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Health | The Atlantic
Health | The Atlantic
We Are Turning COVID-19 Into a Young Person’s Disease
Like many parents, Jason Newland, a pediatrician at Washington University in St. Louis and a dad to three teens ages 19, 17, and 15, now lives in a mixed-vaccination household. His 19-year-old got vaccinated with Johnson & Johnson’s shot two weeks ago and the 17-year-old with Pfizer’s, which is available to teens as young as 16.The 15-year-old is still waiting for her shot, though—a bit impatiently now. “She’s like, ‘Dude, look at me here,’” Newland told me. “‘Why don’t you just tell them I’m 16?’” But because certain pharmaceutical companies set certain age cutoffs for their clinical trial, she alone in her family can’t get a COVID-19 shot. She’s the only one who remains vulnerable. She’s the only one who has to quarantine from all her friends if she gets exposed.In America, adults are racing headlong into a post-vaccination summer while kids are being left in vaccine limbo. Pfizer’s shot is likely to be authorized for ages 12 to 15 in several weeks’ time, but younger kids may have to wait until the fall or even early 2022 as clinical trials run their course. This “age de-escalation” strategy is typical for clinical trials, but it means this confusing period of vaccinated adults and unvaccinated kids will not be over soon. And the pandemic will start to look quite different.How different? Vaccination is already changing the landscape of COVID-19 risk by age. In the U.S., hospital admissions have fallen dramatically for adults over 70 who were prioritized for vaccines, but they have remained steady—or have even risen slightly—in younger groups that became eligible more recently. This trend is likely to continue as vaccines reach younger and younger adults. Over the summer, the absolute number of cases may drop as mass vaccination dampens transmission while the relative share of cases among the unvaccinated rises, simply because they are the ones still susceptible. The unvaccinated group will, of course, be disproportionately children. By dint of our vaccine order, COVID-19 will start looking like a disease of the young.This means vaccines are working, but it also means many Americans are flipping how they think about COVID-19 risk. Adults who spent the past year worrying about their elderly parents are now worrying about their kids instead. The risks are not equivalent, of course: Kids are 8,700 times less likely to die of COVID-19 compared with those older than 85. But “even if the risk is not particularly high, you’re still going to be extra protective of your kids,” says Sandra Albrecht, an epidemiologist at Columbia. “It’s just human nature.”In coming months, parents may find themselves going back to normal while their kids still have to wear masks indoors. “It’s a very strange relationship to feel protected when your kids are still not,” Jennifer Nuzzo, an epidemiologist at Johns Hopkins, told me. But some 30 million households have children still too young to be vaccinated; in these families, parents and caretakers, especially of the youngest children, will have to keep navigating this incongruous world.The biggest risk factor to consider for unvaccinated kids, experts told me, is simply how much COVID-19 is spreading in the community. The U.S. is currently vaccinating at a good clip, and even partial herd immunity will slow transmission of the coronavirus. Seasonal effects may drive case numbers even lower in the summer. “If there’s very little virus circulating, that’s a pretty low-risk situation,” says Sean O’Leary, a pediatrician at Children’s Hospital Colorado.Experts have pegged the threshold where general restrictions can relax at 5,000 to 10,000 cases per day—the point at which risk of COVID-19 is roughly comparable to risk of the flu. (For context, the seven-day average of daily COVID-19 cases in the U.S. reached a low point of 20,000 last summer and peaked at 250,000 during the winter surge; that number has since plateaued at 70,000.) Not everyone will feel comfortable with the same level of risk though. Even before the pandemic, O’Leary points out, parents with children who have high-risk medical conditions were very careful about, say, traveling during flu season. COVID-19 might be another reason for these families to be vigilant.But already, momentum in the country is shifting toward reopening. States are ending their mask mandates and COVID-19 restrictions. How low cases go in the U.S. later this year will depend on the speed at which we inoculate harder-to-reach populations, as well as continued vigilance among the still-unvaccinated. Letting up after a year of social distancing is tempting, but as my colleague Katherine Wu writes, our vaccine cheat days add up.Variants may also influence case levels, but it’s not entirely clear how much. Early on, scientists in the U.K. thought the B.1.1.7 strain might be disproportionately more contagious among children than among adults, but the pattern has not held up. That may be because the variant was first detected after schools in the U.K. opened in the fall, explains Oliver Ratmann, a statistician at Imperial College London who has modeled the implications of the variant for kids. Then schools closed and mobility patterns changed over the holidays, which complicated the preliminary trends. The earlier pattern of B.1.1.7 in kids might just have reflected who had a chance to spread the virus at the time, especially because U.K. schools took fewer precautions, such as mask wearing, compared with many in the U.S. The evidence on whether this variant causes more severe illness is also mixed.What is clear, though, is that B.1.1.7 is more transmissible than the original virus among all age groups. In