In the Bubble with Andy Slavitt: Our Shot

Understanding COVID’s Kid Surge (with David Kimberlin)

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With 180,000 reported COVID cases in kids last week alone, and school just getting started, Andy has a vital conversation with pediatric infectious disease specialist Dr. David Kimberlin about how the Delta variant has changed everything we thought we knew about children and COVID. They cover what David’s seeing on the ground in his hospital in Birmingham, the latest on vaccines for kids under 12, and how to think about the incredibly complicated issue of in-person school. Plus, what parents can do to get school districts to re-think opposition to mask requirements.


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Dr. David Kimberlin, Andy Slavitt

Andy Slavitt  00:19

Welcome to IN THE BUBBLE, I’m your host, Andy Slavitt. Let me begin the episode by just updating us all on some of the news, some of the data where things stand, I think giving everybody a picture. And then we’ll get to I think a really important, great interview about what’s going on with COVID and kids. That interview is with a terrific pediatrician virologist David Kimberlin. He is in Alabama. He is right in the heart of it all. So I think this is going to be a really an illuminating episode about how things are affecting kids. So let me just give a quick, quick, quick, quick, quick update before we get to the interview. We’re now across 200 million number of people vaccinated in the US. That is good. That is good there. 330 million of us we’ve got 200 million with vaccines. 73 and a half percent of adults are seeing the first shot. 63% both shots, that’s progress. 61% of all of us have been vaccinated. That is a good picture. But it’s only the US picture. And if you listen to my episode last week with Jeremy Farrar, which I hope you did, because I think it’s one of the very, very, very best episodes.

Andy Slavitt 

We talked about how we don’t talk about the globe on the show. So I’m going to do the same thing to talk what’s going on around the globe, we hear about 5 billion cumulative global vaccinations, 5 billion. Now there’s 8 billion of us on the planet. So you figure all that out. First, there was a second doses, it comes out to about a third of the planet has now had at least one dose and a quarter, two doses. That sounds encouraging. It’s a long, we’ve come a long way. And I’ll explain a little bit more. But we also have some real, real challenges in there. Because, remember, we’re not just trying to vaccinate the globe, we’re trying to vaccinate the global quickly and equitably quickly before another variant, particularly one that is more immune invasive, gets to us and equitably so we can get the rest of the world fairly vaccinated, not just the wealthy countries.

Andy Slavitt  02:33

But when you lay it all out, what we need is, you know, we need to be doing about a billion doses a month in new vaccinations. And guess what, that’s about what we’re averaging now. Most of those doses today are in Asia. So Asia is coming up to speed with Europe, and the US. You’ve probably all heard this statistic, probably heard this on the show that three quarters of the vaccines are going to the 10 wealthiest countries in the world, that obviously has to change and needs to change right away. The big priority is Africa. And Africa, only a couple percent of the population. but less than 5% has been vaccinated in 40 African countries, in fact, fewer than 10% of the population hasn’t even received their first dose, and then includes healthcare workers. So about a million and a half Africans are getting vaccinated every day. That sounds pretty low. But it’s actually much improved over July, it’s 350% higher than in July. We’ve got to do even better. It is really been improving. Since July 1st, about 10 African countries have increased their vaccinations by more than 500%.

Andy Slavitt

So we’ve got to keep knocking down roadblocks around the globe. And we’ve got of course, the major dilemma and that front is if it’s a three-dose vaccine or two dose vaccine, that becomes a little bit more challenging. But what we talked about with Jeremy, can we vaccinate 70% of the world’s population with at least one dose? By the end of March? The answer is yes, we can. If we do it well and do it efficiently. If we don’t coordinate it, if we don’t do those things. We don’t get there. Next bit of news is really just right on that topic, which is, is mRNA really long term is that a two dose or a three-dose vaccine? Add this conversation with a group of scientists in the conclusion that I heard from people smarter than me is that it is either a three-dose vaccine or it’s a two-dose vaccine that needs to be taken six months apart, but they don’t really know. So that’s interesting.

Andy Slavitt  04:49

Then we’ll also report that Ron DeSantis  in his bid to keep schools from implementing masking policies has lost a major court case. So in fact, it turns out schools can require masks in school. That is good news for kids, good news for families, bad news for politics. So with that, let’s turn to kids. And our guest today is someone that we picked out especially to really dive into what is happening with this wave of COVID. That is striking kids. And there’s no one that will know better about the big picture. And the on the ground picture than David Kimberlin, who’s a professor of pediatrics and co-Director of the Division of Pediatric Infectious diseases at University of Alabama, Birmingham, and children’s of Alabama. He is eminently qualified. This is an intense conversation. I stumped him several times. He is both incredibly smart. And he is feeling every bit of everything he says, I think you’re really gonna love listening to David, and learning a lot about how COVID is impacting kids. Now that we’re dealing with Delta.

Andy Slavitt  06:13

David, nice to talk to you.

Dr. David Kimberlin 

It’s good to be here with you today.

Andy Slavitt

Well, I wish there was a happier topic we could pick David than COVID, and kids. But you’ve been outspoken from where you sit in Alabama, and what you’re seeing on the ground. And I’m wondering if we could just start there. What are you seeing, and help apprise us of the kind of situation we’re facing overall, as best you can describe it with kids and COVID in the US?

