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

In today’s COVID-19 Update, AMA Chief Experience Officer Todd Unger discusses Halloween and assessing risk heading into the holiday season with Aaron Carroll, MD, MS, a professor of pediatrics and chief health officer at Indiana University.

Learn more at the AMA COVID-19 resource center.

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  • Aaron Carroll, MD, MS, chief health officer, Indiana University

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Unger: Hello, this is the American Medical Association's COVID-19 Update. Hey, we're coming up on Halloween and that's what we're going to talk about today with Dr. Aaron Carroll, 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, thank you for coming again today. The last time you joined us, we discussed minimizing the risk over spring break, somewhat of a different holiday than we're facing this time. Now that we're coming up on Halloween and the holiday season, we're interested in finding out more about ... especially younger children who are still not vaccinated. Start by talking about how we should be thinking about activities like trick or treating this weekend. Any strategies for making this less risky?

Dr. Carroll: Well, I think I wrote a year ago and it's certainly even more true now. If I had to design something that would be safe to do during COVID, it seems like outdoor trick or treating ... it would be hard to beat. We're outside, which is already pretty safe. We're traveling in small groups together, which is usually pretty safe. There's no reason if you wanted to wear a mask, you couldn't since so many Halloween costumes involved masking anyway. You don't have to spend 15 minutes at each door, it's a quick in and out. And you can minimize contact as much as possible. So it should be a pretty safe thing to do.

Unger: So this is just a pandemic designed holiday. I never thought about the masking part but kind of built right in.

Dr. Carroll: Yeah. And I mean, I think the biggest thing to stress is, it's outdoors. And that has generally been really safe. Transmissions that take place outdoors, especially between asymptomatic people are very, very rare. Kids, in general, you'd know if they were sick and there just doesn't seem to be a lot of danger with that kind of activity.

Unger: Do we need to be worrying about wearing a mask under our mask?

Dr. Carroll: Well, again, it's an outdoor activity. If parents are vaccinated and I hope they all are. And other adults that are coming into contact with are vaccinated, I hope they all are. And people are in general, not doing trick or treating if they are symptomatic or ill. Again, the risk is pretty minimal. If people wanted to be extra safe, there's no real harm in adding a mask to their costume. But again, it's an outdoor, pretty transient and touch activity, it probably isn't totally necessary for a lot of people.

Unger: So I'm assuming apple bobbing, probably not a good idea.

Dr. Carroll: Well, I've never thought apple bobbing was a good idea, even pre-pandemic. So, no, it's not terribly hygienic or a good way to prevent transmissible illness.

Unger: I agree. So we're entering this whirlwind holiday season with the kickoff in Halloween and soon on its heels, will be Thanksgiving. So let's talk a little bit about what we're going to be looking at in the upcoming holiday season, especially for parties. How do we minimize risk but still be able to enjoy seeing each other in person, friends, family?

Dr. Carroll: So the good news is that in most of the country, cases are actually decreasing now. And hopefully that will continue through Thanksgiving, making it a much safer time than it might have been a month or two ago. Of course, it's not the travel per se that's dangerous. It's often what we do when we do travel. If you are traveling to go see a limited number of family members who are all vaccinated and being pretty safe and you plan to spend most of your time indoors together in the house or just amongst yourselves, that's pretty safe. On the other hand, if you're traveling to go to a massive convention or an indoor concert with tons of unvaccinated party, that's not safe.

So I think people get very concerned about the travel when it's really still, what are we doing on a daily basis? When you're traveling, of course, cars are very safe. But even if you're flying, airplanes are pretty safe. Air circulation is great. The biggest concern are those who are directly around you, but if you mask, wear a good mask if you want, a surgical mask is better than a cloth mask, KN95 might be better than that. Wear the best mask you can, don't eat or drink if you want to avoid it, keep clean, avoid other people. Certainly don't travel if you're ill, all of that should be pretty safe. And then again, once you get there, if you're engaging the same kind of behaviors that are pretty safe, that you would at home, that'd be pretty safe to do even on Thanksgiving.

Unger: Now, I'm curious because you've used the word safe a number of times in here. But I think in the past you've said this idea of safe versus unsafe, maybe that's not the best way to frame it. What do you mean by that?

Dr. Carroll: I think ... hopefully I've been saying pretty safe because I like to put the qualifier in there. Because I agree with you, it's not a binary, this is okay and this is not okay. Safety is a spectrum. And our goal is to maximize safety as much as possible. So again, car is probably safer than plane with respect to COVID, certainly not just in general. Spending time in small groups with all vaccinated people is definitely safer than spending time in large groups of unvaccinated people. Wearing a mask indoors is safer than not, testing perhaps right before you travel is probably safer than not.

But your goal is never perfection, it's not attainable. It's to be as safe as possible while also measuring the risk in an area. If we're at a place where COVID is not nearly as prevalent as it is now, where most people are vaccinated, where perhaps you've engaged in some testing and you're being careful, that's pretty safe. Is it a 100% guarantee and like safe? No, nothing is.

Unger: Yeah.

