August 10, 2020 Vol. 7: It Is Time to Change Our View of COVID

“We need to stop this false view of COVID as either death or recovered. A 25 year old with lifelong lung problems…[c]hronic kidney or heart disease seems increasingly likely….The risks to everyone, including young [people] must be understood.” – Andy Slavitt, former Acting Administrator of the Centers for Medicare and Medicaid Services (@ASlavit)

My primary goal in writing this article is to provide additional information to facilitate a more nuanced understanding of SARS-CoV-2 (“COVID”). At this point in the pandemic we know a lot more than just a few months ago and it’s becoming clear that our initial notion that most who get it will bounce back rapidly and only a few older people will die is not accurate. This virus is turning out to be much more complicated than that, and we can’t make sound decisions if the lens we’re using to do so is flawed. My premise is that day to day decisions and judgments which require weighing COVID risks (such as sending you kids back to school) will be improved when the framework for those decisions is more accurate.

Additionally, I want to clearly state there is no debate as to the value of an in-person education, critical for so many reasons. But, SPOILER ALERT: under the current circumstances in California and many parts of the country, I’m generally not in support of children returning to in-person learning at this time, particularly high school. And it is essential that decisions we make, whether related to school, church attendance, parties, travel or anything else involving contact with others be guided by public health officials and scientists on an apolitical basis and using the latest scientific evidence. 

Early in the pandemic, COVID was framed as deadly for some people, but most individuals were expected to recover, including children and adults younger than 50. COVID was labeled a potentially fatal respiratory disease (especially among the elderly), but it was believed that most people recovered within about 14 days. Now, the emerging view of leading scientists and medical professionals is that these assumptions were not only inaccurate, but also caused many teens and younger adults not to take the virus seriously which has contributed to the disease spreading widely and to the deaths of some of those “otherwise healthy” young people. Fortunately, the early view that most children who do become symptomatic from COVID only have mild acute illness continues to be true. Sadly, this isn’t so for every child who contracts the virus.

I’m keeping my eye on many aspects of this pandemic, including the number of COVID cases, current research, treatments, vaccine development, and patients’ prognoses overall. Based on my current understanding of the disease, it’s clear to me that we need to pay careful attention to the possible long-term effects of COVID on adults and children. It’s critical to recognize that while our knowledge is growing daily, we still have enormous holes in our understanding. We need to make decisions for ourselves and our families that, as much as possible, account for this lack of information and minimize the still unknown risks of contracting (and spreading) COVID. For example, there’s emerging evidence that some adults who “recover” from COVID have structural abnormalities in their hearts and/or persistently elevated myocardial inflammatory markers. In another study asymptomatic COVID positive individuals had lung CT scans similar to those with pneumonia. What we don’t yet know is if children who recover from COVID could have cardiac or other long-term organ damage nor do we understand why a relatively small number of children (< 18 years) experience severe illness—so let’s hit the pause button until we’ve gathered more information.

Of course the next major decision for parents in this COVID era is looming: School. San Francisco Unified School District has already announced it will begin the school year with distance learning. Private elementary schools, on the other hand, may have the option to reopen for in-person learning if they comply with the California Department of Public Health’s guidelines. How should parents be thinking about in-person learning at school? You’ve no doubt read many opinion pieces on this subject and have your own feelings about what type of school (virtual vs. in-person vs. hybrid) will work best for you and your family. Every family is different, and my goal is not to tell you what to do, but rather to help you make informed decisions.

There Is So Much We Don’t Know About COVID

While it’s true that many people who become sick from COVID will recover quickly and will exhibit mild symptoms, it’s not true for everyone, particularly those over 50. That said, a recent American Association for the Advancement of Science article indicates that a sizable percentage of even younger adults who contract COVID may have ongoing problems including debilitating fatigue, a racing heartbeat, shortness of breath, achy joints, foggy thinking, a persistent loss of sense of smell, and damage to the heart, lungs, kidneys, or brain. In fact, some adult COVID patients are being referred to as “long haulers.” These adults experience debilitating symptoms like ongoing fevers and even mental confusion lasting many weeks or months. On July 27th, JAMA Cardiology published preliminary data which raise grave concerns: nearly 80% of basically healthy people (average age 49) who tested positive for COVID infections mild enough to “recover at home” were found to have structural changes in their hearts. To be clear, this data was based on 100 adults and no children and therein lies one of the challenges facing parents: there have been thus far very few studies involving the impact of COVID in the pediatric population. As one physician put it, “[C]hildren can get the short end of the stick and don’t get studied until we figure out what’s going on in adults.”

It’s true that to date, the short-term impact of COVID has generally been milder for children compared to adults. However, “we don’t know what we don’t know” could be COVID’s tagline. We are starting to see preliminary evidence contradicting the initial idea that kids don’t get or transmit COVID, and we now know that a smaller percentage of kids compared to adults may experience severe illness. That said, a new CDC study published last week found that one in three children hospitalized ends up in the ICU, similar to the rate of ICU admission in adults (though adults are hospitalized at much higher rates). My growing concern is that some children who have mild COVID illness could suffer long term health consequences. I hope I’m wrong.

Additionally, it now appears that children may be as likely to contract COVID as adults, they can transmit the virus, often when asymptomatic, at the same frequency as adults by the time they’re 10 years old, and we are only beginning to grasp the possible long-term health effects of this disease. One positive is it still appears that the transmission between preschool-aged children is low. 

