott acknowledged that the photo “does not look good ” but said the school was following state health recommendations. (On Thursday, two teens who posted the photo were suspended from school.) And this just in: New York Gov. Andrew Cuomo announced schools can reopen for in-person classes this fall across a state that was once the epicenter of the global pandemic.

Day cares and preschools might offer a glimpse into how to keep children safe. As KHN’s Anna Almendrala wrote this week, the facilities are “part of an unplanned national experiment” for parents weighing the pros and cons of in-person school. So far, the number of outbreaks at child care centers has remained low.

Other nations are trying different methods, with varied success. Denmark puts students in “micro-groups” of 12. Kids in New South Wales, Australia, go to school just one day a week. In Dandwal, India, students listen to a recorded voice from a loudspeaker. Israel, convinced it had beaten the virus, opened every school in May. By the first week of June, more than 2,000 students, teachers and staff had tested positive. (“[Other nations] definitely should not do what we have done,” said the chairman of the team advising Israel’s National Security Council. “It was a major failure.”)

Ohio Gov. Mike DeWine Tests Positive, Then Negative: Can We Fix Our Testing System?

I live in Ohio, and the whole state practically gasped Thursday when Republican Gov. Mike DeWine tested positive for COVID-19. Everyone asked, “How could this happen to someone who steadfastly supports wearing a mask?” Then, on Friday, another gasp when he tested negative on a second, more sensitive test — followed by a collective, “Well, of course that happened.”

It’s an understatement to say we have had major problems with our COVID testing system. Some places are flush with them; others aren’t. Celebrities, the NBA, NFL and MLB have easy access, but many regular folks have been turned away multiple times, waited more than a week for results or were told their results were lost. Frustrated with delays, six states (Louisiana, Maryland, Massachusetts, Michigan, Ohio and Virginia) announced this week a deal to buy 3 million rapid tests in an effort to reduce turnaround time.

Meanwhile, some people are pushing for universal testing with fast, less-accurate tests, the idea being that you could identify outbreaks, trace them, quarantine people and move on with life. But scientists say this wouldn’t work for two reasons. One: Most tests take samples from behind the nose or the back of the mouth and will come out positive only if that area contained the virus. In some people, however, the virus has been shown in large quantities only deep in their lungs. And two: A false-positive result sidelines a healthy person, leading to unnecessary quarantining that can affect their mental health, job, school, etc. Kelly Stafford, wife of Detroit Lions quarterback Matthew Stafford, wrote on Instagram this week that her family was harassed and put through “a nightmare” after Matthew tested false-positive for COVID.

Hurricane Isaias: How Do You Evacuate But Stay Socially Distant?

For just about everyone on the East Coast, the big talker of the week was Hurricane Isaias. (That’s pronounced “ees-ah-EE-ahs.”) Isaias skimmed Florida’s Atlantic coast as a Category 1 hurricane and banged its way up the East Coast before making landfall Monday near Ocean Isle Beach, North Carolina. All told, Isaias killed nine people, spawned more than 30 tornadoes (here’s one caught on video in Marmora, New Jersey), knocked out power to millions and forced thousands to evacuate. One major health concern was whether people in the path of the storm — including residents of nursing homes — could safely evacuate but still follow COVID safety guidelines. “We were prepared with non-congregate sheltering,” said Mike Sprayberry, director of North Carolina Emergency Management, “but many people heeded the advice to stay with family or friends or at a hotel. It wasn’t needed.” Hurricane season is in full swing (it doesn’t end until Nov. 30), so here’s some advice on how to prepare for an emergency during a pandemic — and more from the Red Cross.

Beirut Blast: The Lasting Health Effects of a Massive Explosion

About 150 people were killed and 5,000 hurt when a warehouse full of ammonium nitrate exploded Tuesday in Beirut. Ammonium nitrate, an odorless, crystal salt, is a common but highly explosive chemical that was used in several other devastating blasts, including Tianjin, China, in 2015 (165 killed); West, Texas, in 2013 (15 killed); and Oklahoma City in 1995 (168 killed). Tuesday’s blast, involving about 2,750 tons of ammonium nitrate, was roughly equal to the power of 1,155 tons of TNT, according to one weapons investigator, making it “many times larger than the most powerful conventional airdropped bomb in the U.S. arsenal [the GBU-43 Massive Ordnance Air Blast],” The New York Times reported.

