From the peak on January 8 to today, following the trajectory of new COVID cases in the U.S. is like a descent on the Matterhorn. The mortality rate has taken a similar plunge over the past few months. Nearly half the country has received at least one vaccine dose. And for more than a month now the majority of schools have been open full time and, predictably, there has not been a rash of associated community outbreaks. Acknowledging the trends, and, belatedly, the science on outdoor transmission, last week the Centers for Disease Control and Prevention updated its mask guidance: Even if you’re not vaccinated, don’t bother with a face covering if you’re walking, running, or biking alone or with household members. And vaccinated people can do away with masks altogether outdoors, other than at crowded spaces.
With all this good news related to the pandemic in the U.S. and the relaxing of a number of controls, the CDC’s newly released guidance for summer camps is notable for its rigidity and strictness: Masks must be worn at all times, even outdoors, by everyone, including vaccinated adults and children as young as 2 years old. The exceptions are for eating and swimming. (The guidance helpfully notes that if a person is having trouble breathing or is unconscious, no mask need be worn.) Campers must remain three feet apart from each other at all times including, again, outdoors. Six feet of distance must be maintained during meals and between campers and staff. If you need to sneeze and you don’t have a tissue, do it into your mask. (Children presumably are expected to carry a cache of spares.) Campers and staff should be cohorted, and any interaction with a person outside the cohort must be conducted at a distance of six feet. Art supplies, toys, books, and games are not to be shared.
The notion that children should wear masks outdoors all day in the heat of July, or that they can’t play any sport that involves physical contact, or put an arm around a friend strikes many experts in infectious diseases, pediatrics, epidemiology, and psychiatry as impractical, of dubious benefit, and punishing in its effects on children.
It has been well documented that kids are at exceedingly low risk of serious illness from COVID-19. For perspective, the CDC estimates that around 600 children died of influenza in the 2017–18 season; during the 2009 H1N1 pandemic, 358 pediatric flu deaths were reported. Each year, more than 700 children die from drowning. Through the end of April, 277 have died from COVID-19.
While the specific statistics differ from study to study, the evidence is unequivocal that outdoor transmission is rare. An Irish study of more than 230,000 cases found just 0.1 percent were derived outdoors. Another study, awaiting peer review, found that the odds of a primary case being transmitted in a closed environment was 18.7 times greater than in an open-air environment. A systematic review found that outdoor transmission accounts for under 10 percent of cases. Another review found “very few examples of outdoor transmission of COVID-19 in everyday life.” It noted that risk increases when there is no social distancing but that temperatures conducive to outdoor activity – for example, summer sun – were “associated with lower COVID-19 transmission.”
For much of last summer, when COVID-19 rates were on par with where they are now — before half the adult population was vaccinated and millions of children had acquired immunity naturally — many camps had far fewer restrictions and there was no corresponding wave of related outbreaks.
The combination of masking and social distancing of children outdoors, said Dimitri Christakis, an epidemiologist and the editor-in-chief of JAMA Pediatrics, the leading journal for pediatric medicine, “is unfairly draconian.” We should let kids be close and play, he said. And with rapid testing twice a week on a rolling basis, a relatively easy program to conduct, he added, we should be able to forgo masks. Even without testing, Christakis said that sports like soccer should be able to be done without masks. And that “keeping children masked for activities like baseball and tennis is ridiculous.”
Mark Gorelik, a pediatric immunologist at Columbia University and an expert on MIS-C, the rare COVID-19-related inflammatory syndrome, said, “We know that the risk of outdoor infection is very low. We know risks of children becoming seriously ill or even ill at all is vanishingly small. And most of the vulnerable population is already vaccinated. I am supportive of effective measures to restrain the spread of illness. However, the CDC’s recommendations cross the line into excess and are, frankly, senseless. Children cannot be running around outside in 90-degree weather wearing a mask. Period.”
An infectious-disease scientist at the National Institute of Allergy and Infectious Diseases, Anthony Fauci’s agency, spoke with me about the CDC guidance on the condition of anonymity because they were not authorized to speak to the media. “With staff and parents vaccinated, there is no reason to continue incredibly strict mitigation efforts or put severe limitations on activities,” they said. “Charitably,” the scientist, who has an expertise in respiratory viruses, continued, “masking kids at camp outdoors is simply virtue signaling. Requiring kids to continuously wear masks at camps, even while outside playing in the heat, when it provides little additional protection is unfair and cruel to our children. Considering that children are at incredibly low risk for developing severe illness, the minimal benefits of mask wearing do not outweigh the substantial costs of discouraging children to be active and their overall health.”
