Children Daycare Social Distancing

K-12 School Relative Risk Index

I don’t intend to flood your news feed today, but many (at least in Texas) are headed to school this week.

This infograph categories school activities within a spectrum of risk.

This is based on CDC and National Academy of Science recommendations. The recommendations were summarized and translated by three scientists (two MD’s and one PhD in epidemiology), resulting in this infograph.

At this time, the only thing we, epidemiologists, can suggest is risk reduction. This is an approach that abolishes the all-or-nothing approach to COVID19, acknowledging the lack rigorous data, the lack of a national, coordinated response, and that abstinence-only is not possible for everyone in this long, drawn out process.

Love, your local epidemiologist

Data Source: Infograph

Children Deaths Hospitalizations

Hospitalizations among kids

Not groundbreaking, BUT really important for physicians and parents to make data-informed decisions.

The majority of childhood COVID19 cases are asymptomatic or mild. For that reason, we really haven’t known what happens to kids that DO get hospitalized due to COVID19. Are they hospitalized at a similar rate as adults? What are their symptoms? What percent have underlying conditions? CDC published a report today! Here are the numbers:

Hospitalization rate: 8 kids per 100,000 are hospitalized due to COVID19. This is MUCH lower than the adult hospitalization rate (165 per 100,000). Kids younger than 2 years old (25 per 100,000) had the highest rate of hospitalization compared to kids older than 2.

ICU rate: 33% of hospitalized kids got sent to the ICU.

Ventilation rate: 6% of kids in ICU required a ventilator.

Underlying conditions: 43% of hospitalized kids had an underlying medical condition. The most common condition was obesity, lung disease, and prematurity.

Symptoms: 54% of hospitalized kids had fever/chills, followed by nausea/vomiting, abdominal pain, or diarrhea (42%).

Death rate: 1% of children died during hospitalization. This is compared to 29% of hospitalized adults.

Translation? Children can (and do) develop severe COVID19 illness, but the vast majority survive to hospital discharge. Hospitalization rates have increased among kids since March, which is indicative of the virus’ incredible reach right now.

Love, your local epidemiologist

Data source: Kim et al. (August 7, 2020). Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 — COVID-NET, 14 States, March 1–July 25, 2020. MMWR 

Children GA

GA summer camp

Attack rate among kids at an overnight camp in Georgia. A case analysis. 

What happened?
June 17–20: Orientation for 138 trainees and 120 staff members
June 21: 138 trainees left. 363 campers and three senior staff members joined staff
June 23: Teenage staff member left camp because of symptoms
June 24: Teenage staff member tested and reported a positive COVID19 test 
June 24: Officials began sending campers home
June 27: Camp closed 

Interestingly, this camp did adhere (to the most part) of state requirements. All trainees, staff members, and campers were required to provide documentation of a negative viral SARS-CoV-2 test ≤12 days before arriving. Staff members also were required to wear cloth masks (if they actually did, we don’t know).

However, some measures were not implemented:
• Kids didn’t wear cloth masks
• Windows and doors were not opened to increase ventilation 
• A variety of activities were indoor and outdoor, including daily vigorous singing and cheering.

Figure shows attack rate: high across all ages. CDC concluded: “This investigation adds to the body of evidence demonstrating that children of all ages are susceptible to SARS-CoV-2 infection and, contrary to early reports, might play an important role in transmission”.

Love, your local epidemiologist

Data source
Szablewski CM, Chang KT, Brown MM, et al. SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 2020. MMWR Morb Mortal Wkly Rep. ePub: 31 July 2020. 

Children Daycare

Estimate COVID19 risk in the classroom

For my teachers and professors (whether in a university or K-12 school)…

A group of scientists at Duke University at the Nicholas School of the Environment created a COVID19 exposure modeler to estimate your COVID19 risk in the classroom. This went live yesterday!

There are several details you will need to fill out, including number of students, duration of your classes, height of classroom ceiling, mask efficacy, and room air ventilation. I didn’t know some of these parameters on the top of my head, but if you press on the parameter, it will explain how to guesstimate.

They are continuing to improve this, but this gives you a general, first idea of your risk. I know the school year is getting closer and closer.


Love, your local epidemiologist

Children Long-term effects

Mental health of parents and their children

In March, many working parents were asked to do the impossible: Seamlessly transition to work from home, continue productivity (or in some cases increase productivity [looking at you public health workers]), and act as childcare or in-home schooling. On top of this, many high-risk parents (like doctors, nurses, police officers) separated to reduce COVID19 risk at home. This led to an additional adjective: SINGLE working parent. To me, this immediate transition had to have been one of the toughest couple weeks.

