School year COVID outlook: Smoother ride likely, but fasten your seat belts

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

As the school year gets underway, the Central New York community and the rest of the U.S. still has a highly transmissible variant of the virus that causes COVID-19 circulating. How can you keep your kids and yourself safe? I'm talking with Dr. Joe Domachowske, a professor of pediatrics at Upstate specializing in infectious disease.

Welcome back to "HealthLink on Air," Dr. Domachowske.

Joe Domachowske, MD: It's a pleasure to be here. Thanks.

Host Amber Smith: As we go into the third fall/winter of the pandemic, how is this school year for kids likely to be different than the last two?

Joe Domachowske, MD: I think the major difference we're going to see are the recommendations. They're going to be different, depending on the level of threat in a particular region or a particular city or state. The CDC guidance is going to seem like it's discordant, but really it's based specifically now on what is the level of threat in our community at the time and how can we keep our kids as safe as possible?

Host Amber Smith: So, very region-specific.

Joe Domachowske, MD: Very much so.

Host Amber Smith: Will we see students in masks, maybe?

Joe Domachowske, MD: I think we will see students in masks at their choice. At the present time, we are pretty much on the low end of risk, as far as things go, but that could change after school starts. If we become at medium risk -- based on the community rates of hospitalization, the number of cases, and metrics like that -- if we become medium risk, then you'll see the kids that are at higher risk for severe illness wearing masks again.

Host Amber Smith: Do you think we'll hear about quarantines if a close contact tests positive?

Joe Domachowske, MD: The CDC (the U.S. Centers for Disease Control and Prevention) has basically removed that completely from the algorithm. And I think it makes a lot of sense, along with removing the "test to stay" paragraphs that were included in the recommendations for schools for a while, because tests to stay were because of quarantine in people who did not have symptoms, right? So I think that all of it makes sense that we don't need to quarantine because of the community immunity at large. We no longer need to do that. And we don't have to do any tests to stay, for the same reason. But quarantine no longer makes sense. It's more of isolation and protection if you become ill.

Host Amber Smith: So someone who tests positive, a teacher or a student, they would still need to isolate?

Joe Domachowske, MD: Well, they should stay home if they're sick, right? That's true, whether it's COVID or not. So, we always start there, and then, as long as they remain symptomatic, with signs or symptoms of a respiratory illness, we ask them to stay out of school, and when they feel better, they no longer have to do a test to prove that they can come back. They just have to mask on return for a total of 10 days from the time their symptoms started. These are the brand new recommendations, and they make a whole lot more sense than what we were dealing with before.

Host Amber Smith: You used the phrase "community immunity," but we still do have some unvaccinated people, kids and adults. Are they still at greatest risk for getting COVID?

Joe Domachowske, MD: Certainly anyone that's not been immunized for whatever reason remains at the greatest risk for serious illness. But the models from the CDC and from Hopkins (Johns Hopkins University) tell us that close to 95% of Americans have either been vaccinated or have had at least one illness consistent with a COVID infection that would induce some level of immunity.

So as we increase our immune repertoire, if you will, and that can take repeated infections or repeated vaccinations or a combination of both, we will start to see the overall illness burden dampen down even further.

Host Amber Smith: If children come from a family where a family member has a compromised immunity, is there still a concern that that child could potentially pick up COVID germs and bring them home to that person?

Joe Domachowske, MD: Absolutely. That's a possibility, always, with COVID with influenza and with other types of infections, that we try to cocoon, protect, if you will, our most vulnerable. And those are going to be somewhat individualized decisions based on the level of immune compromise of the particular individual and the comfort level of the family and the caretakers that are involved in keeping that child healthy.

Host Amber Smith: Well, let me ask you a little bit more about vaccination. If children have not been vaccinated yet, is that something that they need to do before they go back to school?

Joe Domachowske, MD: Absolutely. You know, it's one of the very important tools in the toolbox that we have that just makes perfect sense.

Keeping our vaccination status up to date, staying home when we're sick, good hand hygiene, keeping our respiratory etiquette as careful as we can, given the age groups that we're talking about. And then for schools and buildings, making sure that they're cleaned regularly in a systematic way, and that ventilation is optimized.

Those things are very straightforward, easy things to do, and, going beyond that really requires much more effort, much more interaction, much more involvement about public health and the levels of disease that we're dealing with at the present time.

