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Brigid Bergin: It's the Brian Lehrer Show on WNYC. I'm Brigid Bergin from the WNYC and Gothamist newsroom, filling in for Brian. Back with us now is Dr. Leana Wen, Washington Post columnist, former Baltimore Health Commissioner, and George Washington University professor who has given us so much medical and public health insight during the pandemic and so many things to think about from her opinion writing in the Washington Post. Today, we'll talk about keeping children safe from COVID. This is the third academic year bound to be disrupted in some way by the pandemic. Dr. Wen, we always appreciate it. Welcome back to WNYC.

Dr. Leana Wen: Thank you so much. Great to join you again.

Brigid Bergin: Listeners, we're going to invite your calls right away on this. Parents, do have questions about keeping your younger kids and teens safe or anything about the Delta variant in children as the school year gets underway and the FDA approves the Pfizer vaccine? 646-435-7280. That number is 646-435-7280 or tweet your question at @BrianLehrer. Dr. Wen, while we wait for those calls to come in, the first day of New York City's public school isn't for another couple of weeks, but so many kids around the country are already back in school. So far, what are we seeing around the country in terms of COVID in schools?

Dr. Leana Wen: Well, I want to back up for a moment and say that two things are true at the same time. One is that we are at probably the most dangerous time for children during this pandemic, and we're seeing this with record numbers of children being hospitalized. We're actually at the highest point of children being hospitalized across the country during this entire pandemic. Of course, we have the more contagious Delta variant, and children under the age of 12 are not yet able to be vaccinated. That said, the second thing that's also true is that we can help to keep kids safe in schools.

In fact, schools can be one of the safest places for children from a COVID-19 transmission standpoint if we have layers of protection in place. I think to your question, we're seeing the confluence of these things here. There is this piecemeal approach being used across the country. There are some places that are implementing all these measures, and even if they have high levels of community transmission, they're able to keep their schools from becoming overwhelmed. On the other hand, those places that have not implemented, for example, masking in schools, we're seeing outbreaks, we're seeing hundreds of kids being quarantined, and unfortunately, kids not being able to be back in school in person again.

Brigid Bergin: In your Washington Post piece, you write, "It's a sad indictment of our society that children are paying the price for irresponsible adults and reckless policymakers. As a result, parents like me who have kids too young to be vaccinated must take matters into our own hands to reduce risk." We want to talk about that, and I can tell you, I feel that one very personally. What can parents do to mitigate the risk of COVID as school gets underway, particularly for young kids who have-- May be masking is harder or they don't have the option to get vaccinated?

Dr. Leana Wen: I'm glad you asked the question, and this is why I wrote The Washington Post column. I did want to make the point that kids are in the position that we are in now because of the actions of adults. That adults should have stepped up all along to protect our kids, but even last summer, we were prioritizing opening bars instead of schools. We did not invest in our schools and now even there are parts of the country where school districts are forbidden to implement mask mandates. We wouldn't imagine putting 20 or 30 adults who are unmasked, unvaccinated in a room together all day. Why are we doing that with our children?

I wanted to make that one point, but then the second point, I think more important point is to say, parents are not helpless here, that there are still things that we can do even if the conditions around us are not ideal. One of those things is to make sure that all the adults in the household, everyone surrounding the child is vaccinated. Everyone 12 and older should be inoculated to protect younger siblings and try to make sure that you as the parent can ensure that everybody else around the kid including all relatives who are visiting are also vaccinated as well. If they're not vaccinated, then another idea or another suggestion is spend as much time outdoors as possible.

Outdoors certainly is much more protective than indoors. That's the place to go. Actually, I wrote in my column too about how I think it's important for us to tell our children when it is they should be wearing masks. If we say that they have to wear masks both indoors and outdoors, it actually doesn't put the priority on where mask-wearing is the most important, which is indoors, so I would feel comfortable with children not wearing masks outdoors when they're playing on the play gym or participating in outdoor sports, but that said, I do think masking indoors when our unvaccinated children are around other unvaccinated kids is so critical.

