Update on COVID-19 Infections and Vaccines

February 2022 Update on Covid-19
Infections and Vaccines

Dr. Jill Sells: Thank you so much, Nydia, and welcome, everyone. We are just delighted to have you all join us today for our latest update on COVID-19. I am Dr. Jill Sells. I'm a pediatrician and the medical advisor for the National Center on Health, Behavioral Health, and Safety, and I'm joined here today by my colleague Dr. Sean O'Leary, Dr. Neal Horen, and Dr. Abbey Alkon.

If you've been at previous webinars, you may have seen one or more of them. We are delighted to have this great team together again today. I will introduce them each a little bit more fully at the time of their part in the presentation. Next slide.

We just want to acknowledge that we're glad you're back with us. We're sorry that we're all back together. It's been a long time. It is so important to address the challenges that continue related to COVID-19. We understand that it's hard to continue to be flexible and attentive to the changes in guidance and to adapt to what we do. Our center is here to try to help you, and today in this webinar, by continuing to explain what is new and providing resources to help support you. Next slide.

Overall, just a reminder, the reasons for this work … Implementing risk reduction strategies related to COVID-19 is so important in early childhood programs. It's what we need to do to help keep staff healthy, to help keep children and families healthy, to help programs in early childhood provide in-person services, and the bottom line to really help children and families continue to access the services that we know they need and want. Next slide.

Here's how we've laid things out for today. We're going to have three separate presentations followed by an open question and answers. As Nydia said, please go ahead and put any questions that you have that you hope that we will answer into the Q&A portion of that you'll see at the bottom of your screen.

We will get to as many of them as we can today. Any questions that come in always help us understand what the questions are out there that you have and inform future resources and technical assistance that we provide. Please do go ahead and share with us what you're wondering about as the presentation proceeds or when we get closer to that point.

We'll start with Dr. Sean O'Leary going over the evolving impact of COVID-19. Then we'll switch to Dr. Abbey Alkon and talk specifically about risk reduction strategies and early childhood programs. Then we'll have Dr. Neal Horen talk about supporting staff through all of this, and then we'll do the open question and answers. Next slide, please.

I'm delighted to have Dr. O'Leary back with us today. As you may remember, he is a subject matter expert for our national center. He's a professor of pediatrics at the University of Colorado School of Medicine and Children's Hospital Colorado. He's a pediatric infectious disease specialist and is the vice chair of the American Academy of Pediatrics Committee on Infectious Diseases. He serves as the liaison to the Advisory Committee on Immunization Practices, known as ACIP, which is the committee that makes recommendations about vaccines for the US public.

Since shortly before this pandemic began, he has represented the AAP on the ACIP's COVID-19 vaccine workgroup, helping to advise the CDC on the use of these vaccines. He's also been really involved with the development of AAPs recommendations around COVID-19 in school settings throughout the pandemic. He also cares for children who have developed COVID-19. He's really in a great place to help us understand the history and where we're at. With that, I'll turn it over to Dr. O'Leary.

Dr. Sean O'Leary: Thanks for that introduction, Dr. Sells. It really is a privilege to be here. I really I want to recognize the importance of the work that you all have been doing prior to this pandemic, throughout this pandemic, and in the future. You really are, as the last slide said, absolutely essential.

What I'm going to go through here today in the beginning here is some of the kind of why things are changing over time. I'll go through where we've been, where we are now, just to review. Really, I want to make the point that it felt like whiplash a lot of the time, right? Things keep changing. Why do they keep changing? It's so confusing.

The point I want to make there is that that's really what we should have expected from the beginning. At the beginning of this pandemic, we knew very little about this virus. We know far more now about a lot of things about the virus in terms of how to prevent it, how to treat it. We've learned all of that along the way. As we learn new things, that's why guidance changes. But I know it can be really confusing and can be really frustrating at times.

We'll talk a bit about the surges we've seen as well. Why do we see these surges? I'll talk a little bit about the variants. You've all probably heard about the Omicron variant and the Delta variant. I'll talk a bit about that and how these can create surges and then also the impact of the risk reduction strategies. Next slide.

This slide is from the American Academy of Pediatrics. The American Academy of Pediatrics has been tracking cases in children throughout the pandemic. With this slide, I'm just going to briefly talk about some of these surges that we've seen.

On bars that you see, those are the number of cases that have the number of identified cases, I should say, not estimates but actually identified cases. These are probably an undercount going all the way back to the beginning of the pandemic. On the far left, you can see there weren't that many cases identified. As you may remember, there wasn't much testing around. There are probably a lot more cases than what we saw

But remember the whole flatten the curve thing. You can see that curve stayed flat because everyone is really locked down. We were all staying at home, and we were successful at preventing hospitals from being overwhelmed.

Then things relaxed in that summer of 2020, June, July, August. You can see there was a bit of a surge then and then a pleasant surprise as we entered the school year in the fall. Even though many schools were open at that point, we didn't see a big jump in cases.