Scientists at Vanderbilt University sent out a US national survey to parents. Parents were asked whether things have changed since the pandemic. If they did change…was it better or worse? I’ve been waiting on this type of data to be published.

So, what did they find?

-27% of parents reported worse mental health and 18% worse physical health

-Parents that were female, unmarried, and with younger kids reported much worse mental and physical health compared to their counterparts

-The worsening mental health for parents occurred alongside loss of regular childcare, change in insurance status, and worsening food security.

-15% of parents reported worsening in their children’s behavioral health

As the upcoming school year comes, some parents are again faced with impossible decisions. As a community, we need to keep the unique needs of families with children in mind as we move forward. It takes a village, right?

Love, your local epidemiologist

Data Source: Patrick et al., (2020). Well-being of parents and children during the COVID19 pandemic: A national survey. Pediatrics.


School Outbreak Investigation

The first publication of a mass COVID19 outbreak within a school was published over the weekend. A high school that reopened in Israel. What happened?

  • March 13: Complete closure of all schools
  • May 3: Only kindergarten, grades 1-3, grades 11-12 opened
  • May 17: All schools reopened
  • May 27: First major school outbreak at a public high school
  • May 28: The school was closed
  • May 28-30: Everyone at the school was COVID19 tested
  • Mid-June: 87 contacts outside of school positive (e.g. siblings, friends, teammates, student parents)
  • June 30: 65% students recovered and 64% staff recovered (two negative PCR results)

Attack rate was 13.2% among students and 16.6% among staff. No one was hospitalized. Grades 7-9 had the highest transmission.

The highest classroom rate was in 9th grade (20 cases in one class). The second highest was in 7th grade (14 cases in one class). The third and fourth highest were in 9th grade (13 cases in each class).

What can we (in the United States) learn from this? Avoid the three C’s:

  • Closed spaces with poor ventilation (Outdoor classes should be considered. There was a heatwave in Isreal during this outbreak and this wasn’t possible)
  • Crowded places (We need small classroom sizes. Isreal’s classes were crowded: 35-38 studentsper class)
  • Close-contact settings  (Minimize student mixing; wear facemasks; teachers set example)

Love, your local epidemiologist

Data Source: Stein-Zamir et al., (2020) A large COVID19 outbreak in a high school 10 days after schools’ reopening, Isreal, May 2020.

Children Daycare Deaths Innovative Solutions Long-term effects

COVID19 and child abuse

Thought I would sprinkle some of my own research in this blog because…why not?

For those of you that don’t know, I am a violence and injury epidemiologist. My research lab focuses on how violence is contagious (just like infectious diseases) and predictable. Because if it’s predictable, then it’s preventable.

As we ALL know by now, COVID19 has not only caused major medical problems in our community but has caused social problems. The strains and stresses of the COVID-19 pandemic (like job loss, financial struggles, food insecurity, mental health, and lack of social support) have exacerbated the risk of violence at home.

My colleagues and I are continually working to understand how the stay-at-home orders/school cancelled impacts child abuse.

Figure 1 shows the impact of COVID19 on child abuse hospital visits in 2020 compared to 2019. Briefly, we found less kids are going to the hospital for child abuse after stay at home orders compared to last year. Unfortunately, though, we hypothesize that this isn’t because child abuse is getting better, but rather because kids are interacting less with mandatory reporters (i.e. teachers, daycare teachers) and the public.

Among kids that ARE going to the hospital for child abuse, physicians are reporting even MORE severe injuries (traumatic brain injuries, intentional burns) than before the pandemic. Typically, a hospital system has 5-10 child abuse deaths per year. It is not uncommon for a hospital to now report 2 child abuse deaths in one week.

The realities of this crisis are immediate. Researchers and clinicians are working hard to urgently address this public health crisis in real-time. 

Prevention can also start at home. The Prevent Child Abuse America posted some fantastic resources for parents, children, educators and everyone else. This includes tips for staying connected to the community, tips for staying engaged as a family, and tips to manage stress and anxiety. Check it out:

These efforts are especially relevant given that a lot of schools are delaying in-person school. While this delay is desperately needed medically, it will have an impact on kids’ health and safety. 

Love, your local (violence) epidemiologist

Source: Data comes from my lab in which we are working directly with pediatric hospitals. Data is not published; this is only a high-level preliminary report. We are working on it!

Children Innovative Solutions

Contact Tracing

The power of contact tracing.

Yesterday, the CDC published one of the first comprehensive contact tracing studies. It was conducted in South Korea.

I threw together a figure that depicts the study design. Briefly, South Korea identified 5,706 confirmed cases (i.e. index cases) and asked them to report their contacts (both in the household and out in public). The cases reported a total of 59,073 contacts. The cases and contacts were followed for at least 2 weeks. 