I really hope that schools are implementing indoor mask mandates, but even if they're not, two things for parents to consider. One is try talking to other parents in your child's class. Perhaps a lot of other parents feel the same way, and if the majority of parents are deciding that their kids should be wearing masks indoors, that's going to also help to protect kids. Then also quality of mask matters too. We really with this more contagious Delta variant should not be wearing a cloth mask. We should be wearing at least a three-ply surgical mask. If our kids are comfortable with them, KN95 or an N95 will protect them even better.

Brigid Bergin: Some great advice there, Dr. Wen. I want to bring in Michelle from Staten Island. Michelle, what's your question for Dr. Wen?

Michelle: Hi. Like I said to the screener, I'm just very confused because I'm wondering where natural immunity has gone in all of this, because yes, I read a lot of articles, and the headlines will say, "Kids are now getting COVID." Then you read further into the article, and it says, "Well, for the most part, by and large, kids are fine, and some kids are catching it to a worse extent."

I just read a BBC article where the doctor said, natural immunity, like these kids have the opportunity to have that natural immunity protect them through their lives. If we start immunizing these kids at such a young age, there's no chance for that natural

immunity to occur. Am I wrong in there? Why are we not prioritizing especially for the kids that the natural immunity that they seem to be having from COVID?

Brigid Bergin: Dr. Wen, what is your take on that?

Dr. Leana Wen: Well, I'm glad that you asked the question, because I think it's a question that many people have about their kids and also about themselves. I certainly hear this from patients all the time, even from adults, saying, "Well, what about recovery from COVID? If I get coronavirus, how much does that protect me as opposed to the vaccine?" Here's what we know. We know that if you recover from coronavirus, you get it, you recover from it, you do have some level of immune protection. However, we also know that that immune protection is not as consistent, long-lasting, and robust as immunity from vaccination.

In fact, there was a study done published by the CDC that found that those who get infected but remain unvaccinated are twice as likely to be reinfected as those who got the infection, recovered, and then got vaccinated. There really is a benefit for adults. I know that's not the question, but I just want to explain. Adults who got COVID, recovered, they should still be getting the vaccine because it gives them an additional important layer of protection.

Now, there's a separate question, I think, about children. It is true that children tend to not get as ill as adults, but I actually think that that's the wrong comparison. When you look at children and other illnesses, children are not supposed to die, children are not supposed to get severely ill, children don't get as severely ill as adults from other illnesses either. Children tend to recover much more than adults from other illnesses, so I actually don't think it's the right comparison for us to say, "Hey, children don't get as sick as adults. Therefore, we don't need to worry about children."

In fact, I had written a previous column about this, imagine if COVID-19 were a disease that only affected children, and we knew that on an average day, more than 200 kids around the country are getting hospitalized because of this disease, that more than 500 children have died. Tens of thousands have gotten severely ill to the point of being hospitalized and it strikes previously healthy children.

If this were a disease that only affected children, I think we would all be saying, "Oh my goodness, we don't want our children to get this." The comparison with adults I think is not the right one, but I think the caller also brings up this important question of, basically what I understand is there are some people who are thinking, "Well, why don't we just expose our kids? Kind of in the way that people thought about chickenpox parties of the past. Why don't we just have our kids all be exposed?" Well, here is the reason.

There is a safer and better way for us to build our children's immunity than getting them exposed and potentially having a terrible outcome like our kids getting hospitalized, having long-term consequences, and potentially dying, and that is through vaccination. Ultimately, that's what we've decided for all these other

childhood diseases.

We have not decided that our children should be getting measles, mumps, rubella, chickenpox, and polio. We have said, "There are now vaccines that are developed that can prevent terrible consequences from these illnesses." That's why we want to build immunity this way through vaccination rather than through infection. That's also better protection, longer-lasting protection--

Brigid Bergin: Dr. Wen, I appreciate that. One of the things that we're seeing a lot from our listeners on Twitter are questions about the youngest kids, kids who are not eligible for vaccines yet, and whether or not the guidance that is currently in place around masking in, say, nursery schools or daycares is sufficient. One of our listeners tweeted in, "My kids are three and starting preschool. I'm so unclear on if I should request that they wear masks throughout the day. The preschool does not require them."