Host Amber Smith: Are the vaccines and boosters that are available right now, are they equipped to protect us against this latest variant? Or should we postpone getting a booster or a vaccine so that we get the latest version?

Joe Domachowske, MD: I'm not a fan of postponing. Once you reach the interval duration from your most recent vaccine, please go ahead and get the next dose, the next booster. But it may also mean that you'll get an additional dose once those variant or hybrid vaccines become available for each of the individual age groups. We don't even yet have them for adults. To think that we would have hybrid vaccines for the most recent variants available for children before school starts is fantasy.

I'm thinking that it'll be early into the next calendar year, before we even start to see it become available for middle school students and high schoolers.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate pediatric infectious disease specialist Dr. Joe Domachowske about what the school year may look like, COVID-wise, for kids this year.

Can the COVID vaccine be given at the same time other childhood vaccines are given at the pediatrician's office?

Joe Domachowske, MD: Yes, the advisory committee on immunization practices made a decision quite some time ago as the COVID vaccines first became authorized for use in children that co-administration with other vaccines at the same visit was appropriate, in most instances. And they've stuck with that. And now of course, there's real-life data for having been doing so now for not quite a year. And so we know that it's safe, and we know they remain as effective as they can be, given the variant that we're dealing with.

Host Amber Smith: There's a list of required childhood vaccinations. Is the COVID vaccine on that list yet?

Joe Domachowske, MD: Let's explore what "required" refers to. So, we have public health laws that require certain vaccines for school attendance. We have ACIP, Advisory Committee on Immunization Practices, routine guidance for vaccination of certain age groups.

And then we have all the vaccines that are possible and available for individuals at large. So, when I hear folks refer to vaccines that are required, I'm thinking that they're most likely referring to vaccinations that are required for school entry in New York state, because state by state, the number and types of vaccines you need is different across the board.

That is not true for any state, for any COVID vaccine currently for children, simply because we don't have full FDA approval for the age group at the start of public school. We have emergency use authorization (EUA), and unless or until, we have full FDA approval, I don't think any state legislature is interested in trying to lobby or require COVID vaccine as one of the added vaccines. Now with that said, it is routinely recommended, starting at 6 months of age. Depending on the child's age, of course, they can get one or another of the formulations of the vaccine. The ACIP routine schedule for routine immunization, I think, is what we should be looking at, not the required vaccinations. The ACIP recommended schedule is much broader and comprehensive than the requirements for school entry. And we should not be restricting ourselves to what's required.

Host Amber Smith: Are booster shots for kids recommended?

Joe Domachowske, MD: Absolutely. When they're ready and they meet the EUA criteria, emergency use authorization criteria, for a booster, they should receive it.

I'm even telling some of my clinical trial participants who will be removed from the trial if they get a booster because they aged in, they turned 5. And now the EUA goes down to 5 years of age. I'm telling them, "The clinical trial doesn't accommodate you to have a booster in the trial. Technically, you're still in the trial for another year, but I'm recommending that you get the booster through your primary care office or through a community. vaccinator so that you can maintain that high level of immunization," even though it means compromising their position in the clinical trial.

I do think it's more important than that role in the trial at this point.

Host Amber Smith: At this point, the vaccines are only available as a shot, is that right?

Joe Domachowske, MD: That's correct.

Host Amber Smith: Kids of all ages have been receiving this vaccine for months now. Are there any adverse reactions that are concerning to you?

Joe Domachowske, MD: The typical adverse reactions following the vaccine are the ones that we see very typically from other childhood vaccines and not quite as severe as we might see with a pertussis-containing vaccine (for whooping cough); they tend to be a little bit more reactogenic (likely to produce an adverse reaction), but somewhere in the middle, there are children that develop fever for a couple days, local injection site concerns or complaints. These are self-limiting reactions. I have not personally seen any, long-term effects from vaccine, but I know that, some long-term effects have been reported, very rarely, in the safety databases.

Host Amber Smith: Given that COVID is still fairly prevalent in our community, what is your advice for parents if their children complain of a sore throat and theyw develop the sniffles? How should a parent deal with that?