In addition to all of this recent research, I can tell you from my own clinical experience that getting COVID tests in the Bay Area is continuing to prove extremely challenging. Not only can results take over two weeks to come back, but most of the drive-through testing centers will not swab anyone younger than 18 years old, and most doctors’ offices like GetzWell Pediatrics cannot yet test for COVID. If our community isn’t testing children widely, it’s safe to conclude there’s a lot we don’t know about COVID infection among kids and this situation makes it impossible to identify hot-spots before it’s too late. There is some indication that relatively inexpensive rapid saliva based tests may be available later this year and if these tests are reasonably accurate, this could be a game changer.

Making Decisions About School Amidst Unknowns

In areas where the COVID cases are still rising, or haven’t been tamped down, reopening schools for in-person learning is risky not just for students but their teachers, administrators and staff. San Francisco and other Bay Area counties are beginning to slow the spread of COVID, but cases are still too high for widespread reopening. 

Given all the unknowns, it’s important to do an honest check-in within your family to assess whether to send your kids to any in-person learning while COVID numbers are still up and testing/tracing remain woefully inadequate. If cases are still rising in the community, it doesn’t matter whether your child is in a public or private school, the risks are still too high. Until we control community spread, we cannot safely send our kids back into the classroom. As Molly Jong-Fast, the editor at large for @thedailybeast, wrote in a recent article, “[I] wondered how I could ask my kids to do something I myself wouldn’t do: Go into a crowded school and take their chances.

Options for this School Year

Frankly, all of the current school options available to parents are dismal. Full-time in-person, part-time remote, full-time remote—each of these options has significant downsides. But, maybe it’s time to focus on making the most of the “least worst” options in order to safeguard the health of our children and their teachers, staff, and administrators until COVID numbers are down and testing is fast, easy, and reliable. If schools are opened for in-person learning in August, it’s likely they will quickly be forced to close again when, not if, teachers or students test positive for COVID. 

With in-person learning, in addition to the very real risks of COVID exposure and illness, parents, teachers, and administrators will be left scrambling to accommodate 14-day quarantine periods on virtually no notice. And how do we manage the scenario where individuals have COVID symptoms but get a false negative when tested after they have exposed others? What about the kids who are asymptomatic, attend school because they feel fine, and unwittingly infect others? To make matters worse, as I’ve said, COVID testing options in the Bay Area and turnaround times for results remain abysmal as does contact-tracing. 

We’ve already seen how COVID ripped through a kids’ summer camp where everyone tested negative shortly before their arrival. And remember that 14 days may not be the accurate measure of how long it takes most to fully recover. Some adults take significantly longer, and others are already suffering the effects of damage to their vital organs, including their brains. How do we address these terribly difficult health scenarios we will have caused by reopening too early

On the other hand, if schools wait to reopen until later this year when we have fast and accessible testing, organized contact-tracing, and community spread has waned greatly because we’ve taken the intervening months to firmly tamp down the virus, schools could reopen and stay open—safely— for the remainder of the upcoming academic year. 

Many parents have expressed deep concern about their children missing out on social and emotional development because they cannot attend school in person. This is a very real problem. However, remember that in-person learning during COVID will not resemble what we are used to. Mask-wearing and physical distancing will be part of the day-to-day, plastic barriers around desks may be incorporated, bathroom trips will be closely monitored, recess and lunch activities will be severely limited. 

Even if children start school in person, in communities where the virus has not been brought under control, it’s very likely they will spend even more time in quarantine doing distance learning because of inevitable COVID infections. Will students learn effectively in this environment? How much joy will they experience? Won’t it be turbulent to stop and start in-person learning in successive, sudden quarantines where the disruptions themselves could cause social-emotional trauma? In-person learning might sound great because it’s more normal but in reality poses its own set of challenges and potential harms. In any event, If we proceed with in-person learning, we will need to accept some level of COVID transmission and be prepared to be very flexible to make it work.

Emotional and Educational Resources

You don’t need me to tell you what you already know: This period is eroding many families’ well-being. With school starting, there will be more to handle. If you are struggling, know you are in good company and if you could use some emotional support, contact your pediatrician or personal physician for appropriate referrals in your community. At GetzWell Pediatrics we have our favorite resources and are happy to share them with you. 

In terms of alternative learning scenarios in the face of “Zoom school,” it seems clear that COVID and the advent of “learning pods” will further widen the already unacceptable education gap that exists along racial lines in the United States. In an effort to help San Francisco’s most needy, the City has organized Learning Hubs meant to help up to 6,000 children with their distance-learning needs. Consider finding ways to support the Learning Hubs that San Francisco will be offering beginning in mid-September. 

You’ve Got This

As we grind away into the seventh month of the pandemic and beyond, I urge you to stay vigilant and remember that even though it already may seem interminable, this situation is temporary. All pandemics end. You—and we!—are strong and resilient. 

We need leaders who are making science-based decisions for our communities, and on the personal level it’s critical that our choices are informed by scientific evidence that not only makes sense today but also takes into account that COVID infection could lead to long-lasting, serious adverse health effects. 

As always, we’re here for you—don’t hesitate to reach out if we can help you navigate this pandemic wilderness.