But, as was predicted, we saw going into the winter. We know viruses tend to circulate a lot more in the winter. That big hump in the middle there, that was the winter of the end of 2020 going into 2021. The hope that was going to be our worst surge.

Then we had the big drop off. We had a little bit of a spring surge as mitigation measures were relaxed. Then we went into that nice summer of June 2021 where we were thinking, well, hey, maybe we're out of this. Then remember Delta. That's when Delta came along, and it was a very highly contagious variant. We had a lot of hospitalizations. Then now we saw that start to come down and then Omicron, right? Omicron much more contagious. I'll talk a little bit more about that.

Now, the good news is, of course, as you've probably seen in the news is we seem to be very rapidly coming down from the Omicron variant. I wish I could say this was the end of what we're dealing with in this pandemic. But unfortunately, I don't think we're quite there yet. I'll talk a little bit more about why I say that. Next slide.

As I mentioned, infections, even though we're really coming down from the Omicron wave, if you actually look at the data in your local towns, counties, states, or even across the country, even though we're far lower than we were even a few weeks ago in almost all parts of the US, we're still at pretty high rates. You remember probably hearing a lot about percent test positivity. The percent test positivity is still pretty high in a lot of places. We're not quite out of the woods yet. Omicron is the dominant variant by far. Omicron is a very, very contagious variant. We still need to be careful about spreading this particular virus. Next slide.

As I mentioned, almost all cases in the US now are Omicron. Delta was a very highly contagious variant, two to three times more contagious than what we were dealing with before that. It was hard to imagine that something was going to become more contagious than Delta. But lo and behold, along came Omicron.

Omicron is I've heard some scientists suggest that as it is one of the most contagious viruses now known to humankind, measles probably being the most contagious virus known to humankind. Omicron may be second. Now there's another subvariant of Omicron that we're still waiting to see what may happen from there that appears to be slightly more contagious even than Omicron. It is a very, very highly contagious virus.

Now, one thing you've probably heard a lot about through the pandemic – or in the last six months or so anyway – are these breakthrough infections that vaccinated people become infected. People who have been previously vaccinated, but they still get an infection. I'm sure many of you have had that or at least know someone who has.

It's true that those are more common with Omicron than with the Delta variant. But the really important thing to recognize here is that infection may not be the … It really is not the ultimate goal of vaccination. It's prevention of severe illness. Vaccination is very highly protective against severe illness, even with Omicron, even with seeing these breakthrough infections. Next slide.

Illness with the Omicron variant … I can talk more personally about illness in children because I've taken care a lot of those. In terms of illness in adults, there's a lot of … Every time a new variant comes along, is it more severe? Is it less severe?

The issue with Omicron is it was so much more contagious and caused so many more infections. How severe it was overall paled in comparison to the number of people that got infected. That is why we saw so many hospitalizations. Yes, perhaps it was slightly less likely to cause a hospitalization than prior variants, but it still caused an awful lot of hospitalizations. We saw the same thing in children. We have another slide. I can show you about that.

The point I want to make here, though, is that the people with severe illness are mostly the unvaccinated, and most people who are hospitalized are unvaccinated. I can tell you that in taking care of children in our ICU, or pediatric ICU, here in Colorado, basically 100% of those children had no vaccinations. We did have some children who were hospitalized that did have vaccinations, but a lot of that was for other things that wasn't related to the virus. Vaccination is really highly protective both in children and adults from hospitalization and severe outcomes. Now, it doesn't mean that they never happen, but they are quite rare. Next slide.

This is just to graphically illustrate the hospitalization rates among adults by vaccination status. What you can see … So on the left is a rate, “How many people are hospitalized per 100,000 population?” On the bottom, what you're seeing is over time.

The lower green line, that represents hospitalization rate in vaccinated adults. The line above represents the vaccination rate among unvaccinated persons. What you can see is that there's a huge difference throughout the pandemic of people who are vaccinated versus unvaccinated in terms of how likely they are to get hospitalized. That's only gotten larger as time has gone on. Next slide.

Then this is the childhood cases. This is specifically showing the number of childhood cases by week. This is, again, from the American Academy of Pediatrics. The total number is the bars that you see in and what you see on the bottom is over time. I already went through these surges, but you can see pediatric cases are way, way higher than they ever have been throughout the pandemic. Even though they're coming down quite rapidly, they're still higher than they ever were. That's an important thing to recognize: lots of pediatric infections out there right now. Next slide.

In terms of the specific setting of early childhood programs, why do we still need to do risk reduction strategies? Well, No. 1, children under 5 can't be vaccinated yet. I'll talk more about that in a second. Once they can, it will take time for them to be fully vaccinated and for high rates of vaccination to be achieved. We still need to work hard to protect children in these settings.

We do know that children are getting infected and hospitalized at increasing rates. The children under 5, actually throughout the pandemic, have had the highest risk of hospitalization. That risk has gone even higher as we've seen vaccination uptake increase in children 5 and older.

Then, of course, we all know that – I think early in the pandemic – there is discussion, well, children don't really spread it to other people. That's absolutely not true. Children can spread it to other people.