This is what they found:

  • You are more likely to get sick if you’re in the household with an index case than out in public (12% vs. 2%)
  • The age of the index case can INCREASE or DECREASE your chances of infection
    • Interestingly, an older kid (age 10-19) that gets COVID19 has the HIGHEST rate of infecting a contact compared to other ages (20%). This obviously has important implications for the school opening debate. 

Contact tracing (followed by quarantine) is one of the original and BY FAR the most effective ways to curb a pandemic. Other countries have been highly successful in achieving this. The United States has not. It’s a mess. Why?

  • Funding. We have a terrible history of not funding public health. So, when a pandemic hit, health departments were (and still are) scrambling for support (personnel, technology, infrastructure, etc). Even DURING the pandemic, I know of a couple health departments that have asked for funding for contact tracing and were denied. 
  • Spread. COVID19 has reached SO far, that this preventative measure is just not feasible. In Dallas, we are reporting ~7000 NEW cases per week. If each person had at least 2 contacts, this is 21,000 phone calls weeks PLUS follow-up phone calls. Contact tracing is best to use BEFORE uncontrollable spread. This has led to health departments prioritizing who they call; where they can make the most impact in terms of mortality.  
  • Lack of trust. Even if public health departments successfully reach an index case, the majority don’t answer their phone OR they report no contacts (which is most likely false). This chronic distrust in the US government is significantly impeding on public health efforts. 

Nonetheless, health departments are working incredibly hard with what they got. This has resulted in a few important case studies (see figures 2 and 3).

Contact tracing could answer SO MANY questions. This would better inform decision making and planning. For now, we will rely on small case studies in the US and comprehensive data from other countries. 

Love, your local epidemiologist

Data source:

Children Innovative Solutions

Opening Schools part 2

Alright, an update from yesterdays post…

First off, you are all impossible to please. BUT because of your fantastic feedback, we were able to make this table a bit more detailed. I added the ages of the grades that were opened and incidence of COVID19 (per 100,000). I also corresponded incidence rates to Harvard’s “Key Metrics for COVID19 Suppression” (see Figure).

All the countries that opened schools were either GREEN (below 1 case per 100,000) or YELLOW (1-9 cases per 100,000).

As for the United States….
I added a graph of the incidence rates per state. As of today (and according to Harvard’s standards), we have no GREEN states. However, about half of our states are YELLOW. The other states have high incidence rates: ORANGE or RED.

Each state, county, and city needs to pay attention to their incidence rate and plan accordingly. If a location is in the YELLOW or GREEN, I would also humbly suggest that they ALSO need to have their test positivity rates AT LEAST below 10% (5% would be ideal, according to the WHO).

Schools are not opening today. They are opening in a month or two. So we need to plan for ALL scenarios and be flexible. If we still have record breaking numbers in a month or two, we will have much bigger problems than opening up schools.

Love, your local epidemiologist

Sources: Harvard:…/ . University of Washington, Global Health:…/COVID-19%20Schools%20…

Children Innovative Solutions

Opening Schools part 1

For the teachers. I know you’re out there because you’re so loud in the comments (keep it up).

There is VERY LITTLE data on the risk of COVID19 to teachers because…schools have been closed. School closure was one of the first mitigation strategies implemented because TYPICALLY kids (and elderly) are the worst hit during an epidemic. I have daycare data (but, again, only for kids).

Some rockstar researchers at the University of Washington spent the time to go through ALL national and international media reports AND studies to put together the most comprehensive picture of COVID19 spread in schools. They included all countries that have opened schools, what they have done, and whether or not they have seen COVID19 spread.

I threw together this figure so it’s easier to see on social media. HOWEVER, I strongly suggest to read the report. Yes, details are missing because there is a lot we just don’t know.

Without rigorous data, the only thing we, epidemiologists, can suggest is harm reduction: only open up certain grades; have staggering schedules; and control transmission. Also, keep in mind that all of these countries have different cultures, different family values, different school schedules, and opened at different points during the pandemic. All of this will impact spread. However, this is the best we got.

We have to be extremely strategic in opening schools. There are epidemiologists in every county across the United States. Work closely with them to navigate this unprecedented time.

Love, your local epidemiologist

Data source: Shout out to this team for their work in gathering this important information: Brandon L. Guthrie PhD, Diana M. Tordoff MPH, Julianne Meisner BVM&S MS, Lorenzo Tolentino BS, Wenwen Jiang MPH, Sherrilynne Fuller PhD FACMI, Dylan Green MPH, and Diana Louden MLib, Jennifer M. Ross MD MPH. Here is the report:…/COVID-19%20Schools%20…