Joe Domachowske, MD: Well, they should have medical attention, and COVID testing should be performed as part of that medical attention, if appropriate. Those symptoms that you mentioned certainly could be consistent with COVID. And then we want to make sure that individual is isolated, not quarantined, but isolated and masked for that 10-day period or less, if their symptoms resolve before that.

Host Amber Smith: So COVID tests are still recommended. And if they're positive, does the parent need to alert the pediatrician, or is there anything the pediatrician would do?

Joe Domachowske, MD: If their child is not at high risk for severe illness, and has a mild illness that the parents are comfortable dealing with at home with symptomatic care -- hydration, fever-reducers, pain relievers, stuff like that -- if they're comfortable with it, then I don't think they necessarily need to notify the primary health care provider. But it's always a good idea to let them know, so they can just document it in the health care record so that they're aware that they had an over-the-counter test or point-of-care test at some point, outside of the medical home, that was positive for COVID with symptoms X, Y and Z, so it's very clear: This is what their immunization status was like, this is when their last dose of vaccine was given, this is when they became symptomatic and tested positive outside of the medical home. So that if there's anything unusual that happens subsequently, for instance,repeat testing shows repeat positive results, which almost never makes sense and is caused by different reasons, that they can work through it and give the family a good explanation for why that might be happening.

Host Amber Smith: Are there symptoms that should prompt a parent to be a little more concerned? I mean, I hear you explaining, basically, how to take care of them as you would, maybe for a cold or a flu, keep them comfortable and hydrated and that sort of thing. But is there any symptom that a parent should be on the lookout for?

Because early in the pandemic, there were some concerns about a disease or something that was related to COVID that was affecting kids severely.

Joe Domachowske, MD: The disease that you're referring to is abbreviated MIS-C, for multisystem inflammatory syndrome of childhood. And that's a condition that usually occurs several weeks after the acute COVID infection.

And many of those children don't have much in the way of signs or symptoms of the COVID infection. We're not even aware that they had the infection until their MIS-C presentation shows us otherwise. Those kids present with high persistent fevers, often very uncomfortable, with rash, a lot of gastrointestinal symptoms and can have serious cardiac consequences.

So they're almost always hospitalized, and we treat them very aggressively. The inflammation can be quite stubborn, but we usually are able to get it under control within the first couple of days and give that child some relief. They are followed for months afterwards to watch for different types of long-term side effects.

And one of the under-spoken benefits of vaccination is that we know vaccination prevents MIS-C.

Host Amber Smith: So, if your child is isolated and you're hydrating them and keeping them comfortable, how do you tell when they're no longer infectious and they can come out of isolation?

Joe Domachowske, MD: Well, the CDC says 10 days from the time symptoms start, and, on average, that's a reasonable number to go with. Determining infectivity based on a test result is not useful. So I would discourage people from repeat testing until negative in order to make a decision about whether or not that child can go maskless or be out and about, no longer isolated, but, once the primary respiratory symptoms are gone. it's perfectly acceptable to mask and begin interacting with the community, including going back to school. But as long as the mask stays on up until the end of day 10 from the time the symptoms started, that is what the current guidance is.

Host Amber Smith: So, what is your general outlook for parents, or what do you think parents should think going into this school year in terms of COVID?

Joe Domachowske, MD: It'll be a different year. Expect the unexpected. I think it'll be better, but it's going to feel discordant, I think, for many folks who like to have rules be rules. Because of the way the decision-tree algorithm is written out and the way the guidance is being provided, the level of virus activity in the community is going to play a major role in how schools deal with things such as testing, isolation, maybe even quarantine at some point, even though it's taken out of the official guidance completely right now, or high-risk activities like going to band, team sports, where they get really close, and they're right there in each other's faces. So, in low-risk areas, those are all things that are permitted to be happening, and we should expect them to happen. When there are outbreaks, there's going to be community based decision making that is going to rely on the way the CDC decision-tree algorithm is written out for how to handle them. And so it's going to feel, I think, for many folks that like very specific, black-and-white rules to be followed, they're going to feel like some of this is discordant. It really is taking multiple factors into consideration to make a final decision about what's best for the population, the community and the children at that school.

Host Amber Smith: Well, Dr. Domachowske, I appreciate you making time for this interview.

Joe Domachowske, MD: My pleasure. Happy to do it.

Host Amber Smith: My guest has been Dr. Joe Domachowske, a professor of pediatrics specializing in infectious disease at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.