Similarly, we have another question from a listener who tweeted, "I hear about risk mitigation in K through 12 schools, but with a two-and-a-half-year-old and a four-month-old daughter in daycare and nursery school, where of course, we don't have the option for vaccines, I worry that the protocols from last year won't cut it now." Do you have any sense of what the guidance should be for parents who have very young children, who might be in those congregate settings where maybe masks aren't being required yet because the children are so young. Do you anticipate that guidance might change?

Dr. Leana Wen: That's a really good question, and I will tell you that I am in this boat as well. I have two little kids. I have a son who just turned four yesterday, who will be starting preschool next week, and I have a daughter who is 16 months old and so is too young to be wearing a mask. I've tried putting a mask on her, and she's not at the age yet where she can really tolerate it and will just rip it right off, so I think there are two separate things. One is for kids two and older who should be able to wear masks. That is the recommendation by the CDC, that in settings of where there are children two and older that are gathering, ideally, everyone should be wearing masks.

For example, my son, in his preschool class, masks are absolutely required in indoor settings. That's something that I would inquire about if the three-year-old or four-year-old or others are in a setting where they're above the age of two, ideally, masks are still required in those settings. For younger children under the age of two, it's really hard to keep masks on, in which case, one way to think about this is there are layers of protection, kind of like you have layers in the winter. If you remove one layer, you ideally want to put on other layers, and so in daycare settings, it is so crucial that all the adults are vaccinated. I would inquire to make sure that all the daycare workers and also all the visitors are vaccinated.

It also helps if all the parents of all the children are vaccinated too because that additionally shields the kids who are coming in, there's much less chance of the other kids in that daycare class having COVID-19. Otherwise, the CDC has really strict and very good guidelines on their website about daycare settings. I understand  

that these guidelines were developed in the era pre-Delta.

I don't know that we will have updated guidance just because things are evolving so quickly, but I do think that making sure you ask about the guidelines for the daycare setting, putting them up against the CDC guidelines to see what's there and what's not and then asking the questions about what else can be done.

For example, can there be regular testing done? What are the quarantine protocols if somebody ends up getting [unintelligible 00:13:52]? What about ventilation? Is everything done as much outside with open windows and doors inside as possible? Asking those questions will be important to ensure that your child is as protected as possible, but I would just say that for many parents, daycare is not really an option. It is something that is essential in order for parents to work, and so then our option becomes trying to be as careful as possible.

Brigid Bergin: I want to go to Greg in Stamford, Connecticut, who has a question about his grandson. Greg, welcome to WNYC.

Greg: Thank you. Am I heard?

Brigid Bergin: We can hear you. What is your question for Dr. Wen?

Greg: I've got a 10-year-old grandson who's got asthma. He attends school in a district that does well with masks, but I'm concerned, and I'm wondering if he shouldn't attend for a couple of weeks to see how successful the masking is and whether or not there is the spread of the D variant in the classroom.

Dr. Leana Wen: It's a very good question, and I think that many parents are considering something like this, at least people who have concerns. I mean, many of our children do have underlying medical conditions.

Asthma certainly is something that could worsen the outcomes from COVID-19, although childhood asthma is extremely common, and it's something that many kids have. I would say the following, I think we now know about the importance of in-person schooling on cognitive development, on emotional well-being, and we also know about what happens when our kids don't have that continuous in-person instruction, that it could widen educational disparities and really have many knock-on effects as well.

Of course, this is a personal decision that every family has to make with regard to what their own medical circumstances are and what their own risks are, but I would say that if the 10-year-old-- school actually has very good procedures, including requiring indoor masking, I actually think it's a good idea to start in person in school, again, following the procedures, asking about what they are in advance, also making sure that the 10-year-old wears a very good mask, because with that great mask, the N95 and KN95, if your grandchild is able to tolerate it, that will also protect the grandchild a lot.

I actually think it's better unless, again, it depends on your family circumstances, but  

in general, I would advise people to start in person and follow all the precautions because of how important in-person schooling is.

Brigid Bergin: Dr. Wen, if we can shift gears a little bit, I'm wondering what you can tell us about the practical ramifications of the FDA granting full approval for the Pfizer COVID vaccine. Do you expect that will make vaccine mandates more of a possibility in school districts that have been resistant to take that step up to this point?