Dr. David Kimberlin

Well, starting locally, what we’re seeing is worse than it’s been throughout this past year and a half, if you can kind of wrap your mind around that. Looking at the total number kind of peak of admitted patients to our children’s hospital last, you know, January, early to mid-January, compared with these last couple of weeks, we’ve been anywhere from 25% above the prior peak to twice 200% Above the prior peak, we have babies, as young as one week of age, in the hospital, we have 18-year-olds in the hospital, we’ve had deaths in the hospital, adolescent deaths. Of the 12 and over, at least of the ones that I’m aware of, none of them have been vaccinated. And so we’ve had missed opportunities there, which makes it you know, even more sad and more difficult when we think about how quite likely that hospitalization or that really bad outcome might have been avoidable. We’re doing all this, you know, not only in our own little isolated bubble in and around Birmingham, but it’s happening this way across the state of Alabama. It’s happening this way across the entire southern band of US states, and I don’t see it getting better before it gets a whole lot worse.

Andy Slavitt

And this is really his school is just getting started.

Dr. David Kimberlin  08:02

That’s exactly right. It’s where it’s gonna go next with that we have schools that have started anywhere from, you know, up to a couple of weeks ago, actually, for some of the school systems. When we were getting into the launch of schools, about two thirds of them had mask optional kinds of policies. Now, some of my point earlier in it when I was being asked about that from school systems is we’re going to have mandatory masking. You know, it’s just a matter of whether we want things to, you know, be really bad when we start and then we adopted or whether we take a more measured approach from the outset, not I was suggesting the latter, obviously. And some schools have really done that they’ve stepped up and they said, well, we may not, you know, want to say masking for the entire semester, for instance, but we’re going to do it for a month.

Dr. David Kimberlin 

Or there was a couple of school systems yesterday and said we’re going to do it for two weeks, I’ll take two weeks that at least gets us a chance to try to you know not only hit the goal of getting children in school, that’s a goal all of us have, but doesn’t do much good if you don’t keep them in school. And so that’s what we need to be focusing on now. And as we’re, you know, having these cases, adult cases as well, we can talk a little bit about surging across the state. You know, I really fear that having schools kind of wide open with no masking, especially with our low vaccination rates is going to be a recipe for disaster.

Andy Slavitt 

Nationally, correct me if the numbers aren’t right. But I think we’re seeing something in the order of 180,000 cases in kids per week, at this point in time.

Dr. David Kimberlin 

That’s how I understand it as well, the AAP the American Academy of Pediatrics has been releasing those numbers, those data, that they’re collecting and gathering in conjunction, I believe with the Children’s Hospital Association, and that’s in the ballpark of what I remember as well.

Andy Slavitt 

About a month ago. I think the reporting was somewhere between 35,000 and 40,000. And in many parts of the country school hasn’t even begun yet. So, we can imagine how much that 180,000 grows from here. Do we know what portion of those cases were kids that ended up hospitalized?

Dr. David Kimberlin  10:10

I don’t know the answer to that. I will say that. So there’s going to be a bit of a dichotomy here or a split. On the one hand, we are undoubtedly seeing more pediatric cases in the hospital. And a lot of those are a lot sicker than what we’ve seen in the past, the tangible evidence that we have is that this version of the virus is doing more of a number on children than the prior versions did. Now, we don’t yet know whether that’s because the virus is more aggressive in children than the prior versions were or if they’re just so many more children that are infected, or some combination of the two. We know that the percentage of children hospitalized with the earlier versions of the virus was a low number. And that didn’t matter so much for those parents if it was their child in the hospital. But it was a low number, there’s, you know, that’s just a factual statement. I don’t know whether these surges that we’re seeing in pediatric hospitalizations reflect a major change in that percentage or not. I think to some extent, it’s kind of not as relevant, because so many children of the whole span of age range are being impacted right now.

Andy Slavitt 

Yeah. So I’ll tell you the numbers that I saw, and you could tell me if they match up about half a percent to 2% of kids, that is between one and a half and 2% of reported COVID cases, end up with kids that are hospitalized. And if I do my math, right, it’s been a long time since I had to do actual math. You know, there’s 180,000 cases a week, we’re talking about somewhere between 900 to 3,600 kids being hospitalized in a given week across the country, at this point in time. And I think we both just said we’re kind of still early at it. Does that sound right to you?

Dr. David Kimberlin 

I think the numbers you’re giving are numbers that I’ve seen as well, what I don’t yet know is whether they are representative of this Delta phase of the pandemic that we’re in right now or not. They very well may be. But I will also say that the pace is accelerating, not only across our part of the country, but into other parts of the country. And so even if those numbers are representative now, I mean, you can see with just the total number of hospitalizations that we’ve had per week, increasing so dramatically, you know, we’re on this part of the curve right now. And we don’t have the end in sight yet.

Andy Slavitt  12:34

Right? So let’s just say that they’re 1500 to 2000 kids being hospitalized every week. First of all, help us understand the state of pediatric hospitals in the US, what they’re designed for, what the capacity levels tend to look like, how quickly those might run out of capacity. And then maybe just enlighten us on what’s happening inside the hospital with these kids, as you’re saying, what kind of symptoms are they showing when they’re hospitalized? How long are they typically staying in the hospital? And then we should just make sure to say some very good news as of at least right now, it appears that almost all of these kids, not every single one, but almost all these kids return home. In other words, the number of deaths is extremely low right now, which is not something we’re going to take for granted. But it’s important just to state that. So help us understand, maybe to the insider’s look at what is looking like inside one of these hospitals right now?

