On January 29, 1964, Stanley Kubrick released to the world one of his most brilliant films, Dr Strangelove or: How I Learned to Stop Worrying and Love the Bomb. America was at the height of the Cold War. Children were sheltering under school desks in drills preparing for nuclear annihilation. The last influenza pandemic was 7 years in the rearview mirror, and the next one to come was 4 years in the future. The film viciously satirized world leaders and foretold an era of dark pessimism that defines the world and America to this day.
On January 29, 2020, Peter Navarro, trade advisor to President Donald Trump, wrote an internal memo warning of the threat to the United States of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak that had been recognized in China in late December. On that day, the World Health Organization reported that there were 6065 confirmed cases worldwide, 68 of which were in 15 countries outside of China.1 According to the New York Times, Mr Navarro wrote that, “The lack of immune protection or an existing cure or vaccine would leave Americans defenseless in the case of a full-blown coronavirus outbreak on U.S. soil…This lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”2 A worst-case scenario of more than half a million American deaths was cited in the memo.
By June 29, 2020, Mr Navarro’s prediction was well on its way to fulfillment, with >133 000 Americans dead from coronavirus disease 2019 (COVID-19). Although Americans constitute only 4% of the world’s population, we account for ∼25% of global SARS-CoV-2 infections and COVID-19 deaths.3,4 With a vaccine months or years away, if even possible, we are left with limited options for slowing the spread of the virus. Chief among these is social distancing.5 A century ago, social distancing played a key role in limiting the 1918 influenza pandemic. The principle is simple. If someone is infected with a respiratory virus, they are less likely to spread it to others if they are not in close proximity to them. Significant challenges remain in the embrace by average Americans of the need for social distancing, based on its limited success thus far.
In this month’s issue of Pediatrics, Vernacchio and co-workers6 provide a short but provocative report of diagnoses of common pediatric infectious diseases across a large Massachusetts pediatric primary care network and the changes between 2019 and 2020. Each disease evaluated was dramatically less likely to occur during the initial weeks of enforced social distancing compared to the same time period the previous year. Before social distancing measures, the diseases of 2019 and 2020 followed similar trajectories, suggesting that had social distancing not occurred, this year’s infections would have continued on a similar path as 2019. The difference-in-difference approach is key for analyzing these data, as is the diversity of infections reported (including urinary tract infections, which are not considered contagious). By analyzing the data within the same primary care network, on a population level, the people included are roughly the same; comparing each week keeps the seasons the same from 2019 to 2020, leaving key societal events as the primary differences. In this case, the key differences in the analyzed time periods (pre–week 10 and post–week 12; 2019 and 2020) are social isolation and perhaps decreased medical care seeking both due to reactions to COVID-19.
As the authors note, it is not as clear as to which factor is driving the significant drop in common pediatric infections. If it is decreasing access to medical care, this would be an unforeseen consequence of our social distancing efforts, and our response requires improved outreach and communication with families on seeking appropriate medical care throughout the remainder of the pandemic. On the other hand, if the decrease in pediatric infections is the direct consequence of social distancing, then it would be a rare positive development in the health of Americans during the pandemic.
Similar observations of infections dropping during periods of isolation have been made in Seattle.7 Between February 3 and 11, 2019, a record snowstorm covered Seattle, Washington. Seattle does not have dedicated snowplows, and the city’s steep topography is especially challenging during snow and ice storms. Most public schools in the region were closed, and highway traffic in the region decreased by one-third during those few weeks. The Seattle Flu Study that had started a few months before to evaluate the transmission of influenza and other respiratory viruses was well positioned to assess the impact that this social disruption caused on these infections.8 The Seattle Flu Study researchers calculated that the percentage of infections averted during the period of weather-imposed isolation ranged from 3.0% (95% confidence interval, 2.0%–3.7%) for human metapneumovirus to 9.2% (95% confidence interval, 6.2%–10.3%) for respiratory syncytial virus B.7 In other modeling studies, researchers likewise have predicted that social distancing measures initiated early in the course of a pandemic can reduce viral spread.9–12 Taken together, these reports would suggest that the decline in other infectious diseases reported by Vernacchio and co-workers6 is indeed real.
However, we also now know that immunization rates for American children have plummeted since the onset of the SARS-CoV-2 pandemic.13 The cause of this is a dramatic decrease in use of health care during the first months of the pandemic. This raises real possibility that the travesty of a measles epidemic occurring on top of the coronavirus pandemic could happen. Viewed through this lens, the report of Vernacchio and co-workers6 could be due not to a true decrease in infections but simply a lack of recognition because the infections are going undiagnosed and untreated. It goes without saying that the health and well-being of children would be significantly and detrimentally impacted if this is the case.
What do we make of all of this? First, we simply must socially distance. The immediate threat is the coronavirus pandemic. We must also employ all other public health measures we have at our disposal: wearing masks, practicing excellent hand hygiene, avoiding gathering in crowds, and being mindful of surfaces. Until there is a treatment or a vaccine, we must settle in for the long haul with SARS-CoV-2 as part of our daily lives. We must find a way to live with it, much as in decades past we had to learn to live with the threat of the bomb. This includes going to all pediatric well visits and seeking timely medical attention when sick. Ultimately, the verdict remains out as to whether the observations of Vernacchio and co-workers6 are an unforeseen good consequence of a bad situation or yet another blow in an increasingly long struggle.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-006460.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.