Portland pediatric infectious disease specialist addresses back-to-school concerns

As school begins, many parents, teachers and students are worried about the return to the classroom with COVID-19 cases on the rise in Oregon.

OPB received hundreds of responses to a survey, from people throughout the region about their biggest concerns regarding the return to full, in-person learning.

Dr. Malaika Little, a pediatric infectious disease specialist and director of the in-patient hospitalist team at Randall Children’s Hospital addressed some of those responses in an interview with OPB on Tuesday.

OPB: There’s a wide variance of vaccination rates across Oregon. Adult vaccination rates are about 75% in the Portland metro area, just 50% in southern Oregon and central Oregon. Should parents in different parts of the state think about school safety differently?

Malaika Little: I think it’s a good question, and I think the amount of responses you got is really important, right? So that really shows that parents universally are worried and thinking about this for their kids, and as a trained pediatrician, that’s my number one. I don’t really think that the county rates at this point are the important thing. I think getting kids back to school and accepting that there is going to be up and down fluctuations in risk is a reality. I think we’re deep enough into the pandemic now that we know this is something we need to, unfortunately, live with and figure out how to educate children.

So while I’m deeply concerned about the variation in vaccination rates and think we need to work on that, I think for parents getting back to school, a fairly universal approach and keeping them safe is going to be important.

OPB: Are you a parent? What’s your top concern?

ML: I am, yes. I’m actually a single parent. I have a 7-year-old who is ready to start second grade tomorrow. So I understand the personal side of this is very real, very real.

I mean, I think I’m concerned like every other parent about getting him into a classroom. For him, there’s going to be 30 kids in a classroom. The after-school program is actually not able to open this year due to staffing challenges and COVID actually in a staff member to start the year. So I’m very sympathetic about those challenges. How am I going to juggle being a physician, working, my son, his transition, all of that? I would say in the big picture I’m probably far more worried about families that don’t have the advantages that I have.

So I have a supportive employer, I have a supportive group of colleagues. I have a job that I think is important and he can understand that, but I’m very concerned about the families that don’t have the resources — where food insecurity, where getting to school is a big deal, and frankly kids that have not been very immersed in the education system for up to 18 months at this point. So that probably far outweighs things for me at this point. I’m concerned about his peers and frankly about his generation with everything that’s happened in education.

OPB: If parents want to advocate for their children’s safety at school, what COVID-19 safety measures have the best evidence behind them?

ML: The C.D.C. has looked at this really closely. I think everyone is really vested in going back to school being a success and what they’re recommending is really sort of a tiered approach. So unfortunately it’s not kind of a one-and-done method where we can say, “All you need to do is mask. All you need to do is distance.” It really takes a variety of different strategies. I think they spelled this out quite nicely and at this point, we do have some data and some experience from schools that restarted last year.

I think it is important to remember that Delta is a little bit different. It seems that the contagiousness and the way it’s affecting kids does seem to be a bit more severe and I think that is concerning. But it’s this tiered approach of vaccination, masking, social distancing and then all the other ancillary measures such as disinfection, air circulation, quarantining and contact tracing.

So, I would recommend to families as opposed to looking at one measure and feeling like that is it, really try to get behind the number of things that schools are doing to make this a safe reintroduction and also acknowledge that different school buildings, different school situations are going to be able to implement those in different levels.

OPB: About 5% of responses mentioned a fear that school reopening will lead to more deaths. I want to break that down and ask you questions about that.

Some parents and teachers are afraid their too-young-to-be-vaccinated children will get COVID at school and die. How likely is that?

ML: So I think the short answer really is very, very unlikely. We’re fortunate that COVID-19 does not seem to be a virus at this point which has a high mortality [rate], or that children are dying a lot from. There is a very, very low, it’s called case fatality rate. In fact for estimates, it’s really sort of a 0.1 or 0.0 depending on the numbers that we have.

We have millions of kids at this point that have been tested for COVID. We have lots of experience with test-positive kids and overall it’s milder in children.