Dr. David Kimberlin 

Well, so the spectrum can be pretty broad. Of most hospitals that admit children, to them are not freestanding children’s hospitals, you know, their facilities that take care of adults and children, they might have a floor for instance, for children to be admitted to, there are a number of freestanding children’s hospitals like the one I work in. But relative to the full scale of such a large country as ours, they’re more the exception than the rule. Now in terms of what these children who are being admitted come in with, it’s a spectrum. Right now, what we are seeing is a lot of fever, and a lot of respiratory symptoms. That’s been the main focus here. Children coming in with whether they’re pulling so hard to get oxygen into their lungs that the skin between their ribs sucks in   when they’re breathing in. their nostrils are flaring out because they can’t get enough oxygen into their bodies and they’re struggling to get their breath as an example.

Dr. David Kimberlin  14:40

Now, you can have other things too. You can have vomiting and diarrhea associated with this, but mostly with this Delta variant it appears to be the respiratory symptoms, which really is not that different from what we saw with the earlier versions of the virus as well. they also have very, you know, high likelihood of having respiratory components to them. It’s a respiratory virus. It makes sense that that would be the case. Now, when they come into the hospital, they can have as well, problems with their kidneys from COVID, they can have problems with their liver from COVID, they can have problems maintaining their blood pressure, they can be in shock. In other words, from the acute COVID itself, they can end up in the intensive care unit or not, I mean, they can stay on a regular floor. Now, for those in the ICU, they tend to be here longer as you would expect, they were sicker to begin with or got sicker during the time they were here.

Dr. David Kimberlin

Sometimes when they are coming in just with fever and you monitor and they’re doing okay, from a respiratory standpoint, they can go home just after a day or two. But many times the hospitalizations go on for many days and you know, sometimes out for many weeks depending on the amount of support that they need. I do also want to make one point what I just got through discussing was for acute COVID disease, there is another entity that is an after effect, if you will of COVID in children, especially called MISC it’s a Multi System Inflammatory Hyper Inflammatory condition and the C part is for children. We are just now beginning to see the MHC cases start to go up following this Delta variant. What we appreciated this was you know, April of 2020. So close to a year and a half ago, first in the United Kingdom, and then in other parts of the world, including the United States is that about a month after the virus hits a community, these children would come in with shock, their blood pressure would be bottomed out, their heart would have involvement with it.

Dr. David Kimberlin  16:45

A myocardial involvement, heart muscle involvement with it. They might have a rash, they might have injection of their eyes, their eyes might be red, in other words, looks like a condition called Kawasaki disease. To it’s not Kawasaki, it’s different than that. But these children are really, really sick. And interestingly, if you give them the right kind of support in the ICU, they bounce back pretty quick as well. And we’ve learned a lot about what to do with them in terms of fluids, in terms of steroids and other things that we give to counter the MISC disease. I do think especially in the southeast that we have is we’ve been hammered for these last several weeks with the Delta variant we are very likely to see the MISC patients hospitalizations go quite a bit up from where they are right now.

Andy Slavitt  18:05

In the hospital, kids who are hospitalized for respiratory symptoms. presuming they have a normal healthy immune system, they’re not a cancer patient, do they typically mount a good immune response? Do they have some of the same complications adults have with cytokine storms? Are their treatment protocols? And then does it look like other respiratory illnesses in how might you compare it to, you know, a flu or even polio and measles, some of the other things that have afflicted kids over time?

Dr. David Kimberlin 

It’s a really good question. It does not look like another respiratory virus. This is a really, in my judgment. I’ve been doing this for you know, 27 plus years, virology in particular, this is a different entity, this SARS-CoV-2 virus that causes COVID is just not like any other respiratory virus that I’ve seen. Now measles is an interesting parallel, and it’s not it’s not measles. But measles is spread through the respiratory route. And it’s the only virus we actually know of right now, that’s more infectious than the Delta variant of the SARS-CoV-2 virus, and it causes, you know, 200,000 deaths worldwide every year, and mostly children. Measles does. And so maybe you could draw some parallels with that. But I think we’re probably still too early to we don’t have as many years obviously of experience with the COVID virus to know that for sure.

Dr. David Kimberlin 

I think that the overall pathogenesis, the way that children who are sick enough to be in the hospital present and the way their disease course progresses is really not that different from adults. We have the initial period first week or so where the virus is doing the damage. And then the second period is you know, as you get into week number two, for instance, is when the body’s reaction to the virus, the immune response, does the damage, it kicks into overdrive. And what seems to happen with children versus adults is children’s immune system in overdrive just doesn’t happen as often as it does in adults. why that is, I’ve not seen the data on yet, I think there’s probably a lot of good bench work going on with that right now. But in terms of our management, because the cycle is similar to what we see in adults, we’ve really adapted the adult protocols remdesivir.