Dr. Leana Wen: I do. I think that the FDA's, their approval of the Pfizer vaccine yesterday was huge. Not so much, I think, in terms of moving individuals, I think the individuals who are very dug in at this point. There might be some who are saying, "Okay, they're more likely to get vaccinated at this point." I think that the biggest impact is going to be on changing the minds of business owners and employers, and as you mentioned, schools as well, and now saying, "Hey, this vaccine should be treated like any other."

We routinely have all 50 states require childhood immunizations. Why shouldn't we be requiring the COVID-19 vaccine as well, at least for 16-year-olds and above for whom the Pfizer vaccine now has full approval? I do expect that this is something that's going to move pretty soon. We've already seen a spate of businesses and universities now require vaccines, even in last 24 hours since the Pfizer news or the FDA news came out, so I would expect others to follow.

I just have one more thing to add to for parents, if I may, because I think a lot of times, parents are really concerned, understandably so, about what happens in the school, but actually, we know that most of the transmission for children are occurring outside of school, and so I just want to remind parents about the importance of thinking about risk as being cumulative.

You really do not want to have all these precautions being put into place in school, only to then go to pizza parties and sleepovers and other indoor events after school. Sports are great but make sure that the sports are done outdoors, and then be really careful about the carpool to the sports and about what happens in the locker room. Just really consider these informal activities and the risk there because I strongly believe that in-person schooling is so important, prioritize that and try to reduce the risk in extracurricular out-of-school social activities.

Brigid Bergin: Since we are on the topic of vaccines, I want to bring in Ellen from Manhattan. Ellen, you have a question for Dr. Wen?

Ellen: Yes, thank you. What is the status of a vaccine for children under 12 and what is causing the continued delay in having its availability?

Dr. Leana Wen: Ellen, I hear you. I am also very frustrated as someone who is in this boat and cannot wait to have my young kids being vaccinated. I'm frustrated too because of lack of information and lack of transparency. We had heard a couple of months ago from Pfizer that they were ready to produce their results, I believe, in August, September, and then it became September, October. My understanding is that they did present some kind of interim results of some type to the FDA but that

the FDA told them they need longer safety information, more safety data, as well as more children enrolled in trials that are now extending the time period to when those results can officially be presented.

I want to understand what is happening. So much of this now is hearsay from some health officials and from the company, but I would really like to understand from the FDA and CDC as to what is going on, as in how much data are they requiring? Are they saying two months of safety data as we did for adults and for 12-year-olds and above? Is that enough or are they actually asking for more? Or are we asking for a certain number of children to be enrolled in these studies? I think that that we have to recognize that the risk-benefit calculation has also changed.

Back in May, June, it looks like the number of cases was substantially declining. In late June, I believe that we had gotten to something like 11,000 or 12,000 new cases every day total in the country. We're now at more than 10 times that. Record numbers of hospitalization among children so the risk-benefit has really changed, and I think we need to-- I would love to see a statement from the FDA of, "This is where we are. This is what we're requesting from Pfizer. This is what we anticipate Pfizer having these data." We don't have that level of transparency, and I think that's a problem.

Brigid Bergin: Thank you so much for your question, Ellen. I want to just go back for a moment, Dr. Wen, to a point that you had raised about as you're thinking about the risks, children, particularly young children face and maybe some of the different strategies that parents could be thinking about and you talked about the use of KN95 or N95 masks for kids, but one thing we know is that that's a decision or an option that may be financially out of reach for people, particularly people with multiple kids, that the cost of those masks could really add up.

Do you think that that points to something that needs to be done differently, different policies we should be seeing from schools or from our local governments in terms of trying to help mitigate the risks faced by kids at this age? Because I think for most families, there's a stockpile of those cloth masks that they've gotten over the past year plus that they're relying on, but if the guidance is really that that's not sufficient, do we need to be thinking more structurally about how to address that need?