Then, of course, the issue of long-term effects of COVID-19. There's still work being done to understand how common those long-term effects are, but we know they do sometimes happen in terms of post-COVID conditions like long COVID. It is important to still try to prevent illness in these younger kids. Next slide.

If you've seen one of our webinars here before, you've seen this slide before, this is the Swiss Cheese model. There's a lot of debate about mass vaccinations, et cetera. A lot of these things make headlines. But really, those are individual things to help prevent COVID-19 from spreading or really any respiratory virus. To really do our best job at preventing things, we want to use layered mitigation strategies. That's what's illustrated here.

Now some of these certainly are more important than others. Vaccination is No. 1, the most important way to prevent COVID-19 and prevent severe illness. But there are lots of other things that a varying importance that if we use one or more of these, we're going to reduce our risk. The more we use, the more we're going to reduce the risk of spreading the virus.

But one point to remember is that just because you can't do all of these things doesn't mean you shouldn't do any of these things. The more you do, the better. But, for example, simply wearing masks and being vaccinated, you're going to be in pretty good shape. But if you can do the other things as well, those are going to reduce your risk even further. Next slide.

Now, I said I would talk a little bit more about the vaccination issue. Everyone 5 and older now is eligible to receive vaccines. Everyone at over 12 needs boosters. Vaccines for children under 5 are coming soon. I'm going to go through that on another slide. I know it's been confusing in terms of what's been going on. I'll try and explain that as succinctly as I can.

Now, again, I mentioned the benefits of vaccination – far less risk of severe disease, hospitalization, and death, which is really what we're trying to prevent. Now there is also very much a decreased risk in getting actually infected, but that is not as important as prevention of these severe outcomes.

Now, of course, other benefits besides prevention of those things is just being able to be in society, being around family and friends more safely, also the issue of not having to quarantine if you're exposed. Then also, remember, there is still a lot of people out there … I'm sure many of you on this call who have medical conditions that make it so that you can't be vaccinated, or that if you are vaccinated, it may not work as well.

We have to remember that. That's a good portion of our US population – somewhere in the 3% to 5% range of the US population – who are not going to be able to get the full benefit of vaccination because of a medical condition. We have to remember that. Next slide.

Now I'm not going to go through this in great detail. But this is what up to date means. You can see for the different age groups and for adults that got the Pfizer or Moderna, the primary series was two vaccines, three or more weeks apart. Then, for immunocompromised individuals, a third primary vaccine 28 days later. Then a booster five months after the primary series for all adults 18 and older. Then you can see for Johnson & Johnson as well. Next slide.

The vaccines for children under 5. Let me just briefly explain what happened here. The way vaccines have been developed in children relative to adults … In adults, you may remember there were trials of 30,000 to 45,000 individuals, very large trials. The first thing that is examined in those trials is vaccine safety. They look to make sure the vaccine is safe.

The other thing that they look at is, does it provide an immune response? Whether it … They test the blood, and they say, “Does it look like the vaccine is doing what we want it to do in the blood?” The other thing they look at in is large trials is: Did the vaccine work to prevent infection?

What we know for … This was around November, December 2020 – sorry, yeah, 2020 – where we learned these vaccines were safe, immunogenic, and effective. That's when the vaccine started being rolled out. Then they were rolled out to 16 and older for Pfizer, 18-plus for J&J and Moderna.

For the childhood trials, because there was urgency to be able to get vaccines for the younger children, what they did was they said, “OK, we know that the vaccine works 16 and older. What we can do is make sure, No. 1, the vaccine is safe. No. 2, does it provide the same immune response in this age group that it does comparing it to the older age groups? If it does provide the same immune response, then we can say, ‘OK, it works. It's very likely to work in this population.’”

That's when we saw the vaccine approved for 12 to 15-year-olds. Sure enough, when they looked after introducing it, it worked very, very well to prevent infection. Same thing happened with 5 to 11-year-olds.

Although with the 5 to 11-year-olds, they looked for a somewhat lower dose. The immune system matures over time. Children tend to respond more robustly to vaccines than adults. They looked at a lower dose. Sure enough, the dose in the 5 to 11-year-olds was shown to be safe, and it was also shown to produce an immune response similar to the adults in whom we knew the vaccine worked to prevent infection.

Then they looked at kids under 5. This is where things get tricky. The company, Pfizer, did a press release in December saying the vaccine in the 6-month to 4-year age group looks to be very safe. We don't see any safety issues. In the 6-month- to 24-month-olds, it looks to provide the immune response that we want.

But in the 2 to 4-year-olds, the immune response doesn't look as good as we were hoping. We have asked the FDA to change the trial. Now we add a third dose. Now that makes some sense because we know that a third dose is really helpful in adults. That's what happened in December.

Then, with the Omicron wave, seeing how many infections were happening in children, how many hospitalizations were happening in children, the FDA went to Pfizer and said, well, let's look at your data. Let's see what's going on here. Perhaps two doses would be beneficial knowing that we're going to need a third dose down the road.