Dr. David Kimberlin  20:35

The antiviral drug being used early in the course if they’re hospitalized, and then steroids playing a major role kind of blunting down that immune response. Much as is the case in adult patients, we don’t use some of the fancy monoclonal antibodies, not the preventative monoclonal like the regeneron that you’ve been hearing about, I’m talking about like JAK inhibitors and, and things that very specifically target portions of the immune response to try to lower those. We don’t tend to use those as much in children, you know, partly because we don’t have the experience they do in adults with it. And partly because most children don’t get to that point.

Andy Slavitt 

Right. I want to go back just to one thing you said, which was really interesting, which is, you said this is not like any other virus you’ve ever seen, certainly in kids. And I want to make sure I’m picking up on all of the subtleties of that is the application that it is worse than what you see in other respiratory illnesses have been there, so many of them that kids have gotten over time. This is comparing, in that sense is something that’s scarier in terms of how it’s hitting kids than other respiratory illnesses?

Dr. David Kimberlin

In my judgment, yes. And I think the numbers bear me out on that, you know, the thing that’s, to me seems highly unusual about this virus is it’s a respiratory virus, it should impact you know, the respiratory tract, the lungs, the upper respiratory tract, you know, the sinuses, the nose, and so forth. And it does, but then it also has these, you know, widely systemic kind of effects. But there are many patients with COVID, COVID disease that have myocarditis that have the heart muscle involvement, many more have it from COVID itself, than the very few, the very small numbers that appear to get it linked with the vaccine. So the virus itself does this job on the body, where it creates this massive amount of inflammation. And that inflammation hits the liver, and it hits the bone marrow and it hits the skin and it hits you remember, COVID toes back a year ago, it hits the distal extremities, it hits the heart, hits the brain, you know, with the fog, the brain fog that people describe that does happen in children as well.

Dr. David Kimberlin  22:49

And so it is just a peculiar virus. And it’ll, I want to get to the other side of this pandemic, but eventually, it’s going to be really interesting to learn more about it and how it causes the disease that it causes. Right now, we’re just kind of trying to figure out how to deal with the onslaught of the numbers of patients that have it. And you know, I think we’ll have a chance to get to the vaccines, discussion and so forth. The good news is right now we do have the tools to do that for 12 And over, but we’re still in the eye of the hurricane right now, in terms of it down here in the southeast anyway in terms of what’s going on with this Delta variant.

Andy Slavitt 

If I’m a parent of a young person, and I’m listening to this, it scares me. It scares you. I can tell it scares me. It scares people listening. And so let’s begin to talk about what you could do. And let’s start with parents with kids that are under 12 were vaccinations not an option yet. And then I do want to talk about kids over 12. And I want to talk about the prospects for the vaccine being extended to kids under 12. But your advice that you said early quite powerfully, is that you’re going to have a mask mandate. The question is whether you do it too soon or too late. Our understanding, you know, of masks is they’re far more powerful and everybody wears them than not, what other pieces of advice do you have for parents who really don’t have much choice but to have their kids attended in-person school?

Dr. David Kimberlin  24:21

Well, it’s difficult. There’s no one good answer here. I strongly believe that children need to be in school. […]

Andy Slavitt 

If you had a 10-year-old right now, would you keep him home? Or would you send them to in-person school?

Dr. David Kimberlin 

I would be trying desperately to send them to school. Now it would depend on the situation at the school, my school system, for instance, where my children are in their 20s now, but our school system has adopted a mandatory masks mandate and that they’ve taken a lot of heat for it, but they’ve done that and so I would be sending the, if I had younger children to that school, because I really think we’ve seen the inferiority of remote learning. When it comes to educational advances, when it comes to nutritional status when it comes to mental health and psychological health socialization issues, physical health issues, you know, it just is not as good as being in person. So what we need to be doing here, in my judgment is finding a way not only to get people to school, but keeping them in school. And that requires more than just the children being masked, it requires the adults in the school to be mastering, it involves the surrounding children.

Dr. David Kimberlin 

Schools are not little isolated islands. They exist within a larger community; the community has to buy in and be doing what they can to decrease the amount of virus in those communities. That means masking and it means if you’re 12 and over getting vaccinated, all of it needs to be happening together what we’ve heard and learned, I think, throughout this pandemic, how many times have we thought to ourselves, you know, I’m just done with this.

Dr. David Kimberlin  26:12

On the other side of the world, and look what it’s doing, look at the number it’s doing on us right now, we have got to be more global in our thinking here. And I know that people are tired, and they want to pull the curtains and they want to just, you know, hunker down. And that can be okay for a time. But we cannot turn our back on the other people who are in need right now in our own communities, and whether that community is a local community or a global community, because we are not safe until they are safe. So within our self-interest, our own self-interest to think that way. And to act that way.

Andy Slavitt 

Every day.

Dr. David Kimberlin

And if the virus doesn’t care. I mean, the virus’ is it all it wants to do is infect more people. And so you know, if we need to kind of get in our minds, that this is a, this public health threat requires a public health response, the public has to be part of this. And if they are not, or if at least they’re not in sufficient numbers. You know, I tell you, I have become resigned to thinking that not only are we going to have this in 2021, but we’re going to have it again in 2022, and 2023, and 2024, and 2025. None of us are safe, unless all of us are safe. And by that I mean not only in my community, in my state, in my region of the country, in my country, I’m talking globally, the Delta variant picked up steam so much in India.