The blast released nitrogen oxides, ammonia and carbon dioxide into the air. According to Newsweek and the American Lung Association, some of their health effects include lung damage, asthma attacks, lower birth weight in newborns, blindness, convulsions, suffocation and death. In the years after the Oklahoma City bombing, doctors tracked survivors’ physical and emotional health. A 1999 report from the National Institutes of Health said that up to a third of survivors reported having anxiety, depression, PTSD, asthma, bronchitis and problems with their hearing. As Tommy Muska, the mayor of West, Texas, put it this week: “We don’t seem to learn that chemical is deadly.”

Other Stories You May Enjoy:

Happy reading! Have a great weekend.

— Lauren

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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With Caveats, Hopeful News for Preschools Planning Young Kids’ Return

Sabrina Lira Garcia is proud to work as a clinical assistant in the COVID-19 ward of a Los Angeles hospital, but sometimes she wishes she could just stay home with her infant son until the pandemic is over.

Pulling her child from day care has never been an option for Lira Garcia, however. She can’t let her career lapse. Her husband was born in Mexico and is undocumented. The family pays monthly legal fees to help him get residency papers. If he were ever deported, she’d have to support Jeremiah, born in October, by herself.

“I couldn’t afford to just stay home,” she said. “I have no kind of family who lives around me or any source of help.”

Lira Garcia and thousands of other essential workers have had no choice but to use day care, and thereby run the risk of exposing their children to possible coronavirus infection over the past several months. In effect, they have been part of an unplanned national experiment of deep relevance to parents weighing the pros and cons of letting their children return to school this fall.

So far, it seems fairly successful. The number of outbreaks at child care centers is low. Research to date has shown that children rarely get sick with COVID-19, and those under 10 seem not to be as efficient at transmitting the disease to older family members. These dynamics, combined with additional precautions schools are taking around masks, classroom adaptations and keeping parents out of school buildings, appear to make day care and school reasonable options for families with healthy younger children.

There are no guarantees, however. An overnight summer camp in Georgia saw an outbreak despite several measures to mitigate risk, infecting 76% of those for whom test results were available. Fifty-one percent of kids ages 6 to 10 became infected, while 44% of those 11-17 were infected as well. Asymptomatic infection was common among the children, who weren’t required to wear masks, though adults were.

Still, while a single death tied to a day care center could be devastating to parents in any community, “child care centers are probably reasonably safe,” depending on the community transmission rate, said Ashish Jha, the incoming dean of the Brown University School of Public Health. Dr. Robert Redfield, director of the federal Centers for Disease Control and Prevention, currently defines a “hot spot” as an area with a positivity rate of more than 5%.

“If you’re in the hottest of the hot zones, and you have massive outbreaks, I’m not sure if you can do it,” Jha said of in-person schooling. “Even if the kids are all right, you still need to have teachers and staff in elementary schools.”

In California, where most in-person classes have been closed since March, about 33,300 child care facilities were open as of July 22. These facilities have the capacity to care for 720,882 children, although the actual number is probably much lower because of frequent closures and children kept at home during the pandemic.

The state had recorded 1,365 COVID-19 cases linked to child care facilities as of July 22, of which 261 were among children. During the same period, 9% of all California’s 425,616 cases were among people under age 18, and there were no COVID-related deaths reported in this age range. Since then, California has confirmed the state’s first COVID-19-related death of a teen.

In Los Angeles County, 268 cases — including 75 children — had been reported in the 7,238 day care facilities open as of the end of July. Children under 5 account for less than 1% of all hospitalizations in the county, according to data that public health department director Barbara Ferrer presented at a news conference July 29.

The picture is similar in other states that have collected data on outbreaks in child care centers, including Texas and Ohio.

But the low case counts don’t mean COVID-19 “is a completely benign disease in children,” Ferrer said. “We still have a lot to learn about the short- and long-term impacts of the virus.”

There’s a “big void” of information about how the virus spreads among small children and between children and older people, said Dr. Jeffrey Gunzenhauser, chief medical officer of the Los Angeles County Department of Public Health.

“We don’t quite understand the infection dynamics, and we don’t really know the transmission dynamics,” he said, so parents will have to balance the relative lack of information against their own need for child care.

Adding to the stress of these decisions, parents may not want children who are in school or day care to see grandparents or other relatives who have helped watch the children in the past — for fear of passing the virus on to them, Gunzenhauser said.