Then that's what happened all over the news in the last couple of weeks is they started to look at those data. They said, well, I think we need to wait for the third dose not because there was a safety concern but because it looked like they wanted to make sure that they followed the process to a tee, because they wanted to make sure that the vaccine was safe and was going to work in this population before rolling it out. That's where things are right now. Let me go to the next slide.

This is just to show you the process. You'll notice in the lower left, this is a slide from 2002 regarding how vaccines are developed, licensed, and approved for use in the US population. This has not changed one bit in the COVID-19 pandemic. This whole process is happening essentially the same way as this slide represents, except instead of what's called a biologics license authorization because we're in a pandemic, it was these vaccines were under an emergency use authorization, although now the Pfizer vaccine and the Moderna vaccines are under a full BLA for adults.

But what I have circled here on the left, a lot of people have said, “Well, I don't understand what's going on here with all of these things going back and forth. It seems like it's all happening behind closed doors.”

The reason I have that particular box circle, that long name there, VRBPAC, that's a committee that actually meets in public. They don't work for the US government. They actually are external experts who review the data in a public meeting. That meeting was going to happen last week about the Pfizer vaccine for under 5. That's where they decided, OK, we're actually not going to have that meeting yet. We're not ready yet. We're going to wait till we get all the data.

If you're really interested in seeing how this process works, you can see that meeting will happen probably late March, early April, I would guess. I will go through the rest of this. But the point here is there is a very extensive process for how vaccines are licensed and recommended. That process has been followed throughout the pandemic. Next slide.

OK, now masks. I know there's a ton of questions about masks right now. You're seeing it all over the news about different places that are taking away mask mandates, etc. The effectiveness of masks, though, however, has not changed. Masks still work to prevent infection. That's why the recommendations really have not changed at this point from any national guidelines, whether that's CDC or AAP because the recommendations are the same because we still have a lot of infections out there. Again, everyone 2 and older as you all know.

The benefits of masks, one, it lowers the risks of spread between people. Early in the pandemic, you may remember hearing that it really didn't protect the wearer. It just protected those around them. We know that's not true. It actually protects both the wear and those around them. Of course, as I mentioned, it helps protect people who can't be vaccinated, people who are immunocompromised, as well as young children. Next slide.

Now, the other thing that I think is important … This is another one of those things that, gosh, why do things keep changing? Well, it's because we have more information. That's why things keep changing. This is another one of those things. It does matter what type of mask you wear in terms of the likelihood of prevention of spreading infections.

This is a slide from CDC actually from a recent study showing how much each of these different types of masks lower your risk of getting infected. On the far right, you can see that N95s or KN95s provide the greatest protection. Those are perhaps a little harder to get but also perhaps not as comfortable.

In between a cloth mask and the respirator or N95 or KN95 is a surgical mask. That's probably better than a cloth mask, but a cloth mask may provide some protection. This is from a personal standpoint. If you really want to do your best to absolutely decrease your likelihood of getting infected, an N95 or a KN95 is probably the best mask you can use. Next slide.

OK, testing. Of course, always lots of questions about testing. This guidance has not changed. When do you test? If you have symptoms, you should get tested or if you're exposed to someone with COVID-19. There are two main types of tests out there – the rapid tests. Basically what to know about those tests is if you're positive probably means you've got the infection. If you're negative, you still could have the infection, but you're probably not very contagious.

The PCR test is the one that if … Again, if it's positive, it means you have the infection. If you're negative, it means you probably don't. The scientific term used for those are sensitivity and specificity. Sometimes you hear people use words like positive predictive value or negative predictive value.

But the bottom line is the PCR test is going to be the one that is most likely to detect the infection. Guidance on how and when to use those tests actually depends on your local jurisdiction. But the rapid tests are the one that you can usually do at home and can be very helpful.

I mentioned what the results show. If you're positive, that does mean that you're infected. Again, negative, probably not infected. Then how should those results be used? Well, to inform quarantine and isolation decisions for the person that's being tested and their close contacts.

Now, again, these guidelines may change. They're already changing in certain jurisdictions. They may change nationally in the coming weeks to months. But we don't have information on that yet. Next slide.

Just to refresh, this has been confusing throughout the pandemic, but quarantine applies to people who have been exposed to COVID-19. You're supposed to stay home if you've been exposed and do certain things. The details of how you do that actually depend on your vaccination status.

Isolation on the other hand, applies to people who either have symptoms of COVID-19 or are positive for COVID-19. Those details are the same regardless of your vaccination status. You can see the link for the CDC guidelines on quarantine and isolation, which most jurisdictions are still using. Next slide.

To get into a little more detail on quarantine, if you're up to date on your COVID-19 vaccines, as I mentioned, you don't need to stay home. You are recommended to wear a mask for 10 days regardless of local mask guidance and also to get tested after five days and sooner if you develop symptoms.

If you're not vaccinated or not up to date, including children younger than 5, then you're supposed to stay home and away from other people for at least five days, wear a mask for 10 days, and then get tested after five days or sooner if you develop symptoms. Then, of course, in either case, avoid being around people who are particularly high risk for severe disease from COVID-19. Next slide.