Again, I would give the caveat that delta is a little bit different and certainly just like an adult, there are comorbidities, or there are reasons why some children get sicker than others. So there are some risk factors such as if you already have a lung problem, obese children, if you already have another medical condition such as sickle cell disease — those are all reasons why some kids may get sicker than others. And those, the ones we worry about especially for sort of an in-patient management.

OPB: Teachers are also afraid their colleagues will get sick and die due to transmission in schools. Who is most at risk?

ML: So the short answer is those that are unvaccinated. That is really who we continue to see getting sick being in the hospital. And I am worried about that for teachers. I think we need to move beyond that and be able to embrace how lucky we are to have the availability of vaccines that we have now.

I think as we see children hospitalized, as we see even older individuals hospitalized, most of the time it’s household contacts. So it’s coming from households where there’s unvaccinated individuals. And I think for teachers that is an incredible thing they can do to keep themselves healthy.

I think again the tiered approach that C.D.C. is outlining has shown to be effective. There’s a study that looked at Chicago when they reintroduced in-person learning. And actually though in a high COVID disease environment, a place where there’s lots of COVID in the community, those kids that actually were in a school environment and able to mask and have air circulation and some control actually even had lower rates than those that were home.

So I think teachers can feel safe just like I do as a physician being at work if they can protect themselves by a vaccine.

OPB: Last year, a major concern around school was that children would bring home the virus to grandparents or other vulnerable adults. How much has vaccination reduced that risk?

ML: Great question. So I think there’s a tremendous reduction in that. We’re not exactly aware of the specific rates on prevention for that. We do know those individuals that are vaccinated have much less severe disease. So all of those grandparents that hopefully are now vaccinated. All those individuals at home have really taken the most important step to keep themselves out of the hospital and keep themselves healthy.

I think we’re all disappointed that Delta does seem to be more severe. We’re also disappointed in breakthrough cases and the fact that it’s not a complete coverage for individuals that are vaccinated.

But again, I would say that the transmission risk usually is going the other direction, that children are not often the ones that are bringing it home to the household. It’s far more likely that children are the ones getting infected in the household.

I think again, remembering all of our feelings about vaccination, not vaccination, that children at this point are universally unvaccinated if they’re under 12 years of age and keeping a real careful public health look on that and remembering the risk to them is important.

OPB: Adults are concerned about some high-risk settings in schools where children will be close together: lunchrooms, where students are eating unmasked, was the top concern.

As a pediatrician, are you concerned about the lunchroom, or any other specific parts of the school experience?

ML: So again, I think the CDC has tried to address this. I also think here in Portland, [Portland Public Schools] has tried to address this, and I was happy to see the outdoor lunch for the first six weeks of school. I’m a big believer in outdoor time whenever possible. So frankly, I think everything we can move outdoors is good for children’s mental health as well as their COVID prevention.

I think it does seem that schools are embracing this and looking at unique ways to handle that. So this does go back to some of the tiered approach and that it’s not a one-time strategy.

So I have concerns, but I think there is real potential to think in an innovative way, and I do think that we can do this all safely.

OPB: Some parents question whether masks are necessary and have concerns about the social-emotional impact of masking on kids.

Do we have any data yet on the impacts of masks on developing children?

ML: It’s a good question. There certainly are people that are coming out very concerned about that, especially young kids that are learning to read and looking at those effects. I think it’s too early to really know the long-term changes in that. Certainly, we know kids all over the world learn in different ways and that education works in different ways.

Again, I’m probably more worried about not having that strategy in place. I think actually our children are quite resilient and they will weather through this and be successful, but I do think some innovative ways to be tracking that in the future will be important.

OPB: How do you think about the trade-offs involved in mask-wearing for children?

I think I would say the counter to that concern about early social-emotional health is really the anxiety and the mental health burden that this entire pandemic is putting on kids. So a way for them to feel empowered and protect themselves I think is very important. I think really leaning into ways to support their mental health through this, big picture is something we are seeing lots of data in and something we know is really affecting all children at every age.

So I think if we think a little more broadly about it, then feeling safe, having a mask, feeling empowered, all those things can be very positive for children.

