Population Care

Preventing COVID-19 and monkeypox in schools with Aaron Carroll, MD


 Watch the AMA's COVID-19 Update, with insights from AMA leaders and experts about the pandemic.



Aaron Carroll, MD, MS, a distinguished professor of pediatrics, chief health officer at Indiana University in Indianapolis—and good friend of the show—discusses what parents and physicians need to know as kids head back to school this fall. American Medical Association Chief Experience Officer Todd Unger hosts.

Note: This episode was recorded prior to the release of the CDC's updated COVID-19 guidelines on Aug. 11, 2022. Visit the CDC for more information.

Learn more at the AMA COVID-19 resource center.


  • Aaron Carroll, MD, MS, distinguished professor of pediatrics, chief health officer, Indiana University

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.

Unger: Hello. This is the American Medical Association's COVID-19 Update video and podcast. Today's topic, can you believe it? Back to school and what that's going to look like in the fall. I'm joined today for the third annual back-to-school episode with Dr. Aaron Carroll, a distinguished professor of pediatrics and chief health officer at Indiana University in Indianapolis, Indiana. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Carroll, welcome back.

Dr. Carroll: Well, thank you for having me.

Unger: And we were talking just before this. It's hard to believe this is the third time we've spoken about back to school. Are we ever going to get out of this?

Dr. Carroll: I hope. We just don't seem to be there yet. And, unfortunately, we're still needing to deal with the ongoing pandemic and what it might mean as everybody comes back together for school.

Unger: Well, I don't know that I'd want to be in the shoes of the parents and educators, administrators, and students right now that have been dealing with this for some time. Are they generally optimistic or just fatigued, both, at this point?

Dr. Carroll: I think both. I mean, certainly fatigued. Nobody hoped that we'd still be doing this for a third time. But I'd also say that things are unquestionably safer than they were a couple of years ago. We had no vaccines. Hospitalizations were rampant. We were crushing the health care system. Significant number of deaths every day. ICUs were full. A lot of that has slowed down.

People are hospitalized but sometimes also with COVID as opposed to because of COVID. Many, many, many more people are vaccinated. Deaths, while still higher than we'd like, are much lower than they used to be. And things are much better.

Unger: So that is good news. And as you mentioned, we've had a rollout of vaccines for many age groups even as young as six months old, which is a game changer, obviously, for a lot of families. Unfortunately, what we've seen is that the uptake on these vaccines is way, way, way lower than we hoped it was for all those age groups, including the 5- to 11-year-olds. With the hope of this kind of maybe a little bit of return to normalcy, what is the disconnect? And how do physicians approach these conversations with parents as we head back into the fall?

Dr. Carroll: Well, I do worry that our messaging in the way that we're talking about this is not working and the fact that something that—

Unger: That seems to be a theme of this entire pandemic.

Dr. Carroll: Yes, the entire time. We talked about it before. But the fact that only about 5% of parents have vaccinated their 6-month and 5-year-olds and the fact that something like only 30% of 6- to 11-year-olds are completely vaccinated really shows that the message is not getting across. Parents are not feeling that this is something that needs to happen.

Pediatricians are generally usually—and family physicians are usually very good about convincing people that vaccinating kids is important. I'm not sure how well we're doing that. I'm not sure also that it's happening as fast as we like because if people are waiting for their well care visit to get the vaccines, of course, that will take time.

But you're right in that it was thought that this would be a game changer. It clearly hasn't been given that parents are not rushing to get this done. A lot of them are waiting to see what happens. And some of them are saying, "My kids have already had COVID and it wasn't such a big deal. Why should I bother?" I also see a lot of news that compares this to flu and saying that it's much more dangerous than flu. I worry that that comparison doesn't really work because we have a tough time convincing people to get immunized against flu as well.

So we've got to get better at this. We have to get better at explaining why immunization is good for everyone, not just those who get immunized, that achieving very high levels of immunity even amongst young patient populations will help to slow the spread of the disease period.

Unger: What do you say to parents who say, "Hey, my kid had COVID, and it didn't seem to be that bad?"

Dr. Carroll: I talk about the fact that it probably isn't that risky for them comparatively. But they probably have loved ones for whom it is much more risky. It could be grandparents, that could be people who are ill or immunocompromised. It could just be even other friends because, of course, if lots of people get it, bad outcomes become more common. But a lot of pediatric immunization is about protecting everyone against very minor diseases.