Dr. Leana Wen: That's a great point. No one should be priced out of the ability to wear a mask at this point. My other advice, by the way about masks, is that you really should be tailoring the mask to your child, as in the best mask for your child is the one that they are able to consistently wear comfortably. You do not want to be putting on even if the KN95 or N95 is the most protective, you don't want to be putting it on only for your child to be pulling it off every two minutes. That really defeats the purpose of the mask and a lot of kids, including my own, my four-year-old will not tolerate a KN95 or N95.

For him, we have a three-ply surgical mask that he's very comfortable with. I'd make sure to practice that mask at home and prior to starting school, wearing the mask for longer and longer periods at home to make sure that your child is able to wear it at

school consistently and comfortably, but to your very good point, I hope that we are able to provide these masks, these higher-quality masks free of charge to children.

Utah, interestingly enough has actually done this, has provided, even though they have not implemented a mask mandate in schools, which obviously I think is the right thing to do, but at least they have made these KN95s available free of charge to their children, as I understand, and I think that's important.

By the way, these masks are also not that expensive, I understand still prohibited for some families, but the cost of a KN95 or N95 is about $1, and it can be worn multiple days, including potentially for weeks at a time if the mask does not get soiled. It's not prohibitively expensive now, although recognizing the many structural barriers for families, something like masks, high-quality masks and also testing should absolutely be available free of charge on demand without question.

Brigid Bergin: That's good to know that those masks are also re-wearable, reusable. Let's go to Daniel in the Bronx. Daniel, welcome to WNYC. What's your question for Dr. Wen?

Daniel: Hi, thanks for the call. I'm curious about what your feelings are about maintaining the three-foot social distancing in K-5 New York City public schools? We were at six feet when there were fewer kids in the buildings and we were dealing with a less transmissible variation of the virus. Now we're going to have all the kids going back to school, and we're still going based on the three-foot social distancing in the same way as-- Whether or not CDC is adjusting to new data, I wanted to hear from her.

Brigid Bergin: Dr. Wen, what do you think of that guidance that has shifted from a six-foot to a three-foot social distancing requirement in schools?

Dr. Leana Wen: I think we need to recognize that this shift from six feet to three feet occurred because of necessity, because there is no way to bring back our kids in person full-time in most of our schools if we continue with that six-foot distancing. That said, I still think that this could be done safely if we first of all recognize that there's no such thing as zero risk.

Everything that we do at this point, even if it involves going to the grocery store or going to visit relatives at their homes, everything has some level of risk, but we have to recognize that some things are essential and we have to reduce risk, while still making sure that we do these things in in-person schooling full-time should be one of those things.

The second issue is regarding the layers.

Again, think of it as in the winter, you're wearing multiple layers. If you take off one layer, you need to replace it with another. Well, if we are removing the layer of six-feet physical distancing, we should be replacing it with other layers. Improve ventilation is such a layer, having every educator in school be vaccinated, that's another layer, I understand that that's something that New York City is doing. I think that's fantastic, and other places should follow as well.

Then, also testing, something that we haven't talked about as much, but actually the CDC recommends that unvaccinated children in areas of all but the lowest rates of transmission should actually be tested once a week, at least once a week, and if they're involved in extracurricular activities that are higher risk, for example, contact sports and other things, they should be tested twice a week. I really hope that we see vaccination, ventilation, and testing as additional layers that can help to replace the need for distancing, and of course, indoor masking remains even more important if kids are going to be in such close proximity with one another.

Brigid Bergin: Thank you so much for that. Let's go to Shetal in Holmdel, New Jersey. Welcome to WNYC.

Shetal: Hi, my question for Dr. Wen is our BOE in Holmdel [unintelligible 00:27:30] to make an exception for the mask mandate in our schools, and I'm extremely concerned since the vaccines aren't out and our kindergartner classes don't even have three feet distance, they're sitting right next to each other. My kid is completely okay in wearing a mask because he did that in his preschool, but now that that might not be an option, what can we do? I would have personally liked to keep him remote till he got vaccinated and then send him back in November, but since that's not an option either, what can we do to protect our kids?

Dr. Leana Wen: I am so sorry that you're in this position, and I think there are a couple things that come to mind. One is more on the kind of broader advocacy level and the other is on the what are the individual things that you can do. On the advocacy level, just want to make the statement that I think the very loud voices tend to be the anti-mask, anti-vaccine individuals, and I actually think that it's time for those of us who support masking, who support vaccinations to also make our voices heard as well.