An epidemiologist at the CDC, who has felt the agency’s guidelines for schools have been overly strict and who also spoke on the condition of anonymity, asked rhetorically, “Putting kids in masks outside all day? Not allowing them to share objects?” Relatedly, the guidance recommends staggering the use of shared playground equipment. Yet fomite transmission – that is, viral spread through surfaces – outdoors has proved to be almost non-existent. One laboratory study showed that SARS-CoV-2 was inactivated within minutes when in direct sunlight.
Even beyond questions of utility and fairness is that of practicality. Allison Baker, a child and adolescent psychiatrist at Harvard Medical School, said the guidelines are “not realistic and can’t be enforced systematically. Kids will find a way to get their needs met.” The CDC epidemiologist said: “Camp is not about being three feet apart.”
Oddly, outside small groups like bunkmates, the guidelines don’t even allow for relaxing restrictions for overnight camps, where, with limited effort, the whole camp can essentially function as one large cohort. Dr. Christakis, the epidemiologist and editor of JAMA Pediatrics, suggested overnight camps could institute a testing protocol like the NBA bubble. “There could be a short quarantine and then everyone can act normally, as if there is no COVID.” Instead, the CDC says campers should be split into small groups that “will remain together for the entire camp session without mixing with other campers and staff in close contact.” Many sleep-away camps run anywhere from two to seven weeks.
The CDC guidance says that camp administrators, in collaboration with state and local health officials, can tailor its recommendations to the needs of each community. But this qualifier shows a lack of understanding of how most politicians and businesses operate. As we’ve seen with the reluctance of school superintendents to do anything less than what is perceived as maximum safety, few camp directors will be keen to take on a similar liability of not following the CDC guidance to a T, nor will most state and local officials, at least in blue-state America.
The World Health Organization’s guidance offers a useful counterexample. The WHO says when deciding whether children ages 6 to 11 should wear masks to consider if there is widespread transmission in the area. This type of language gives the necessary latitude, not to mention political cover, to local officials to ease up on restrictions. By contrast, the CDC camp guidance allows for no such reasonable calculation to be factored in. The WHO also says that children under age 6 shouldn’t wear masks at all, whereas in the U.S. 2-year-olds are expected to do so. The WHO further advises that children should not wear a mask “when playing sports or doing physical activities, such as running, jumping, or playing on the playground, so that it doesn’t compromise their breathing.”
Several camp directors I spoke with said they hope that, as cases continue to fall, the CDC will revise its guidelines in May, or that, at minimum, their states will allow for a more sensible approach. Indeed, many overnight camps hope to enact a plan similar to the NBA bubble that Dr. Christakis suggested.
The CDC says that its “layered” approach of universal masking, distancing, repeated testing and screening, disinfecting, and significant limits on indoor activity protects children and staff.
But, as noted, staff will be vaccinated and children are at a likelihood of a poor outcome on par with the flu, for which they don’t prophylactically wear masks or distance, never mind doing so outside. More broadly, the CDC’s camp guidance seems to be divorced from the realities of how children play and socialize and seems to take little account of their essential human needs. It is unlikely that even one decision-maker at the CDC spent their childhood wearing a mask all day every day for more than a year, let alone outdoors in the summer. The larger response to the pandemic in the U.S., typified by the camp guidance, has wrought a bizarre and unjust irony for children: They are the least at risk, yet in many ways have been forced to bear a disproportionate share of burden.
While vaccinated CDC officials can meet others without masks or distancing in air-conditioned conference rooms, and can do close to any activity they want outdoors maskless and with no distance restriction, children, for whom COVID-19 poses little risk, have been expected to not touch another human being outside their immediate family for more than a year. As several experts told me, these measures imposed on children have virtually nothing to do with their safety.
Dr. Christakis said, “We’ve consistently deprioritized the essential needs of human childhood. Keeping kids out of school, enforcing social distance on them.” We have to learn to tolerate some level of risk, he said. It’s clear that children’s well-being is not the priority in these guidelines, he said, and “we have to try as best we can to give children their lives back.” Mark Gorelik, the pediatric immunologist, said, “Irrational recommendations will do no good, could in this case do harm, and really discredit federal agencies.”