Then for isolation – this is regardless of vaccination status – you do want to stay home for at least the first five full days when you've been infected. Then if you're severely ill, stay home for at least 10 days. There are various definitions you can find for how to define severely ill versus mild to moderate. Then you should wear a mask for at least 10 days, and, of course, avoid being around people who are high risk, and don't travel for at least 10 days. Next slide.

I will pass it back to Dr. Sells. Thank you.

Dr. Sells: Thank you, Dr. O'Leary. A lot of great information. Really appreciate you sharing that with us. Now I am delighted to introduce Dr. Abbey Alkon. She is on the leadership team of our National Center on Health, Behavioral Health, and Safety. Dr. Alkon is a professor at the University of California San Francisco School of Nursing. She is the director of the California Childcare Health Program. Dr. Alkon has both a clinical and research background as a pediatric nurse practitioner and an epidemiologist. She conducted several studies showing the importance of working with child care health consultants to improve health and safety practices in child care centers and family child care homes. She also works with a staff of experts at the California Childcare Health program where they develop health and safety curriculum, posters, information sheets, and toolkits specifically for child care professionals and families. She's also been working closely with us at the center throughout the pandemic and providing support through these previous webinars as well.

We're excited to have her back with us today.

Dr. Abbey Alkon: Thank you, Dr. Sells. Next slide. The National Center on Health, Behavioral Health, and Safety has shared a layered approach of multiple strategies since early in the pandemic. Dr. O'Leary talked about, we really believe that these risk reduction strategies, which are based on evidence, are important. We've developed a new poster, and it's called Steps to Stay Healthy. There is a link to the poster on your handout. It soon will be also posted on the ECLKC website, but let me just take you through the poster here.

As Dr. O'Leary said, the most important thing is to get vaccinated, and the next is to wear a mask. As we've heard, masks protect both the user and those around them. We've also had guidance in early education programs that say stay home if you're sick. This is the same type of guidance that we've been using all along for screening and making sure that anyone who is not feeling well does not come in to an early care and education program.

A newer strategy that we just heard about today is about getting tested. If you're exposed or have symptoms, you should get tested. We're fortunate to have both the PCR and the rapid antigen test now for COVID-19.

The guidance on quarantine and isolation, as we've heard, has changed. But it's changed because of the availability that we have of vaccines and test as Dr. O'Leary just reviewed. Increasing fresh air is a great way to ensure that we have good ventilation, and it reduces the amount of the virus in the air.

Washing your hands is familiar to all of us, anyone who works in early education programs. We want to remember to wash our hands for the usual routines but also when we put on and off our masks. Clean and disinfect. Routine cleaning has always been important in reducing the spread of viruses. We only need to disinfect when we're working in diaper-changing areas, bathrooms, and when we're exposed to blood or other secretions. Next slide.

Dr. O'Leary reviewed the current guidance related to vaccines. But here, I want to share with you some of the resources that might be helpful for you. We have a new poster on vaccines for children 5 and older, and there are also some new handouts. We've updated the handout on the vaccine frequently asked questions, and they're all available on the website. There are also other vaccine posters that are specific to adults and staff. Next slide.

I'm going to talk a little bit about masks. The two things that are really the take-home message here is that how the mask fits around your face is really important and filtration. We'll go over both of these.

When we talk about proper fit, we're talking about a mask that snugly fits, that covers your nose, mouth, and chin. For adults, we want to make sure that it fits well and that it's worn consistently. For young children, we say that the best mask is the one that they will wear. We hope that this would be one that would be fitted very well. We can have adults to help decide which mask is the best one for their child but really to talk to their child and see which one they feel comfortable wearing.

When we're talking about filtration, we're talking about the highest quality masks that's possible. It used to be that we really focused on surgical masks and cloth masks. But now we've learned that, as Dr. O'Leary was mentioning, the N95, KN95, also a KF94, which is one that is made in Korea, are also good masks, and they're high quality. But you want to make sure that they're from a reliable source.

Young children have surgical masks. Some of them are small enough to fit, or that you can actually put them around their ears and tie the loops in such a way that it's tight to make sure that it's a tight fit. If you're using a cloth mask, it's best to have one with multiple layers and also with a filter. The KN95, the N95, KF94 masks are not actually certified at this time for young children, but some of them are made for young children. You can check more about the mask and find out which ones are good.

There's a website here that's for Project 95. This is a clearinghouse that has really good information about masks. You can access that information for free. There's also a link on the handout. Next slide.

We heard about testing. I just want to review some basic pieces of it that could be applicable for everybody. The question always is, OK, if we have tests available, what day should we test? Well, it depends on the reason that you are testing. If you're symptomatic, then you should be testing. If you've been exposed after five days and you've had no symptoms, you should be testing just to make sure that you don't have COVID-19.