Uncertainty about transmission is one factor that has led parents to keep their kids at home. Some 18% of U.S. child care centers and 9% of family child care homes remain closed in the wake of the pandemic, according to the National Association for the Education of Young Children. In California, about 25% of child care programs are closed, according to the Center for the Study of Child Care Employment at the University of California-Berkeley.

“Based on what we’re hearing from providers, we expect many programs to permanently close in the next two months if they do not receive financial assistance,” said Sean Doocy, a researcher at the center.

Ricardo Rizzo, 52, runs a child care center in the Panorama City neighborhood of Los Angeles with his wife and two adult daughters. After the initial statewide shutdown in March, Rizzo and his family closed the center for two weeks to stock up on food and cleaning supplies. They also set up a sanitizing station outside the center and scheduled new cleaning routines.

Despite the new safety plans and added precautions, the center still lost eight children because of layoffs, shortened work hours and parental fear about the virus. Eighteen kids are still in his care, Rizzo said, ranging in age from babies to a ’tween.

The center’s families are low-income and receive state subsidies to pay for child care. Nearly all work in positions deemed essential since the pandemic — factory work, gas station clerks, grocery workers and certified nursing assistants. Some have multiple jobs.

“We feel blessed because we’re helping them by taking care of their kids,” Rizzo said. “I know they go to work knowing their kids feel safe.”

So far, the center and its families have been COVID-free, said Rizzo, who finds comfort in “following the protocol” — adult caretakers wear masks, do a deep clean once a day and keep parents outside the facility when dropping off and collecting their children. And he lets his center’s families know they should also take precautions.

“I say we have to work together,” Rizzo said. “If we do it here, you have to do it at home.”

Infections can still break through the child care bubble.

Anna C., a 30-year-old essential IT worker in Kent, Washington, who asked that her last name not be used, tried to keep her 4-year-old and 20-month-old sons home until the toddler fell off a bed and split his lip while Anna and her husband were on separate conference calls.

The couple, realizing they couldn’t work and safely watch their sons at the same time, decided to send them back to child care in late April. They had to pull them out again a week later, after the spouse of the toddler’s day care provider tested positive for COVID-19. No further infections arose during a two-week quarantine, however, so they sent the kids back again.

“This is going to happen with any day care center or provider,” Anna said. “It’s just the new reality.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Medi-Cal Agency’s New Head Wants to Tackle Disparities and Racism

When Will Lightbourne looked at the statistics behind California’s coronavirus cases, the disparities were “blindingly clear”: Blacks and Latinos are dying at higher rates than most other Californians.

As of Monday, Latinos account for 45.6% of coronavirus deaths in a state where they make up 38.9% of the population, according to data collected by the California Department of Public Health. Blacks account for 8.5% of the deaths but make up 6% of the population.

Lightbourne, who led California’s Department of Social Services under Gov. Jerry Brown, describes this pandemic as one that “rips the bandage off” a health care system long riddled with inequity.

So, when Gov. Gavin Newsom asked Lightbourne, 70, to come out of retirement in June to lead the Department of Health Care Services, he said, he couldn’t say no.

“He has committed his whole professional life to public service,” said Mike Herald, director of policy advocacy at the Western Center on Law & Poverty. “He’s not joking when he talks about the importance of these issues and the important role that government plays in addressing societal inequities.”

The Department of Health Care Services oversees the state’s Medicaid program for low-income people, called Medi-Cal, which provides health care to some 12.5 million Californians.

Lightbourne said he sees the job as a chance to refocus Medi-Cal on reducing disparities — improving people’s health not only by providing better access to doctors, but also by linking them with behavioral health programs and using health care dollars to get them into housing.

He said the department also plans to amend contracts with health providers and use routine performance reviews to make sure providers are addressing disparities.

Health care advocates say Lightbourne has a track record of getting things done.

At the Department of Social Services, he persuaded Brown, a known penny pincher, to increase cash assistance to low-income families, restoring cuts lawmakers had made in the Great Recession. And he was instrumental behind the scenes in the repeal of the contentious policy that had prohibited Californians from receiving increased welfare income if they had more children while receiving public assistance, Herald said.

“Will is very purpose-driven and has made substantive changes in every role he has ever had,” said Graham Knaus, executive director of the California State Association of Counties.

Before embarking on state service, Lightbourne served as director of the Santa Clara County Social Services Agency, the Human Services Agency of the City & County of San Francisco and the Santa Cruz County Human Services Agency.