Andy Slavitt 

Every parent probably is nodding along to the idea that, yes, the cost to their family and their kids development of them not being in school is real. It’s high tangible, it’s measurable. And the risk of getting COVID is not something that they find acceptable. So this is rock […] hard place. No question about it. This is one of the most difficult and challenging things to think through, your point, I think seem to be that if you have at least a cooperative school district and community that that risk becomes lower, and the benefit higher. And you as a world expert pediatrician specializing in these diseases feel like your individual choice would be that’d be that simple circumstances send your kids to school.

Dr. David Kimberlin  28:43

For what we know right now, yes. And not only are we looking at the risk of going to school, but you also have to balance that with the risk of not going to school and things we just got to talking. I think that you know, there have been a number of studies, there was one just I think in the last month or two in nature, I think or science that looked at the number of mitigation efforts that were implemented within school systems. And you know, that student masking, its teacher masking, its distancing, it’s, you know, it’s separation and lunch rooms, you know, it’s two different factors. And they found that when you get out now, this was prior to Delta. But if you get out to 7 to 9 or 10, or more of the factors implemented within a school, that you don’t have transmission within the school, you may still have children that are sick in school, but that’s because of the transmission and the community around the school. So schools, at least prior to Delta schools could do this. It required discipline, and it required a universal approach with this highly infectious, you know, respiratory disease. But the question is going to be whether it’s going to stay that way with Delta that we don’t know yet.

Andy Slavitt 

Well, there’s a worst set of circumstances and I can hear the people listening, banging their phones against the table or the glass or their whatever it is that they’re saying, but wait a minute, my school district doesn’t even do that. I live in Florida, I live in Texas or I live, in any state in the country, quite frankly, where my school refuses to issue masked mandates, let alone the 2-12 other mitigations that you’re talking about. And I wonder, as a pediatrician, and someone who sees all sides of these issues and all sides of children’s health and development, in that circumstance, would you say, you know, what, I will probably not send my kid to school, or would you say, I still would because the harms and the risks of not doing so warranted?

Dr. David Kimberlin  30:50

That’s a legitimate question, a very challenging question. I’m going to hedge a little bit. It depends on for example, the other people that would be around that child, if the dad in the household has cancer and is on chemotherapy, I might hold the child back. If everyone in the household is vaccinated and in good health, and the grandparents, you know, are not at risk of or maybe they you know, live in a different place in this, I wouldn’t see them, then I would be more likely to send to school, I guess I would say it this way, my default would be to go to school. And my exception would be to stay at home.

Andy Slavitt 

Well, now I’m gonna put words in your mouth here, because you didn’t say these words. But what it sounds like you’re saying is if they get infected with SARS-CoV-2, they will in all likelihood probably be okay. That’s what I think the implication of what you’re saying is.

Dr. David Kimberlin 

I can understand why you would summarize it that way. I’m reluctant to embrace that those exact words. The likelihood of harm from being at home is greater than the likelihood of harm of going to school, they get to go to school. And you know, even without mitigation, it’s not like 100% of the children, they’re going to get infected, as an example. And then if they are infected, you know, it hopefully will be a mild infection. Although they could then be […] to transmitting at home, for instance, or to grandparents, or aunts, and uncles, or whoever it may be. None of these are desirable options to look at. And it’s a matter of which of these less desirable options is least […]

Andy Slavitt  32:51

Absolutely, the pandemic is a series of bad choices. And I have the easier part of be the interviewer. So I get to try to put words in your mouth and allow you to push back. But I didn’t really intended to do that. I just think it’s such a difficult thing for people to figure out. And of course, everybody has different attitudes and approaches to this. And I think not only does everybody have different approaches, but we probably all go through different cycles in our own minds, where if I had to ask you this question on a Monday, versus on a Tuesday versus on a Wednesday, you know, it’s very reasonable to feel differently.


Dr. David Kimberlin 

Well, you know, I’ll tell you, if we’d recorded this show in June, it would have been a much easier answer to give. Delta’s changed things, it’s changed the calculus, but it also is not changed the negative aspects of not going to in person class. And the other thing I would point out, and I really believe this, parents have power. And so if your school district is not requiring universal mandatory masking, let I mean, you know, be polite, don’t you know, don’t yell and scream, but go to the superintendent, go to the Board of Education, go to the principal at your school, go to the teachers in the classrooms and say I really, really want a mandate for masking in school. They hear a lot from angry loud people that are generally against masking. What they don’t hear is what is from what I believe to be a more silent and more quiet majority.

Dr. David Kimberlin  34:29

And you can make a difference. We have a local school system, who just last night, mask optional. And just last night had yet another meeting Board of Education meeting where they had a number of people stand up and parents were standing up and counselors. In other words, therapists, psychologists were standing up, some of my colleagues and pediatric infectious diseases and pediatric critical care medicine were there to speak and this is to speak to a board that had already made up their mind and yet their now I don’t know if they’re actively reconsidering or not I pray they are the time will tell. That said, just the fact that it is stayed on their radar means that they are hearing from people that say, look, we need to have our children in class. And the best way to do it, the smartest way to do it is with a mask mandate.