Some people have been using tests because they want to make sure when they're having a gathering indoors that nobody is transmitting the virus at that time. People are using tests for that purpose. The rapid test is the one that Dr. O'Leary talked about, it really helps you identify if a person is infectious and spreading the COVID-19 that day. We know that testing protocols differ by state local, regional, and tribal jurisdiction, so please check your local jurisdictions.

Also, work with your health services advisory committee or your child care health consultants because they can help you develop a protocol for testing in your facility. There are free tests now available through the United States government. This is the website where each household can get four free tests. They are mailing them out now. Next slide.

I wanted to talk a little bit about caring for our children. As you know, these are the National Health and Safety Performance Standards. They are available for free on the website, nrckids.org.

They provide new guidance on reducing the risk of COVID-19. They're included now in what we're calling the CFOC modifications. The website home page has a list of the modified standards and appendices. They include things like food preparation, ventilation, daily health checks, oral hygiene drop off and pickup.

There's also going to be some changes and revisions to Appendix K, the one for routine scheduling, for cleaning, sanitizing, and disinfection. That will be released soon too. Please check the website for a list of the modified and updated standard on a regular basis. Next slide.

I wanted to end by just going through a summary of some of the things that we've learned during the pandemic. We know that early care and education, early childhood programs are unique places. You're caring for vulnerable children who are not eligible yet for the vaccines. Some of them cannot even be wearing masks.

This has been a long pandemic, and we're all tired. We're looking back on the two years, and we're saying, “What have we learned? How are viruses spread?” We've learned a lot. We learn different ways to protect ourselves and our communities. We've been fortunate to have vaccines developed, tested, and distributed to the general population. These vaccines have been shown to reduce the severity of COVID-19.

We've also learned a lot about ventilation of our buildings and how much it matters to reduce the spread of COVID-19. Testing for COVID-19 is new. It's a useful tool for us to use, especially if we have symptoms or if we're concerned that we might be transmitting or spreading the virus.

We know that masks are effective. If we need to wear masks to reduce the spread of the virus, we should be wearing them. We know that children under 2 and children with special needs cannot wear masks. This makes it even more important that the adults and older children around these vulnerable children are wearing masks.

Since we keep learning new things about the virus and our ability to cope with the virus, we know we need to communicate clearly and often with each other and our community partners. Most of all, we've learned how to be flexible and open to change. As the virus changes, we need to change. Next slide.

Dr. Sells: Thank you, Dr. Alkon. Now for our last speaker before we go into the Q&A session, we have Dr. Neal Horen. He is co-director of our Head Start National Center on Health, Behavior Health, and Safety. He's a clinical psychologist who is focused on early childhood mental health for the last 20 years.

He's director of the Early Childhood Division for Georgetown University's Center for Child and Human Development. He's delivered hundreds of trainings across the country and developed materials and trainings related to topics like trauma, infant mental health, disabilities, and staff wellness. He's one of the nation's leading experts on infant and early childhood mental health consultation and leads the national center of excellence related to that, and has developed trainings to support that work.

He continues to be actively providing mental health consultation as part of his clinical practice. He's been our partner in helping to support you throughout this pandemic. We turn it over to Dr Horen. Thank you.

Dr. Neal Horen: Thank you, Dr. Sells. I was right. At this point, 45 minutes in, wow, right? It's just every time. I work with … I talk with Dr. Sells and Dr. Alkon at least once a week if not more. I've been on a number of these with Dr. O'Leary. Every single time I'm watching, I'm like, man, I got to write this. There's a lot to take in, and there's a lot for you all to handle.

It was interesting to look at that slide from Dr. Alkon that talks about being flexible and open to change. I think it's the thing that we've probably all learned in our work but also in our personal lives, that we've had to do a lot of shifts and changes. Lots of things have happened.

I just feel like every time we talk about all of this and we see all this information, I have to say and stop just because I want to be able to go to him and ask him questions about my children. But when Dr. O'Leary talks, I'm watching, I'm like, “OK, that totally helps me understand this part of it.” When Dr. Alkon talks, I'm like, “Oh, OK, right. Swiss cheese. Yeah, I get it. OK, I got it.” But it's still a lot to take in.

One of the things that we really want you to know and look in your resource list is to look at some of the things around mental health. This really has had a huge impact on all of us, on staff, on children, on families. We have a couple of staff wellness webinars coming up, tomorrow, February 17, March 21. Really encourage folks to take advantage of that.

We also have these kinds of things. When you saw here a couple of posters, that's when I perk up because it's in the language I speak. Just a couple of pictures and some words, I can understand that. That's good for me. That's what's helpful.

Here's one on mental health. We have a number of resources that we put in the resource list. You can see the link here. Really encourage folks – we say this all the time – you got to take care of yourself. We're trying to provide those ways to take care of yourself. It's not an exhaustive … This will make sure that everyone is fine. We don't try and fool ourselves into thinking that there's lots of stress on all of you. It's a lot to handle. There are lots of things that we are trying to offer to be of support for you, for your staff, for the children, families that you're working with. OK. Next slide, please.