Lightbourne’s local and state experience give him a valuable skill set as state and county officials grapple with providing health care to some of California’s most vulnerable residents during a pandemic, Knaus and other advocates said.

The task won’t be easy. The previous director of the Department of Health Care Services, Brad Gilbert, left the job after less than four months.

Lightbourne talked to California Healthline about why he returned to state government, how the department is responding to COVID-19 and how he hopes to improve access to health care for those who need it. The interview has been edited for length and clarity.

Q: Why did you come out of retirement to take a job that’s difficult under normal circumstances — and even tougher during a pandemic?

Events of the past six months have made it blindingly clear that we’ve got structural inequities that are not just immoral but are, at an existential level, unsurvivable. It’s a pandemic that landed on top of a pandemic of inequalities, opportunity and income that’s been raging since the 1980s. And that pandemic has been enabled by a pandemic of racism that has rotted in our society for generations.

I think we have to use the moment to insist that our publicly financed health care system really partners up with our public health network and with our social safety-net system to address community and population health with a laser focus on reducing disparities.

Q: How has the department responded to COVID-19 to address the most vulnerable Californians?

The growth in telehealth is something that would not have occurred without this experience. There’s work still underway to look at how we can come up with some approaches to reduce the number of people in skilled nursing facilities, where the rate of spread is so much more severe and with really mortal results.

I have the suspicion that we’re never really going to get to a point where we say the effect of COVID is over. The mere fact that so much health care utilization is down now, particularly down in the places where people who start at a disadvantage normally seek care, we’re going to find long-term health consequences into the future, even post-vaccine.

Q: In January, Gov. Newsom outlined a proposal to broaden a Medi-Cal program known as CalAIM that addresses physical and behavioral health needs in patients’ care, and even pays for their housing with health care money. Can your department still move forward with those goals even though there isn’t money in the budget for it?

We may be delayed to some extent. It was never intended initially as a big-bang system change. It was always going to be a degree of iterative development, and that remains true — whether some things have to go a little slower because of money reasons.

Q: You have talked about access to health care and how COVID-19 has really highlighted systemic disparities. In Medi-Cal, lack of access to care has long been a problem, especially in rural areas. So has inadequate care for children. Are those issues you intend to address?

One of the things we need is an adequate network of providers that really covers the medically underserved areas of the state. We need to work effectively with our rural health clinics, as well as our urban Federally Qualified Health Centers to expand access, particularly to the populations that historically haven’t had that access.

In terms of services for children, that’s a big part of that agenda both in physical and behavioral health and also the dental health system. There’s a big focus on how to improve access and preventive services for children.

Q: In the Great Recession, California lawmakers made many deep cuts to safety-net programs, some of which have been restored only recently. The governor proposed a number of health care-related cuts this year that were ultimately rejected by the legislature. How will you ensure that Medi-Cal enrollees won’t see their benefits scaled back in the future?

It’s going to be my job to make the case not to reduce services that poor people rely on. That said, we live in the real world and if we ever have to reduce things, my approach would be to try to say, “How can we reduce things we can readily rebuild rather than destroy things that are foundational?”

Goal No. 1 at this point is to work very closely with our congressional delegation to really encourage the federal government to support the core services and activities so that we can meet the needs of the people of the state.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Must-Reads of the Week

While you, loyal reader, wait for a wonderful new permanent Friday Breeze writer to start breezing, welcome to this week’s rundown brought to you from St. Louis by me, Midwest correspondent Lauren Weber.

I’m sadly here to inform you the news is … still bad. So bad, in fact, that “doomscrolling” — the act of not being able to escape your smartphone feed of misery — was examined by The New York Times.

And that’s because all you need to know about the current state of the coronavirus can be aptly summed up in renowned infectious disease reporter Helen Branswell’s latest piece for Stat, titled “How to Fix the Covid-19 Dumpster Fire in the U.S.

The Week’s Latest

But to be more precise: New coronavirus cases in the U.S. shattered a single-day record with over 75,000 Thursday. That number of daily cases has more than doubled since June 24. Deaths from COVID-19 are rising yet again while hot spots across the Sun Belt continue to flare. The Center for Public Integrity uncovered an unreleased federal document saying 18 states are in the “red zone” for COVID-19 cases and should consider stricter protective measures.

And as outbreaks strain lab capacity nationwide, some people are waiting seven or more days to get test results, hobbling potential containment responses. Now, the CDC is urging people to not be retested.