some places, that could tip the balance toward rising cases, but other factors are clearly at play too. For example, Michigan has a lot of B.1.1.7 cases and is experiencing a terrible COVID-19 surge, but Florida, which also has high numbers of B.1.1.7, is not. “The variants don’t help, but they’re not fully to blame,” Nuzzo said. The same precautions that worked before—including good ventilation, masking, and social distancing—still work against B.1.1.7.All of these concerns could come to a head in schools, which are one of the main places where unvaccinated people—e.g., kids—will congregate. As the U.S. is already seeing, school outbreaks do happen, but they can be contained with precautions in place. This means younger kids, who likely won’t get vaccinated before the fall, may have to continue to wear masks indoors. But the benefits of in-person schooling are significant enough, experts told me, that schools should open even if kids can’t get shots yet.The trickier question is what kids can do outside of school when it comes to playdates, sports, and extracurricular activities. In Michigan, officials have suggested that high-school athletics and the socializing around sports—rather than classes themselves—are driving the uptick in cases among teens. Parents and kids will have to decide together which risks are worth taking. Newland told me his 15-year-old daughter sees her core group of friends and plays sports. But she’s decided to keep taking virtual classes, even though her risk of contracting COVID-19 at school is low, because exposure to any cases at school could trigger a quarantine that keeps her from playing sports, which is important to her. That’s the tradeoff they’ve decided to make, but they’d of course prefer not having to make it. As Newland said, “I feel much better about my other daughter, who got vaccinated at 17.”At least 15-year-olds have an end in sight; they are likely to be eligible for Pfizer’s vaccine soon. Parents of younger kids may have to keep making these split decisions a lot longer. In their strange world, a dinner party with their adult friends is fine, but a birthday party for their 5-year-old could still spread the virus. When I asked several experts about a hypothetical party for unvaccinated preschoolers in the fall, they told me they would continue to think about ways to reduce risk, such as keeping the gathering small and outdoors. These assessments are hard to make in advance: We don’t know exactly what the situation will look like and how much the virus will still be circulating. Perhaps COVID-19 will have faded enough that people won’t be spending every waking minute thinking about the virus anymore. Perhaps not.To make these decisions more difficult, the situation probably won’t be the same everywhere in America. Already, rural residents report less interest in getting the shots than people living in cities and suburbs. Whether because of vaccine hesitancy or unequal access, “I think there’s going to be a huge amount of variation geographically,” says Whitney Robinson, an epidemiologist at UNC Gillings School of Global Public Health. The virus may continue to circulate in pockets of the country where not enough eligible adults are vaccinated. These adults plus still-ineligible kids could add up to a pretty large pool of susceptible people.Ultimately, the risk to unvaccinated kids later this year depends on the actions we take now. The faster we vaccinate and the better we suppress cases through other measures, the safer the situation will be for anyone who remains uninoculated in the fall. Then, finally, parents can stop telling kids to do things that they themselves are not doing—which, as former kids I think can agree, is literally the worst.
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theatlantic.com
The Suicide Wave That Never Was
In January, The New York Times published an alarming article about teen suicides during the pandemic. The story featured heartbreaking quotes from parents who had lost children, and was illustrated with photos of an empty classroom and a teenager sitting alone on his bed. The school district of Clark County, Nevada, the story said, had recorded the deaths of 18 students from suicide from mid-March 2020 to the end of December—twice as many as the district had in all of 2019. “There’s a sense of urgency,” the superintendent told NPR, when the same local crisis made national news again in February. “You know, we have a problem.” The prospect of a wave of suicides has loomed over the national debate about COVID-19 restrictions from their very beginning. Just days after the first stay-at-home orders were put in place, Donald Trump predicted “suicides by the thousands,” and reports emerged of increases in calls to suicide hotlines and emergency-room psychiatric visits. Fears about the mental-health toll on kids were particularly acute: What would happen if they couldn’t go to school, or play sports, or hang out with their friends? While the coronavirus appeared far more worrisome for adults, the harm that the shutdowns posed was another story: Teenagers seemed to be at the greatest risk.A year later, we’re starting to see signs of what actually occurred. Many parents say in surveys that the teenagers in their home have developed new or worsening symptoms of depression and anxiety since the start of the pandemic; a new report from the Department of Education states that, as schools begin to reopen, students will need “supports to address the isolation, anxiety, and trauma they have experienced.” Even just watching their kids sleepwalk through months of scholastic gloom and Zoom has given parents reason enough to be concerned.Youth suicide is already the second-leading cause of death among those ages 15 to 19, and the numbers have