How do we do it? One of the ways that I want you to start to think about this is when you were in school on a daily basis … I have a kindergartner. She comes home every day. I'm like, what did you learn? Sometimes she'll just be like, well, not much. Then we'll talk through. I'm like, well, that's an interesting thing.

Imagine if everything you were supposed to learn just got crammed in in two years. That's what's happened for many of us. In two years, somehow, we've had to become experts on things … I don't know … Not all of us were trained on how vaccines get developed, how masks can protect us from communicable diseases, how infectious disease works. I'm not even sure that I use the word "infectious disease." Well, I did. I have to because I'm on a center that does it.

But point being that we've all had these dramatic changes, things we had to learn, practices that suddenly went from doing the daily health check to a whole new level of daily health check over the last two years. I want to encourage you, remind you again. Allow your staff some time, some space to talk about this.

Boy, us mental health people, we like to talk about being reflective and really taking care of ourselves and things like this. There has not been a time in the 25 years that I've worked in Head Start – I started when I was very young. But in the 25 years that I've worked in Head Start, that's been more important to allow staff to at least address their concerns, to have that communication that Dr. Alkon mentioned, and to really understand that probably more than we've seen in a long time, there's a lot of emotion involved. There's emotion involved about yourself, about the children, families you work with, about your own children, about your own families.

There's been a tremendous amount of loss and grief. We'd be remiss if we didn't mention that many people, if not directly impacted, are probably one step away from being impacted by somebody who has had COVID, who has been very sick from COVID, who has died from COVID. I'd like to talk about those kinds of things, right? I like to make lots of jokes. But I also like to be realistic that this has impacted all of us. We have to let people experience those emotions, help process them, be reflective, and then figure out, so what are we going to do to move forward?

Have some time for those breaks. Not just the breaks from wearing a mask, which our partners at DTL, the other national center, Gail Joseph and others have done – this really nice job of laying out a visual schedule, ways in which teachers and assistants in classrooms can schedule breaks from masks – but just to schedule breaks from everything where you can take that respite from, wow, we're trying to figure out, how do we keep the mask on? How do we keep children keep some distance? How do we get out in the playground? How do we get fresher? How do we do all those Swiss Cheese things? I can't even remember all the things on the Swiss Cheese slide.

I got to keep looking at, how do we give people a break so they can get back to that? Not an hour and a half every single day but just a little bit more time than maybe we've thought about in the last few years. I really encourage folks to be supporting staff in as many ways as you can. OK, next slide.

Last thing I'll say – and it's just a way that I go about – this is also the way that I try and get out of doing a lot of work is I just keep telling my coworkers I'm doing the best that I can. But I really, all joking aside, I want you to start to think about everybody's doing the best that they can.

Sometimes it might not feel that way to you, or it might not look like that, or there may be some misunderstanding or disagreement. But let's assume good intent. Let's all start to think about that: “Doctor, how can you use the word ‘community’?" When I think about Head Start, I think about community and support, engagement, those kinds of words.

Let's start to think about how we assume good intent and how we address staff wellness for everybody. That may look different for different folks, what is more helpful for one versus another. I really encourage folks to be thinking more creatively. If there's a hallmark of work in Head Start, it's being creative.

Dr. Alkon mentioned flexible. I think flexibility and creativity are really the way in which if I had to describe Head Start to somebody, that's what I would say. I encourage you to do the best that you can as you've been doing, support those folks in your program, support children and families and your staff, and just assume that good intent, and really make that space for everyone. I'm going turn it back to Dr. Sells.

Dr. Sells: Thank you so much, Dr. Horen. Really appreciate all those thoughts. Next slide, please. Actually, let's go ahead and just take the slides down and have all our speakers come back up on video. Want to acknowledge that we covered a lot of information and to really thank you for all of the questions that you have put in there, you can take that down. Thank you. Put in there for us.

We have captured all of them. We will reflect on all of them and use them to inform things after today. But I went through a lot of them, and I'm going to try to just paraphrase and offer a few that were most frequently asked. A lot of them were to Dr. O'Leary. Just ask you to try to give us a quick and answer as you can so we get through as many of them as we can. We had a question about vaccines in people who are pregnant or breastfeeding. Could you just comment on that, please?

Dr. O'Leary: Yeah, it's a great question. I should have mentioned it. Vaccines are recommended for all pregnant women and breastfeeding women. Pregnant people are at higher risk of severe outcomes from COVID-19. That's become increasingly clear throughout the pandemic. The vaccines have been shown to be very safe in pregnancy and also very effective at preventing disease.

There have been a lot of really tragic stories about unvaccinated pregnant people being hospitalized and even dying from COVID-19. The vaccines appear to be highly protective in those settings. I can't emphasize that enough. It's really, really important. ACOG, the American College of Obstetricians and Gynecologists, has really been trying to promote the importance of vaccination in pregnancy really since over a year now. I can answer offline any other specific questions about that.

Dr. Sells: Thank you, so much. Had a lot of questions about testing. I'm going to load it with part of what I think the answer might be. Then you can correct me and/or add to that.