Even when we started with varicella vaccinations, we had to talk about these same issues because a lot of people thought chicken pox is a nothing-burger problem. Why should I worry about it? But some number of babies died every year of chicken pox and adults were at serious risk too, especially the elderly. And since we've started immunization the number of babies who've died of varicella has dramatically decreased. And that's because sometimes we get vaccinated to protect others who can't protect themselves. That's the kind of message I think we need to lean on.

Unger: Well, that's a great message and especially right now because we're in the midst of a highly contagious variant. We're still seeing according to Andrea Garcia—we talked with yesterday—120,000-plus cases a day. You recently said you were concerned but not worried about the BA.5 strain. What's that mean?

Dr. Carroll: So I'm concerned by the fact that new variants keep popping up and that they cause subsequent waves or surges depending upon how you look. But this feels more like a wave than a surge in the sense that it's not causing a dramatic increase in really bad outcomes—hospitalization, death or significant illness. And because of that, some protection from Omicron seems to be continuing with respect to BA.5. It's not as if it's a completely new variant, which is overwhelming everything and causing diseases if we had no immunity to begin with.

So yeah, I'm concerned because clearly, we're in the midst of a wave and we're seeing increases in cases. But most of those appear to be mild, and people do seem to carry some protection from immunization and from previous infection. And so we're lucky in the sense that this is not an incredibly bad variant, which is causing, again, a massive surge.

Unger: Especially for those that have been vaccinated and boosted. I know as formerly a parent that used to have kids in school, September was like the time when I caught my first cold of the year because who knows what kids bring back from school? It must be very important also for those parents who haven't had that booster to get it.

Dr. Carroll: Yep, anyone—I mean, at this point, anyone who is up for a booster should get one. And it does appear that immunity wanes. And it wanes especially for getting an infection. It appears that still there's pretty significant benefits with respect to preventing significant morbidity and mortality. But infections do occur and immunity does wane. So if you had your booster in 2022 and you qualify, it's probably worth getting one.

On the other hand, we know that more Omicron-specific boosters are coming out in September. And given that we are a month away from that, it's not unreasonable, I think, for people that are waiting for those specific boosters to do so.

Unger: Well, let's talk a little bit about testing. I've been to some events over the past few months and despite how the request to test before you depart, when you test on arrival, inevitably, in any kind of large group, somebody is going to—say, in the next day, I got COVID. So testing is still so, so important. And we think about kids going back and be around hundreds of other kids. Having that process in place for parents and students can be so important.

You talked about your own family's bout with COVID, which not unlike what I've heard from a lot of people, is you test negative. You're starting to feel symptoms. And then finally, you test positive. Whereas a lot of people think, I took a test and done with that. It said I was negative. Like, how do you talk about how to test with people?

Dr. Carroll: Well, it's important to understand as with all tests—and I mean, physicians understand this—tests are not perfect, and tests help us take pretest probabilities and convert them into posttest probabilities. But if your pretest probability is already really high, the test only adds so much. So in my instance, my wife and daughter had COVID. I was living in that house. And I started to get a sore throat and not feel great. I was pretty sure I had COVID. And even though the antigen test was negative the first two days I checked, I was pretty sure I had COVID. And on day three, I tested positive.

Antigen tests are probably a pretty good approximation of whether you're infectious but not necessarily whether you're infected. PCR tests might be better at that. I mean, they each have their value. But I do worry that too many people don't test when they're symptomatic at all. But even if they do, they use antigen testing as a one-time check. And if it's negative, assume that, oh, this illness, even if it gets worse and my symptoms worsen, I don't have COVID. I'm safe to go out.

We probably need to serially check with antigen tests, especially when pretest probability is reasonably high. That messaging is not getting out. I think people think that, again, testing is a one-time check. And if I'm negative, I'm good. If you've been around a lot of other people or been in contact with someone that has COVID and you've got symptoms, there's a fairly good chance you've got COVID.

Unger: And so this probably leads me to my next question, which is—so, obviously, you test positive. You stay home. How about in those cases where you probably have a good reason to believe you might be positive but haven't tested yet? What's the rule of thumb for telling people when they should stay home?

Dr. Carroll: I mean, I think if you've got symptoms that would be considered pretty indicative of COVID these days, whether it be sore throat, which seems to be more common with Omicron, or really feeling lousy or certainly fever, cough, I mean, I'd have a pretty low threshold for staying at home. Just the occasional runny nose or congestion—sometimes that's allergies. It's other things—I'd certainly test.