been inching upward for more than a decade. The reasons for that rise are much debated among suicide researchers, though they believe that a hard-to-unravel combination of factors is at play in each death. The recent testimony of parents and school officials suggests that the pandemic has, at least in certain cases, added new elements to that lethal mix. [Read: The millennial mental-health crisis]Deeply painful stories, combined with unsettling survey data, have made the connection between shutdowns and suicide seem like common knowledge at this point. President Joe Biden asserted not long ago that “suicides are up.” You'll hear the same presented as fact by news anchors, politicians on both sides of the aisle, and (as I did recently) on your neighborhood listserv. But the evidence supporting a broad, pandemic-driven suicide crisis among teens—or adults, for that matter—was always a narrative in search of data.For the record, there was no spike in teen suicides in Clark County last year.The county’s school district serves approximately 320,000 students in and around Las Vegas. You would expect, in a population of that size, to see minor year-to-year fluctuations in the number of suicides, as you would in the number of pregnancies, drug overdoses, or accidental deaths. Indeed, suicides did go up in 2020 compared with 2019, as The New York Times reported: The Clark County coroner’s office, according to the most recent tally, lists 16 youth suicides last year and 11 in 2019. (Those totals differ only slightly from the school district’s.) But that uptick tracks well within the county’s range in recent years. In 2017, the coroner’s office reported 12 suicides in this age group; in 2018, there were 20. The state numbers tell a similar story. Preliminary data from Nevada’s Department of Health and Human Services indicate that the rate of suicides per 100,000 youths last year was 2.3. The state’s average rate across the five years prior was 2.7. That doesn’t in any way diminish the tragedy of the suicides that did occur, or prove that the pandemic played no role in individual deaths. Still, when it comes to suicide rates for teens in Clark County, and in Nevada as a whole, 2020 was a sadly typical year.Accounts of other supposed suicide hot spots also tend to fall apart on closer inspection. In November, The Washington Post published a lengthy article that examined both teen and adult suicide during the pandemic. It quoted unnamed experts who feared that a “toxic mix of isolation and economic devastation could generate a wave of suicides,” and the piece described some “troubling signs” that the wave had already begun. The Post said that in DuPage County, Illinois, for example, deaths from suicide had increased by 23 percent: 54 occurred in the first six months of 2020, compared with 44 during the same period in 2019. That may be a 23 percent increase, but given that more than 900,000 people live in DuPage, it shouldn’t be overinterpreted. In fact, when you look at deaths from suicide in the county for all of 2020 (as opposed to just the first half), there’s hardly any change at all: There were 94 suicides in total last year, compared with 90 the year before. (There were 107 in 2018.) As for teenagers and adolescents, six died by suicide in DuPage in 2020, compared with eight in 2019.With more than 3,000 counties in the United States, it would be easy, in any year, to pick out some where the number of deaths from suicide went up. It would also almost certainly be meaningless. Inevitably, some counties will record an increase, while others will record a decline. And if you wanted to find some place where youth suicides had doubled, like they did in the Clark County school district, that’s easy too: When the number of incidents is relatively small, you’re likely to find places where the total goes from 10 to 20. Or vice versa. Whatever narrative you’re trying to support, a county or a school district will provide the numbers you need.At times, evidence for the broader mental-health troubles teens have faced during the pandemic has been overstated too. The most recent round of dramatic headlines was prompted by a study of insurance claims for mental-health services from a nonprofit called FAIR Health. The numbers for teenagers had “skyrocketed,” according to the coverage: In just the first two months after schools closed, teens’ insurance claims for mental-health treatment were “approximately double” what they’d been during the same period in 2019. In a similar vein, reports about a CDC study from November emphasized that youth mental-health emergencies had soared during the pandemic, and that related ER visits among teens had gone up by nearly one-third from the year before. All of these data were said to reveal that the pandemic’s effect on kids’ mental health was “in some ways worse than the experts feared.”But what many news outlets called a rise in claims or an increase in emergency-room visits was actually a rise in the percentage of claims or visits. So, for instance, the number of insurance claims related to intentional self-harm among those ages 13 to 18 did almost double as a percentage of overall medical claims in March 2020 compared with March 2019. But the total number of medical claims dropped by about half that month, likely because people were postponing their less urgent trips to the doctor. Similarly, the total number of ER visits among teens went down by roughly one-third. At the same time, the absolute number of insurance claims related to intentional self-harm among teens decreased by 2 percent compared with the previous year, and the absolute number of teens’ mental-health ER visits decreased by 15 percent.The FAIR Health study did show a modest year-over-year increase—of less than 10 percent—in