It is challenging to figure out how to implement any testing protocol or support to families or staff related to that. I believe that we've already mentioned thinking about working with your local health jurisdiction to understand really what's happening in your community around that and particularly for programs to partner with their health service advisory committee in Head Start or a child care health consultant in other settings to help them really understand what makes sense. But I would like to just defer to you, Dr. O'Leary, to see if you have other things to add to that to help people sort this out.

Dr. O'Leary: Yeah, I think that's pretty concise. We could talk for hours or just leave it at that. I mean, I think it is a very complicated topic. It really is contextual in terms of what's available to you, what are your resources, what are your local public health rules. I guess the best thing I would say is look at what your local public health department is recommending and start there. But it is complicated and very local and contextual.

Dr. Sells: OK, yeah, and that is why it's so great to partner with other folks around you to help you understand that we understand it is a challenge. One specific other question related to that is someone noted that the home test kits that they have and that have received from the government say that they can't be used in children under 2. Do you have anything to add to that?

Dr. O'Leary: Yeah, it's tough. They haven't been tested in that age group. They probably work. But the recommendation is going to be that you shouldn't use them because they haven't been tested in that age group. But they probably can give you some information, but you just have to take it with that grain of salt.

Dr. Sells: Likewise, probably talked to the same folks that we were just talking about how to interpret. A question about, how long do people need to wait if they're infected with COVID and they're not fully vaccinated or they're due for another dose? Is there a current recommendation on whether they need to wait or how long?

Dr. O'Leary: Wait for another vaccination?

Dr. Sells: Yeah. At some point, in the past …

Dr. O'Leary: The recommendation is when you are out of your infectious period. As soon as you can be around other people, you can go ahead and get vaccinated. Certainly, within 90 days is the recommendation. You don't need to go the day after you are not infectious. I think if you go in the first couple of weeks after – even a little bit longer – that's fine. But I wouldn't wait longer than 90 days because we know infection from natural immunity wanes just as it does from the initial two-dose series of vaccination.

Dr. Sells: OK, great. I have a question. I'm going to try to quickly post to, I think, to Dr. Alkon and Dr. Horen together. Do you have their questions about supporting children who have disabilities around masks or in general, thinking about perhaps kids with autism as one example?

Dr. Alkon: Yeah, we know that some children cannot wear masks. Those children that can't put on and take off the masks themselves are not recommended to wear a mask. But those that can wear a mask, we feel like it's still very important. I think that communication skills are important. We are aware that certain children might need some special care. I'll leave it to Dr. Horen to see if there's something else you want to add.

Dr. Horen: Well, I think it's a very individual thing to say that when you say autism, that doesn't really help me very much except to know that's a pretty wide variable continuum of children. With each child, trying to figure out if there are sensory issues, there are creative ways in which children could have masks that are more comfortable. As Dr. Alkon said, it may be that the child doesn't wear a mask.

But each child we want to start to think about. If we're working on communication skills, what about communication skills are we working on? Is it a pragmatic skill that we might have alternative ways to do it? I think it's hard to just say if there's a disability, you do X. It's what's the disability for this child? What have you been doing to support this child's development?

Dr. Sells: Thank you. One last question for Dr. O'Leary, and then we'll bring the slide back up. "Are people getting infected more than once?"

Dr. Horen: Yes. I know people who have been affected three times. I saw a lot of questions in the chat around natural infection and where things stand with that. We have to acknowledge there is some protection from natural infection from more severe outcomes. But we also know that vaccination on top of natural infection offers even more protection.

That's why the recommendations haven't really changed around, “Oh, I've been infected before. I don't need to be vaccinated.” Well, yes you do because it is going to reduce your risk even further and your risk from spreading it to others as well.

Dr. Sells: OK, thank you all very much. And again, we will review the other questions that have come in and have that inform our work moving forward. Livia, you can go ahead and bring up the slides, please.

I know it has been fast and furious with people making comments in the chat. We thank you for your engagement and remind you that resources have been loaded in there and shared with you. If you please stay on the line here afterwards, you'll get links to continue to look at the resources that have been shared.

This is just a slide to show you that one of our pages on ECLKC under Physical Health has COVID-19 health considerations. That's your gateway to all of the resources that we've developed related to COVID-19. Next slide.

With that, I will turn it over to Nydia. Thank you all so much for joining us today, and I'll let her close things out for us.

Nydia Ntouda: Thank you so very much again, to Dr. Sells, Dr. Alcon, Dr. O'Leary, and Dr. Horen. Very, very great information. If you have more questions, you can go to my peers or write to health@ecetta.info. Remember that the evaluation URL will appear when the webinar ends, so be sure not to close the Zoom platform, or you will not see that evaluation pop up.

After submitting the evaluation, you will see a new URL. This link is what will allow you to access, download, save, and print your certificate. Thank you all. Thanks to our panelists. Thank you to all of the participants today for your participation today.

You can subscribe to our monthly list of resources using this URL that I mentioned. You can find our resources in the health section of ECLKC or write us at health@ecetta.info. Thank you, all so much. Livia, you can close the platform.

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