Andy Slavitt 

Just to finish up on the masking point for a second, the people who do push back on masks, raising argument that I have tended to be honest, to be very dismissive of, which is this argument that masks can be harmful to kids, that masks can be psychologically harmful, they can be physically harmful. They cite studies which I will admit, I tend to look at as bogus, without really fully spending a significant amount of time on them. Because I think of them as people with agendas. And when I do take a look at the studies, they don’t appear to be very substantive from my lay eyes. But I do want to give this proper due here and ask the question, is there any merit to the argument that masks are harmful to kids?

Dr. David Kimberlin  36:43

No, none. Study after study after study found masking to be beneficial in terms of the impact on the virus, impact on any respiratory virus, impact on the pandemic, I think we can see that in terms of looking back over these last 18 months and when we’ve had more widespread masking versus less wide spread masking. And the studies have also looked at the impact on children from the standpoint of their physical health and so forth. There is simply no evidence, no evidence that there’s any harm whatsoever, except maybe, maybe a situation let’s say a child has severe neurologic impairment and physically cannot take the mask off. Well, that’s probably a situation you don’t want to have a mask on, you know that kind of makes sense a child under two can’t coordinate the movement and plus the masks are too large for their faces. There are, I’m not saying that literally every human being on the planet should have a mask on. But the overwhelming majority sure should.

Andy Slavitt

Let’s do a couple more quick questions, vaccines for five- to 12-year-olds, it is taking longer than we initially thought it would. No one will come out and say it quite that way. But I will say that they expanded study to include more people. It looks like it’s going to drag into 2022. If you’re a parent who feels like well, ultimately they’re just going to approve it and maybe lower doses or what have you. It’s very frustrating. Yet the FDA has a job to do. They’re looking for signals. They’re looking for enough data, they want to be extraordinarily careful because these are kids. These aren’t short adults. These are kids, their bodies work differently. So tell us what you think is going on there.

Dr. David Kimberlin  38:29

Well, so I’m going to push back a little bit, Andy on what you said. You’re right about the FDA saying to Pfizer and Moderna that they need to expand their sample size. But I have not yet seen the decision from the FDA to wait for X period of time after those new subjects are enrolled before they can entertain the possibility of an authorization for the 5- to 11-year-old age group. And indeed the American Academy of Pediatrics I think about a week and a half ago Dr. Beers that Lee Beers is the president of the AAP wrote a letter to the acting director of the FDA, Janet Woodcock, strongly suggesting that FDA looks at the standard duration two months after the last vaccine and the last arm of the first cohort that was enrolled the first that several 1000 subjects that were enrolled in that five to 11 study, in order to make a decision on authorization are all well and good to enroll more all well and good to follow them, you know out for additional safety. But let’s not delay a decision on authorization. And of course the data have to lead us to where you know what that answer should be. I’m hoping that it will be an authorization for that we live in. But if that’s right, then we’re still on track for a full potential, fall authorization for 5 to 11 fall of 2021 Not gonna concede that just yet. Of course, I’m not on the inside at FDA. So I don’t know what their timelines actually are. But word on the streets suggests that we still may have it in the fall for that 5 to 11 age group.

Andy Slavitt  40:11

Well, I feel like it’s the next priority. I feel like I look, I’m sort of reading tea leaves here, as opposed to disclose an indirect conversation, which I’m not above doing, but I just haven’t had one. It seems to me like, they’re adding a layer of caution in figuring out whether it’s the dosage or the safety, that the bar is higher, or that they have a very specific concern, which I don’t know if they do or not, because they understand, certainly, the importance of the school year, the studies be done. The fact that they asked for more data, anything you can offer, in terms of what you think?

Dr. David Kimberlin

I do understand, you know, the tea leaves, you’re talking about kind of looking down into the cup and seeing these marks down at the bottom of the glass, but I’m not sure that those marks really connect with one another. I just don’t think we know enough right now of what the deliberative processes are within the FDA. When it comes to the 5 to 11. I, you know, the VRBPAC is their external advisory group. And I think it was, it might have been made, but I think it was the June VRBPAC meeting, that was specifically focusing on pediatric vaccine development. And the VRBPAC kind of said do something, you know, they didn’t say what they didn’t say what they were concerned about. They didn’t say what their anks was, but they kind of said, just do something. And my connecting tea leaves or connecting dots. Is that that is then why FDA said, alright, we’ll enroll some more pediatric subjects. But the AAP’s point, I think, is it is exactly right. And that is, we are not likely at all to learn anything from an additional 1000 subjects enrolled in terms of any rare side effects, which may or may not be there, you need, you know, 100,000 to be able to see that, you know, and that, you know, that’s not a desirable, you know, samples.

Andy Slavitt  42:12

No, then you might as well just introduce it.

Dr. David Kimberlin 

Exactly. And the AAP came out very strong on that.

Andy Slavitt

Is that your view? And that’s your view as well?

Dr. David Kimberlin 

It is. Absolutely it is yeah, I personally would probably have not added the additional subjects. You know, I think the studies were designed well, they give a very good assessment of safety, and immunogenicity, you know how robust the immune response is. And so I think the original design was adequate. And I was very pleased to see the AAP back to sort of organizational responses to have that kind of response to say, look, we, the AAP take care of kids every single day. That’s our mission. And we think this is the right thing to do. Assuming again, that the data that FDA is looking at warrant an authorization, they need to look at the safety and the immunogenicity and the data are in their hands, or will be in their hands to do that. But before they’re open to the rest of us to look at.