Masks, Schools and Tony Fauci

Mass mask confusion continued to drive the week, with Georgia Gov. Brian Kemp suing Atlanta Mayor Keisha Lance Bottoms over her mandatory mask order. Later, he urged all citizens to wear masks for four weeks — but said he would not support a mandate. Meanwhile, Georgia hospital workers are sounding the alarm and attempting to send patients out of state as hospitals fill up. Across the country, more than half of states have issued mandatory mask orders at this time. And this detailed map of just who is wearing masks in the U.S. is worth your time.

The sharp divide over back-to-school plans for those in public and private school came into focus (private schools have the money to hire their own epidemiologists!), all while Bloomberg reported the percentage of cases of children and teens with COVID-19 is on the rise. The Centers for Disease Control and Prevention postponed releasing further guidance on how students could safely return to school this week. That follows previous complaints from President Donald Trump, who said on Twitter the CDC’s initial recommendations were too tough. Or, as White House press secretary Kayleigh McEnany said Thursday, “The science should not stand in the way of this.”

The big distraction of the week had to be the attacks on the reputation of America’s favorite scientist, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. He withstood a White House attack on his credibility, led by Peter Navarro, Trump’s trade adviser, in an op-ed in USA Today — one that USA Today has since said “did not meet its fact-checking standards.” To his credit, Fauci called to “stop this nonsense” and focus on the coronavirus. For more of a deep dive on the ongoing fireworks, check out this week’s amazing-as-usual episode of KHN’s “What the Health?” podcast. And never forget that Fauci did manage to sneak in this InStyle digital cover with some killer shades and he read a college kid’s thesis on the side during his tenure.

Speaking of op-eds, here’s one worth reading. Larry Hogan, Maryland’s Republican governor, wrote an op-ed about how he felt the Trump administration left his state to fend for itself amid the pandemic. Best part: how he and his wife, who was born and raised in South Korea, were able to secure half a million tests by going outside of the federal response, tapping into her contacts and then protecting them from the feds with the state National Guard.

The disappearance of public data from the CDC website created another firestorm this week. While the data has been restored, it’s another chapter in the saga of tension among the CDC, the administration and public access.

Pocket Change

The insurer UnitedHealthcare posted its most profitable quarter — EVER — proving that, yes, you can get rich during the pandemic. Meanwhile, hospitals face the harsh reality of a surge colliding with their plans to resume profitable elective surgery.

And, no, you won’t be getting on a cruise ship anytime soon — the “no sail” order from the CDC has been extended through September 2020.

Long Reads and Graphics Worth Your Time

Racial inequities in COVID exposure, treatment and care persist at every level, as this piece zeroing in on East St. Louis shows. And this week, over 1,000 employees of the CDC sent a letter to its head calling out systemic racism within the agency.

I still can’t stop thinking about this profile of Lorna Breen, an ER doc who took her own life after becoming overwhelmed not only by the coronavirus crisis but by an exacting medical culture.

These New York Times graphics stress how drug overdose deaths hit a new high in 2019 — many worry the coronavirus is exacerbating their continued rise.

Finally, What’s Abuzz

In case you didn’t have anything else to worry about, mosquitoes are flying into the blind spots of health departments overwhelmed with COVID-19. The CDC is buzzing with concern, as Anna Maria Barry-Jester and I reported yesterday as part of our Underfunded and Under Threat series with the AP.

And for a speed round, these guys tried really hard to hand out free masks at Huntington Beach, California; the inside tale of how a Qatari prince had USC at his beckoning takes many a turn; and you just may have been using hand sanitizer wrong this whole time.

Try to lay off the booze, folks — experts say it’s only supposed to be a drink a day. Also maybe, just maybe, think about staying away from the bars altogether.

If we have a football season — a big IF — here’s what the “mouth shield” helmets would look like.

Plus superhero heartthrob Henry Cavill somehow spent his quarantine staying swole AND learning how to build computers?

But our favorite British superhero might just be Tom Moore, newly knighted by Queen Elizabeth II. The centenarian captured the world’s heart after raising millions for British health care workers by walking laps in his garden with his walker.

Why Doctors Keep Monitoring Kids Who Recover From Mysterious COVID-Linked Illness

Israel Shippy doesn’t remember much about having COVID-19 — or the unusual auto-immune disease it triggered — other than being groggy and uncomfortable for a bunch of days. He’s a 5-year-old, and would much rather talk about cartoons, or the ideas for inventions that constantly pop into his head.