Because otherwise, the idea of "freedom" for some individuals will actually overwhelm the need for the majority of people who actually want to do the right thing and keep our children safe. I think it is time to make sure that our collective voices are heard in this regard. I would say to your specific issue of how do you impact things now, I still think that everything should be done as much the local level, and I don't mean this in terms of your jurisdiction, but I mean in your actual class that your child is in. It actually won't really impact you that much if other classes are not wearing masks.

It really impacts your child if the other kids in your child's class are wearing masks. See if you can get a pact going among other parents in your class, and the more parents will agree to wear masks in class, the more parents will say that they themselves are vaccinated in your child's class, the safer that environment is going to be. If for whatever reason that's still not going to work, see if you and other parents can talk to the teacher together about at least having those highest risk activities be done outdoors, for example, lunchtime, snacktime, depending on the age of the child, is that something that could be done outdoors.

Even if it comes down to it, could your child be seated next to other kids who are

also wearing masks at least while they're in class, that also helps to protect your child. Again, the quality of mask for your child will also matter a lot too.

Brigid Bergin: Thank you so much for that, Dr. Wen. I just want to take another quick moment going back to questions related to the vaccine to talk a moment about booster shots. The news about FDA approval came just in time for those booster shots which are already being offered to some people who are immunocompromised and who had also received either the Moderna or Pfizer vaccines. Do we know any more about when people who got the Johnson & Johnson vaccine will need booster shots?

Dr. Leana Wen: Well, this is a great question and one that I wrote an entire column about, because I am one of those 13 million people who received the J&J vaccine. It seems that we have been left behind by guidance. All of the guidance that we're hearing, including right before the booster shot announcement came out, the CDC independent advisory panel met to recommend a third dose for those who got the Pfizer or Moderna vaccine, but did not provide recommendations for those who got the J&J vaccine.

The booster dose news also affects only those who got Pfizer or Moderna. Our federal health officials basically said, "To be determined on Johnson & Johnson." I actually think that there are two separate questions for the J&J recipients. One question is this question of, is immunity waning and will there need to be a booster dose for that reason? We will be getting more information about that soon. Johnson & Johnson has a two-dose vaccine trial that they're going to be releasing data for.

We should get information from that trial, that should touch upon this issue of waning immunity. I actually think there's a separate question. That separate question is we now know that the J&J vaccine is less effective than the Pfizer and Moderna vaccine. Some people who have gotten the J&J vaccine have said, well, if this is less effective, and we know actually based on other countries, the AstraZeneca vaccine is similar to the J&J.

It's also an adenovirus vector vaccine. In other countries, there have been studies done looking at one dose of AstraZeneca followed by one dose of Pfizer. They've actually found that that combination is more effective than two doses of AstraZeneca or two doses of Pfizer. In fact, Germany, the UK among others, recommend this mix and match approach. Those mix and match studies are still being done in the US; however, I think that there is enough evidence at this point based on AstraZeneca, at least for individuals who are elderly, who have chronic medical illnesses and will have chronic exposures or who have high-risk exposures to COVID-19.

I think they should be able to have a conversation with their physician to choose to receive a Pfizer or Moderna booster. That is not what CDC and FDA are recommending. I think that, especially now that the Pfizer vaccine has FDA approval, it's something that patients and physicians should make a decision together about. I really hope that our federal officials are at least allowing this even if they're not recommending it. I hope that they will allow this practice because at this point we really need to tailor booster guidance to the individual.

Brigid Bergin: Dr. Wen, thank you so much, so much good advice and perspective there. You can read her columns in The Washington Post and see her on CNN where she's a medical analyst. Her new book is called Lifelines: A Doctor's Journey in the Fight for Public Health. Dr. Wen also has a new weekly newsletter with The Washington Post, where she answers listeners' questions. You can sign up on The Washington Post's website at wapo.st/checkup. That's, one more time, W-A-P-O dot S-T slash checkup. Dr. Wen, thanks so much for joining us this morning.

Dr. Leana Wen: Thank you. Great to join you.

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