Andy Slavitt 

Have they figured out the dosages?

Dr. David Kimberlin 

Right now, let’s take Pfizer as an example. So you know, Pfizer is now approved for 16. And over. Pfizer is authorized for 12 through 15. The amount of the mRNA, that’s in those formulations for 12 and up is 30 micrograms. For the 5 to 11 dose that’s being assessed, it’s 1/3 of that 10 micrograms. And for the under 5, the, you know, six months through 4-year-olds. It’s one tenth of the 33 micrograms. So I’m very happy, you gave me a chance to make that point. Because now that this, you know, formulation of 30 micrograms is an approved formulation. Some doctors and parents may want to go out and just say, well, just give me some of that, you know, give my child some of that, you know, just don’t pull up as much. That’s not going to be the safe way of doing this. We and I strongly discourage parents from doing that I understand the urgency I understand. not panic, but the desire to make something happen quickly. But first, do no harm. And we cannot simply give the adult dose to a six-year-old or try to guesstimate what the right amount in a syringe from the adult should be. That’s not a safe thing to do. Be patient Hang in there. I think the FDA is going to move quickly enough. I can’t promise it but I think they are.

Andy Slavitt  44:41

Yeah, that you will know exactly where hoped you would go with there’s a lot of messages I get from people saying hey, can’t I get my 11-year-old an off label. They’re just about the size of a 12-year-old. And I think you’re saying quite clearly. These are pretty significant differences and dosage that they’re recommending. This is the reason we’re collecting data. These months feel painful. They feel like they’re lasting forever, whether it’s one month, two months or three months, it’s some level doesn’t matter that it feels excruciating. And the reality is when they’re done, we’ll be glad that we were patient and did the work. You know, you mentioned […], maybe even asked this question a little bit of historical frame. Polio, besides its most famous victim struck children. And not only that strike children, it struck them in the most cruel way imaginable. I mean, it just took their ability to play and zapped it away.

Andy Slavitt 

And it was something that, you know, we live with for a long, long, long time until there was a vaccine. It’s almost impossible to imagine something afflicting kids like that, until you think about measles. Were up until the early 60s, it was 8 million people were dying, kids were dying every year, when COVID-19 came, you know, I think there was a sense that ah will at least it’s bares kids, there was a discourse that we’re sort of more willing, for some reason to discard older people although speaking as someone who is approaching those ages, I think that just bad strategy, we need to rethink that. But do you know that thankfully, we’re sparing kids now that it’s no longer sparing kids to the same level, people are now changing the rules a little bit as well, but it’s not really killing them.

Andy Slavitt  46:30

And I think we convince ourselves that any amount of change and sacrifice in order, it’s just there, it’s not going to be worth it for the incremental benefit, given the legacy. And so we talk ourselves into these situations. And then, you know, we see some of these things were kids do have long term consequences, will end where kids who we don’t know that they’re having long term consequences, could end up having longer term consequences from the virus, which could continue to remain in people’s systems, as we know, for a long, long time. So I’m wondering, you know, as someone with the breath of years, and the study that you’re done here, if you can maybe give a little bit of perspective for us on how we might think about what’s happening, and what could be happening to our kids, and how to put that in the appropriate frame not alarmist, but in historical context of something that’s attacking kids in the way that this is?

Dr. David Kimberlin

Well, it’s a multifaceted question, you know, that there’s the harms that children are experiencing through this pandemic, I’m sure have not been fully quantified. We know that children who have died, the 400 or so children who have died, I mean, that’s quantifiable, we have a good contact with the children who’ve been in the hospital for long periods of time, and that struggle with you know, physical rehabilitation afterwards, that might have brain injury from it, or maybe might have, you know, longer term heart problems from the virus itself. You know, they can be followed over time in multidisciplinary clinics and can be, you know, papers written about them, and, you know, showing what the percentage likelihoods, are and what we’re learning is more and more that this long COVID kind of description that adults have, there are counterparts to that in children as well. So just because children survive doesn’t mean that they’re, you know, scot free, hopefully they are, but not all of them are.

Dr. David Kimberlin  48:36

And then you get into the huge number of children who are orphans from this, their parents have died from COVID, and the loss that they have, or the loss that a young child might have, because the grandparent was taken too early. And they never got to know the grandparent, you know, as they went through adolescence and into adulthood to learn from them. And then you get just the scariness of all of this. And the anxiety of Mom and Dad, you know, being laid off during the shutdown last year, and the jobs aren’t fully back yet and kids are excellent at picking up signals. They’re not very good at interpreting those signals a lot of times the younger children, but they see what’s going on, and they know when there’s discord among adults and we have more than our share of discord these days. So I would suggest on all, you know, everything from physical to mental, and the full spectrum that this is, this has been a terrible pandemic for children. It’s been a terrible pandemic for all of us. I don’t think we should set aside and I appreciate so much the opportunity on this program to be focusing on children, because I do think the Delta variant is targeting them more.