“Hold your horses, I think I know what I’m gonna make,” he said, holding up a finger in the middle of a conversation. “I’m gonna make something that lights up and attaches to things with glue, so if you don’t have a flashlight, you can just use it!”

In New York, at least 237 kids, including Israel, appear to have Multisystem Inflammatory Syndrome in Children, or MIS-C. And state officials continue to track the syndrome, but the Centers for Disease Control and Prevention did not respond to repeated requests for information on how many children nationwide have been diagnosed so far with MIS-C.

A study published June 29 in the New England Journal of Medicine reported on 186 patients in 26 states who had been diagnosed with MIS-C. A researcher writing in the same issue added reports from other countries, finding that about 1,000 children worldwide have been diagnosed with MIS-C.

Tracking the Long-Term Health Effects of MIS-C

Israel is friendly and energetic, but he’s also really good at sitting still. During a recent checkup at Children’s Hospital at Montefiore, in the Bronx, he had no complaints about all the stickers and wires a health aide attached to him for an EKG. And when Dr. Marc Foca, an infectious disease specialist, came by to listen to his heart and lungs, and prod his abdomen, Israel barely seemed to notice.

There were still some tests pending, but overall, Foca said, “Israel looks like a totally healthy 5-year-old.”

“Stay safe!” Israel called out, as Foca left. It’s his new signoff, instead of goodbye. His mother, Janelle Moholland, explained Israel came up with it himself.

And she’s also hoping that after a harrowing couple of weeks in early May, Israel himself will “stay safe.”

That’s why they’ve been returning to Montefiore for the periodic checkups, even though Israel seems to have recovered fully from both COVID-19 and MIS-C.

MIS-C is relatively rare, and it apparently responds well to treatment, but it is new enough — and mysterious enough — that doctors here want to make sure the children who recover don’t experience any related health complications in the future.

“We’ve seen these kids get really sick, and get better and recover and go home, yet we don’t know what the long-term outcomes are,” said Dr. Nadine Choueiter, a pediatric cardiologist at Montefiore. “So that’s why we will be seeing them.”

When Israel first got sick at the end of April, his illness didn’t exactly look like COVID-19. He had persistent high fevers, with his temperature reaching 104 degrees — but no problems breathing. He wasn’t eating. He was barely drinking. He wasn’t using the bathroom. He had abdominal pains. His eyes were red.

They went to the emergency room a couple of times and visited an urgent care center, but the doctors sent them home without testing him for the coronavirus. Moholland, 29, said she felt powerless.

“There was nothing I could do but make him comfortable,” she said. “I literally had to just trust in a higher power and just hope that He would come through for us. It taught me a lot about patience and faith.”

As Israel grew sicker, and they still had no answers, Moholland grew frustrated. “I wish his pediatrician and [the emergency room and urgent care staff] had done what they were supposed to do and given him a test” when Israel first got sick, Moholland said. “What harm would it have done? He suffered for about 10 or 11 days that could have been avoided.”

In a later interview, she talked with NPR about how COVID-19 has disproportionately affected the African American community, due to a combination of underlying health conditions and lack of access to good health care. She said she felt she, too, had fallen victim to those disparities.

“It affects me, personally, because I am African American, but you just never know,” she said. “It’s hard. We’re living in uncertain times — very uncertain times.”

Finally, Children’s Hospital at Montefiore admitted Israel — and the test she’d been trying to get for days confirmed he had the virus.

“I was literally in tears, like begging them not to discharge me because I knew he was not fine,” she recalled.

Israel was in shock, and by the time he got to the hospital, doctors were on the lookout for MIS-C, so they recognized his symptoms — which were distinct from most people with COVID-19.

Doctors gave Israel fluids and intravenous immune globulin, a substance obtained from donated human plasma, which is used to treat deficiencies in the immune system.

Immune globulin has been effective in children like Israel because MIS-C appears to be caused by an immune overreaction to the initial coronavirus infection, according to Choueiter, the Montefiore pediatric cardiologist.

“The immune system starts attacking the body itself, including the arteries of the heart,” she said.

In some MIS-C cases — though not Israel’s — the attack occurs in the coronary arteries, inflaming and dilating them. That also happens in a different syndrome affecting children, Kawasaki disease. About 5% of Kawasaki patients experience aneurysms — which can fatally rupture blood vessels — after the initial condition subsides.