overall mental-health insurance claims for teenagers from March to November 2020. That’s worth taking seriously, but the stats did not skyrocket.In a column earlier this month, the Washington Post’s Glenn Kessler, who writes the paper’s Fact Checker feature, dug into Biden’s claim that “suicides are up.” (He also referenced his own newspaper’s coverage of an apparent suicide crisis.) “Politicians should be wary about citing preliminary or partial data and declaring that it is a fact,” he concluded. It's possible that suicides were up last year, he wrote, in part because some deaths from drug overdoses may have been suicides in disguise, but we can’t know for sure, because some of the numbers are still being tabulated.It’s true that suicide tallies from around the country trickle in over months, and we don’t yet have a complete picture from last year. What we do know at this point, however, doesn’t suggest a new dimension of calamity. According to Tyler Black, a suicidologist and the medical director of emergency psychiatry at British Columbia Children’s Hospital, 2020 was, for all its many horrors, likely just an average year when it comes to suicide in both children and adults. “There was no wave from March to August—like, none—and we’re quite certain about that,” he told me. In fact, the preliminary data from the CDC show that deaths by suicide dropped by 5.6 percent in 2020 from the year before, reaching their lowest total since 2015. Other recent research seems to bear this out: A new paper in The Lancet Psychiatry found that in 21 countries, “suicide numbers ... remained largely unchanged or declined in the early months of the pandemic,” while an analysis of national mortality data for the U.S. concluded that suicide numbers went down during the first five months of the pandemic. Jeremy Faust, an author of both of those papers and a doctor in the emergency-medicine department at Brigham and Women’s Hospital, in Boston, says he’s noticed that any news of a drop in suicides, however welcome it might seem, leads to pushback. “There’s this knee-jerk reaction to say, ‘Ah, well, that doesn’t mean that everyone’s fine,’” Faust told me. Of course the pandemic has led to mental-health fallout, but it doesn’t necessarily follow that deaths by suicide went up.As for whether a spike in suicides might be hidden in other categories, such as drug overdoses, Faust calls that idea “extremely unlikely.” Deaths by suicide or overdose undergo medical investigation, and while some misclassification is inevitable, those determinations are considered largely reliable. Black noted, likewise, that the CDC’s final mortality numbers don’t usually differ by more than a percentage point or two from its preliminary numbers, so the suicide total from 2020 will “almost certainly be a decrease when all is said and done.”[Read: When will people get better at talking about suicide?]Surely the upheaval of the last year has exacted a psychological toll on young and old people alike, and we’re still in the midst of that trauma and disruption. Some have also clearly suffered more than others. But Jonathan Singer, the president of the American Association of Suicidology and an author of Suicide in Schools, cautions against drawing a straight line between pandemic shutdowns and suicide rates among teenagers. He believes there were indeed teens and adolescents at higher risk from suicide last year, or who died by suicide, because they felt cut off from their friends, or were in an abusive home, or found a parent’s firearm. But other kids might actually have been protected from harm by being out of school, because “their stressors were in-school bullying, or being misgendered, or maybe access to substances through peers,” Singer told me. He pointed out that school attendance is itself a known risk factor for suicide, as rates have dipped consistently during the summer months and over winter break.Meanwhile, on Twitter, Black has been skewering stories like the Times piece about Clark County, and likens the rhetoric regarding school closures and teen suicide to the moral panics linking video games and violence. And while he’s always annoyed when he sees suicide statistics either misunderstood or intentionally misconstrued, in this case he believes the stakes are much higher. “People are using that disinformation to advocate for, for example, ending lockdowns in schools where maybe the viral numbers support the school being locked down, or maybe it’s returning to work before we’re ready, or maybe ending a mask mandate,” Black said. “The part of it that bothers me the most is the fact that suicides were politicized as a tool to argue for particular outcomes.”The wrangling over school closures and other pandemic restrictions—whether they went on too long or not long enough, how much good they really did—will continue to play out for some time. And while it's reasonable to worry about the pandemic’s effect on teenagers, unfounded claims about a spike in suicides only muddle the important issues. The irony is that youth suicide is a vexing public-health situation that deserves our attention, says Julie Cerel, a social-work professor at the University of Kentucky and a past president of the American Association of Suicidology. Researchers like her will keep sifting through the data for explanations of the disturbing long-term trend, and they’ll keep searching for solutions, well after the threat of shutdowns to teenagers’ mental health has disappeared from the headlines. “It’s not a schools-are-closed, kids-are-killing-themselves problem,” Cerel told me. “That makes it look very simplistic, and like reopening schools is going to solve it. The problem is that there isn’t an easy fix.”
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theatlantic.com