And if you were just recently around a lot of people, again, your pretest probability should be pretty high that you could have been exposed to COVID. But lots of us have small kids. And they get colds and everything else. And if it's a run-of-the-mill cold, then you're checking again and again and it appears to not be COVID and they're getting better, yeah, probably safe to go out into the world again. But as much as possible, we really want to stay away from other people or at least be safe and mask up if we're showing any kind of symptoms at all.

Unger: So in addition to the COVID part of this, you've also said that back to school is a good time to check in with kids and how they're doing. We know there's just terrible issues right now around mental health and teens. How do you advise parents to have that discussion?

Dr. Carroll: So one of the things is I hate when—I hate that people think it should be like a one-time check-in. I mean, ideally, it should be part of an ongoing conversation. Check in repeatedly. You should have many conversations with your kids about how they're doing, how they're feeling, how the world is going. People get nervous about it when it's a big deal because it hasn't happened in a while or because they think this is the time to do it.

As much as possible, make it routine. Don't make it a big deal. Check in on how your kids are doing, asking about their day, asking about how they're feeling. It's something we should be doing all of the time so that it doesn't—now, if you haven't done it a while, it's a good—it's a good time to start checking on anxiety, on fears, on concerns, how are they feeling, how are they sleeping, how are they getting along with their friends, how are they doing.

I mean, these are just all simple questions that could be slipped into the day. And we all know how hard it is to sometimes get information out of kids. But if it's routine, they're going to be better about it.

Unger: You can tell them, we're going to have that conversation but not that conversation.

Dr. Carroll: Well, yeah, of course, there's always that. But that conversation should also be all the time in routine. So yes, we shouldn't make these like one-time check-ins. They should become more of our regular conversations.

Unger: Well, in addition to COVID, obviously, big concerns out there about monkeypox. We haven't said or seen any widespread cases in children as yet or college campuses or any of that. But I have to imagine there's the potential for that in the fall. How are you at IU and colleagues that you know from across the country approaching this latest public health threat?

Dr. Carroll: Well, I mean, again, this is one of those words like we're very concerned. But I don't think panicking yet. First of all, it's a problem and we really are behind and I wish that we would get more on top of this and have more vaccination and everything else. But this is much more likely to be diagnosed in the clinical setting than it is in the outside world setting that COVID—I mean, COVID testing is everywhere. You go by them in retail stores. This is much more likely to be picked up in an office where somebody has a concerning rash or something.

So medical professionals are going to be much more involved. And then, of course, contact tracing and figuring out, especially if they're sexually transmission involved, it's going to be, again, much more clinically handled. So we're activating our student health centers more where we're recognizing that that's where testing is likely to occur, not off in some other area. The contact tracing is likely going to be performed by a combination of the actual public health system and clinical settings as opposed to trying to set up a whole different infrastructure that's going to do that.

And that this is going to be much more clinic focused in finding people, getting postexposure prophylaxis to those that need it. That our doctors and nurse practitioners, that our providers are going to be much more on the front line of this in the detection and then management than perhaps was happening with COVID where a lot of it was stay home and we'll handle it over there.

Unger: Are you talking to your incoming students or return?

Dr. Carroll: We're starting to—we already put stuff information up on websites. We're clearly going to have to have some information set up, what you would want to look for, what you would want to do. And, of course, we're most concerned about our congregate living settings where that's where close contact could happen that's not sexually oriented.

But this is—I don't think this is going to be as much of a problem as someone is infected has no idea and manages to spread it to large groups of people or some of whom don't know they have it and we get significant massive outbreaks that warrant large level quarantine. I think this is going to be handled more retail. But it's a concern. And it's certainly something that our college age students, especially if they're sexually active, are just much more at risk for.

So I would absolutely agree that a lot of colleges and universities are certainly focusing on this. But it's a slightly different approach than what we had to do with COVID.

Unger: OK, better to be armed with that information and on guard. Dr. Carroll, pleasure to talk to you again. We'll look forward to seeing you next year regardless of what situation we're in.

Dr. Carroll: Hopefully not talking about COVID. But we'll see.

Unger: All right, that's it for today's COVID-19 Update. We'll be back with another episode soon. In the meantime, for information on COVID-19, you can visit our resource center, ama-assn.org/COVID-19. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.