Choueiter and her colleagues want to make sure MIS-C patients don’t face similar risks. So far, they’re cautiously optimistic.

“We have not seen any new decrease in heart function or any new coronary artery dilations,” she said. “When we check their blood, their inflammatory markers are back to normal. For the parents, the child is back to baseline, and it’s as if this illness is a nightmare that’s long gone.”

For a Pennsylvania Teen, the MIS-C Diagnosis Came Much Later

Not every child who develops MIS-C tests positive for the coronavirus, though many will test positive for antibodies to the coronavirus, indicating they had been infected previously. That was the case with Andrew Lis, a boy from Pennsylvania who was the first MIS-C patient seen at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Andrew had been a healthy 14-year-old before he got sick. He and his twin brother love sports and video games. He said the first symptom was a bad headache. He developed a fever the next day, then constipation and intense stomach pain.

“It was terrible,” Andrew said. “It was unbearable. I couldn’t really move a lot.”

His mother, Ingrid Lis, said they were thinking appendicitis, not coronavirus, at first. In fact, she hesitated to take Andrew to the hospital, for fear of exposing him to the virus. But after Andrew stopped eating because of his headache and stomach discomfort, “I knew I couldn’t keep him home anymore,” Lis said.

Andrew was admitted to the hospital April 12, but that was before reports of the mysterious syndrome had started trickling out of Europe.

Over about five days in the pediatric intensive care unit, Andrew’s condition deteriorated rapidly, as doctors struggled to figure out what was wrong. Puzzled, they tried treatments for scarlet fever, strep throat and toxic shock syndrome. Andrew’s body broke out in rashes, then his heart began failing and he was put on a ventilator. Andrew’s father, Ed Lis, said doctors told the family to brace for the worst: “We’ve got a healthy kid who a few days ago was just having these sort of strange symptoms. And now they’re telling us that we could lose him.”

Though Andrew’s symptoms were atypical for Kawasaki disease, doctors decided to give him the standard treatment for that condition — administering intravenous immune globulin, the same treatment Israel Shippy received.

“Within the 24 hours of the infusion, he was a different person,” Ingrid Lis said. Andrew was removed from the ventilator, and his appetite eventually returned. “That’s when we knew that we had turned that corner.”

It wasn’t until after Andrew’s discharge that his doctors learned about MIS-C from colleagues in Europe. They recommended the whole family be tested for antibodies to the coronavirus. Although Andrew tested positive, the rest of the family — both parents, Andrew’s twin brother and two older siblings — all tested negative. Andrew’s mother is still not sure how he was exposed since the family had been observing a strict lockdown since mid-March. Both she and her husband were working remotely from home, and she says they all wore masks and were conscientious about hand-washing when they ventured out for groceries. She thinks Andrew must have been exposed at least a month before his illness began.

And she’s puzzled why the rest of her close-knit family wasn’t infected as well. “We are a Latino family,” Ingrid Lis said. “We are very used to being together, clustering in the same room.” Even when Andrew was sick, she says, all six of them huddled in his bedroom to comfort him.

Meanwhile, Andrew has made a quick recovery. Not long after his discharge in April, he turned 15 and resumed an exercise routine involving running, pushups and situps. A few weeks later, an echocardiogram showed Andrew’s heart was “perfect,” Ed Lis said. Still, doctors have asked Andrew to follow up with a cardiologist every three months.

An Eye on the Long-Term Effects

The medical team at Montefiore is tracking the 40 children they have already treated and discharged. With kids showing few symptoms in the immediate aftermath, Chouetier hopes the long-term trajectory after MIS-C will be similar to what happens after Kawasaki disease.

“Usually children who have had coronary artery dilations [from Kawasaki disease] that have resolved within the first six weeks of the illness do well long-term,” said Choueiter, who runs the Kawasaki disease program at Montefiore.

The Montefiore team is asking patients affected by MIS-C to return for a checkup one week after discharge, then after one month, three months, six months and a year. They will be evaluated by pediatric cardiologists, hematologists, rheumatologists and infectious disease specialists.

Montefiore and other children’s hospitals around the country are sharing information. Choueiter wants to establish an even longer-term monitoring program for MIS-C, comparable to registries that exist for other diseases.

Moholland is glad the hospital is being vigilant.

“The uncertainty of not knowing whether it could come back in his future is a little unsettling,” she said. “But I am hopeful.”

This story is part of a partnership that includes WNYC, NPR and Kaiser Health News.