I think in my experience, helping talk through it with kids and help them understand why they’re wearing a mask for their own protection, for the protection of their families, the protection of their friends. That feeling that it works both ways and they’re part of a bigger community and they’re part of a bigger way of helping this pandemic really be dampened down at this point. I think that can be very empowering for children and a message we can spread that’s really positive.

OPB: Other parents are concerned that cloth masks are no longer an adequate protective measure for unvaccinated children in face of the delta variant.

How effective are cloth masks on children?

ML: There’s always going to be levels of protection based on little factors such as the specific variant you’re talking about, what exactly the exposure is, how close who is from, etc.

The long and short of it is a mask that fits and a mask that’s on is the best mask. So figuring out for your kid what mask that may be. If your child would wear an N95 all of the time, that’s one factor. If they’re going to wear it only for the first two hours and be constantly pulling it down, rubbing their eyes, itching their mouth, etc., then obviously that’s not an effective mask.

So I do think for some ages practicing mask-wearing has been very important. And then I think again, being in a controlled setting where that is an expectation and where children are universally masking is super important.

Again, there have been studies that have looked at pods and cohorts and the ability to maintain the same levels of masking and the same levels of processes to keep kids safe and it’s very difficult. So I really, you know, I really want to give kudos to teachers that are out there, they’re going to be responsible for trying to maintain these measures. Universal masking is absolutely going to be an important part of it.

OPB: Some parents and teachers are concerned that our core mitigation strategies — masking, distancing, ventilation — won’t be adequate given the transmissibility of the delta variant.

There are lots of concerns about schools being a crowded setting, where distancing won’t be possible or adequately enforced.

How critical is distancing to reducing the risk of transmission of COVID-19 in schools?

ML: I think it’s a great question and one that is certainly emerging with Delta. Most of the data we have really is before Delta. So again, I would say that the infectiousness of this variant may make a difference.

From the school reintroduction information we have, it does seem that the difference between 6 feet and 3 feet may not be that important. The C.D.C. has really gone through all of this and not just here in the United States, but in Germany and other parts of Europe. They were able to reintroduce with a shorter distance successfully and not see real outbreaks and real challenges in school settings.

I think we all share concerns about school classrooms overcrowding and the ability of some ages to keep that distance. I’m actually a bit less worried about the classroom than I am just general social clustering.

So we had this challenge even in the hospital, right. We like to be closer to people, we’d like to connect with them. I think things like staggering lunch, staggering times in hallways, all those sorts of measures may end up being more important in the long run than even specifically how much room you have around each desk. I also think there’s a fair amount that has gone on in terms of air circulation.

So thinking about airplanes, which worried us a lot in the very beginning. Airplanes have exceptional air circulation. And so again, we have not seen major outbreaks from air travel. We haven’t seen people that are much closer than 6 feet from each other, traveling for a number of hours, all becoming symptomatic and transmitting COVID. So I think again, we can do this in school settings. Things like open windows, open doors will be important.

And again, I would go back to, if you have everyone vaccinated that is able to be vaccinated, you are cutting down a lot of your transmission to start with.

OPB: Is there anything else you would like worried parents, teachers or community members to know in regard to school restarting?

ML: I would just say again how much I share that worry, right? I think this is a stressful time. I think our children are very stressed by this.

I think there’s a lot of other aspects to children’s health that are important to keep forefront of mind right now. So certainly when I think about the children that we’re now seeing in the hospital, at Randall Children’s, yes, we are seeing kids that are sick with COVID, but the majority of kids that we see still have other pediatric illnesses. So we’re seeing kids that are sick from asthma. We’re seeing kids that are sick from their baseline medical problems. We’re seeing diabetics. We’re seeing kids for mental health reasons.

What I want parents to remember is that things like annual vaccines, annual visits to their primary care doctor continue to be extremely important. Keeping an eye on their kids’ mental health and any other measures we can do as a community to help those that are a little bit less fortunate with things like food security, child care assistance, transportation. All of these things are a part of children’s health and I don’t want COVID to over-dominate that.