Dr. David Kimberlin

I think the data the numbers show that but so much of the time, they have kind of been an afterthought up until recent months. And that’s not the way it should be, our children are our future, and we need to invest in that future. And I would I would suggest that the way you invest in a child’s future meaning therefore your own future, is by getting vaccinated and putting on a mask. It’s not that difficult. And it’s really not asking that much. In my judgment, if you think about what it means for our society and what it means for getting through this hellacious period that we are still not only emerging out of, we’re still in the vortex of, and we’ve got to do it. I mean, we’ve got to do it by setting aside our arguments, and by focusing on what we can agree upon, and what we can work toward together. And what if not children would that be.

Andy Slavitt  50:52

Seriously. I’ll close with this question, David, which is the what I think maybe one of the most significant things that gets in our way of doing what you just said, which is the ability to have a dialogue. And in longer, a healthy dialogue with one another, including people we disagree with. This is an emotional time for all of us, this is an emotional issue. This is an issue that a divided country finds comfort in identity politics […] and so forth. You are very clear, very outspoken, and very fact-based way, and a very responsible way. And you’re an authority on this topic. And you’re in the southeast of the United States, you’re in Alabama, where people have strong opinions. And as you say, there’s low vaccination rates. Are we finding ways to talk to one another and make progress in these issues? Is there any hope there? Is it just continuing to deteriorate? And do you have any clues for the rest of us to figure out how to how to take that temperature down so we can have these conversations? So you can say things like, hey, maybe we got to talk about getting vaccinated and protecting one another without it? You know, I don’t know what kind of reaction is even trading? I’m assuming that it’s creating some controversy around you. But maybe that’s not the case.

Dr. David Kimberlin  52:21

I don’t have the magic answer. I can say this. I mean, speaking from my own state, Alabamians are good people. They are kind people; Alabama is I believe this is correct. is number one per capita in charitable giving. And we’re a poor state. And it’s not just the rich folks that are doing it. It’s the poor folks that are doing it, because they care about each other. They we all care about each other. We’re also a very faith-based state. And I continue to have hope that churches, synagogues, mosques can be a way forward, there’s got to be a way where instead of you know, locking my eyes below the horizon and seeing you know, somebody to do battle with that, we can both look our eyes above the horizon and see a distant hill that we want to walk toward, there’s got to be a way to do that. And I think it starts by, it’s gonna sound simplistic, it starts by loving your neighbor. And that is a hard thing to do. Sometimes I fall short on that every single day. But I’m not gonna stop trying, and I hope and I pray that people around me Don’t stop trying and they start, you know, they don’t see my faults. And they are they forgive me my faults, and they allow me to have a dialogue with them, have a conversation with them. And then if we talk about the things that we I believe most likely will have a shared interest in our children, you know, it would be an example, their own health, you know, if it’s the parent, you know, not to had a conversation with a mom in clinic the other day, and I, you know, is begging her to get vaccinated begging her to get vaccinated, she had two young children, and I don’t want them to be orphaned.

Dr. David Kimberlin  54:05

You know, I mean, she doesn’t either. So we have a shared goal there. And so we got to find those kinds of things that it took too much of the time. And the stress of this pandemic clearly is a part of this, but it preceded it, too much of the time, we are ready to go from zero to 90 miles an hour to bludgeon one another. And that doesn’t do any good. You know, it’s not a fun way to live. It’s not a productive way to live. And it sure in a way we get through this pandemic. So we got to find a different way. And it means lowering the temperature, it means having a dialogue it means respecting one another and it means learning from one another. I’ve had conversations with folks that that do not agree with me on vaccines, and I learned from them, and I hope anyway, they learned for me to

Andy Slavitt

really interesting I mean, those are very wise words and compassion words, but what you said at the end was a bit of a light bulb went off for me which is, you know, tell someone who you disagree with, perhaps, wow, I just learned something I didn’t know. Thank you for sharing that. And it’s just it’s such a universal truth that if people don’t feel heard, you’re really not going to connect with them. Well, David Kimberlin, I so grateful for you making the time to come on and talk about such a challenging topic. And for a career you’re spending, taking on the most important issues that the most important times in people’s lives, not just patient by patient, but its public health leader and thinker as well. So I’m grateful.

Dr. David Kimberlin 

I appreciate so much the opportunity to be with you and your listeners today. We’ll get through this. We will get through this. I hope we get through it with the least amount of injury and damage.

Andy Slavitt  56:00

Okay, a lot to take in a lot to be concerned about. I know that many of you are facing tough decisions. Let me tell you where we’re taking this conversation. Next with three of our I think most interesting guests, and we’ve had some pretty interesting guests on the show. What is COVID like from a kid’s perspective, how are young people viewing this crisis with David Hogg, David Hogg knows something about being let down by adults. David Hogg was in the Marjory Stoneman high school when the Parkland shooting occurred. He’s been a fierce advocate since then, he’s been going through his own challenges. And he talks about the neglect and the feelings that kids have. And I wanted to provide a young person’s perspective on this show, since we’ve got a lot of people who are older, so the young person’s perspective next, I think you should listen to it. I did the conversation already. It’s a great one. Then a guy named Anthony Fauci will talk about all kinds of great things. And then Stéphane Bancel, who is the CEO of Moderna, and we’re going to really get into the mRNA platform for people who need to know love to know want to know all these details. Alright, that’s it for me. Over copy out, have a great couple days.


Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produced the show. And our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen and please stay safe, share some joy and we will get through this together.

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