Dr. Carroll: But it's pretty safe and it's something I would engage in.

Unger: So for a fully vaccinated family, would this perhaps be the most normal possible Thanksgiving that we've had in a couple years?

Dr. Carroll: Oh, absolutely. I think that it's hard to underestimate the impact of the vaccine. They have made things much, much, much safer. And if you happen to be in a family where everyone is lucky enough to be vaccinated, that's really pretty safe. And even if you have a few small children who are not yet vaccinated, as long as you're being very careful and you could even consider some antigen testing right before you go, that is also pretty safe. The vaccines work and we should acknowledge that. And it should make this Thanksgiving much, much safer for many people than it was last year.

Unger: I'll tell you what, I'm very thankful for that vaccine. Is there a way for physicians to communicate the level of risk to patients and concern parents in a way that is easier to understand? Especially because the risk has fluctuated throughout the pandemic and there continues to be a lot of uncertainty.

Dr. Carroll: I think trying to explain how things get safer or less safe works a lot better than trying to just use, again, the blanket binary term.

I think too many people are waiting for the stoplight to turn from red to green and they think everything just goes back to normal. That's unlikely to happen. And moreover, if you're waiting for that, it could be a long way away.

But things do get safer. And when they do get safer, it's possible to do more. And when they get more dangerous, perhaps you reign it in a little bit. And helping people to understand the gradations and perhaps this is a time when you could do more, and this is what more might look like. And this is a time when you got to be a little bit more careful. Would help more people to adjust than to say nothing until it's all okay. But unfortunately, that feels like the way many people are handling it.

Unger: Well, we're closing in on the EUA for the Pfizer vaccine for kids age five to 11. That could have some kids fully vaccinated by the holiday season. As a pediatrician, you communicate with parents about immunizations and obviously address a lot of misinformation that's out there. Do you expect pushback from parents about the vaccine or vaccinating their kids? And if so, how would you suggest that pediatricians address that?

Dr. Carroll: I totally expect pushback. One, because that's always been the case. When varicella vaccine was approved, we had to go through this. It's a nothing ... illness, why do I need to vaccinate my children against it? Natural immunity will be better. I mean, these same kind of arguments have always existed.

And I expect that pediatricians will hear them with COVID, especially since surveys are showing that something perhaps like one third of parents might rush out to get this, leaving a lot of people either waiting or absolutely, no. I think it's going to be hard to get many, many kids vaccinated. And so pediatricians will have to use the same playbook that they always do, talking about the overall benefits of vaccination and how it doesn't just benefit the children themselves but also loved ones at higher risk, grandparents, parents or grandparents with chronic conditions or who are immunocompromised or loved ones who might be in those situations. So there's a benefit not just to them but to those that they love.

And in the overall scheme of things, I think that the benefits far outweigh the risks even for small children. But it will take the usual thoughtful explaining and convincing that health care providers have to do all the time for their young patients and families. And luckily they're all skilled at this and experienced.

Unger: Well, interestingly, learning from experience over the past year, a big difference in the rollout for this age group is going to be having more pediatricians involved. In fact, the Biden administration has said that pediatricians are going to be tapped to play a bigger role in the distribution of this age group. Maybe moot but tell us why is that important?

Dr. Carroll: Well, for a bunch of reasons. First of all, just from a logistic standpoint, while we could line up a hundred adults in a line and keep jabbing them. That'd be very hard to do with children. Small children cry and the worst thing you can imagine was at the front of a line of a hundred kids, all of a sudden the first kid starts throwing a tantrum. It's a pandemonium, we can't have that. We need to have more scheduled, contained blocks in privacy to both talk about and give vaccines.

But the talking about it is also important. I think one of the mixed things that went on for the beginning of the pandemic and roll out of vaccines is that we're distributing them in the way that's not usual. People often get their vaccines from their physicians or health care providers. And that's how they do it. And especially childhood vaccines, which are most often given in a family physician or pediatrician office. And so employing those kinds of trusted voices and usual trusted mechanisms to both explain and distribute vaccines makes a ton of sense, especially for this population.

Unger: And especially, we see, again, people trust their doctors.

Dr. Carroll: Yep.

Unger: And so that's an exciting development for this.

Dr. Carroll: I agree.

Unger: We talked a little bit about misinformation before ... you spent a lot of time and effort over the course of this pandemic fighting misinformation. Any particular things that you've found to be most effective in reaching people?

Dr. Carroll: I think it's unfortunately small detail, retail work. It's trying to find out what the barrier is, what the specific bit of misinformation or disinformation it is. And then trying to find a trusted voice to deliver correction. We're all looking for a tweet or a quick TikTok video that'll somehow change everyone's mind and bring them around. That's not going to happen.

It takes thoughtful, long form communication and explaining and a level of trust to really start to change people's minds. And luckily, again, that's one thing physicians are very good at. Because they do have that trusted relationship and often the time and the relationship to bring it about and make behavior change. And so, again, I'm really excited that we're learning lessons and we're trying to change things as we increase the number of people who are eligible for vaccines. But I think in the long haul, the way we get this is to make use of more trusted voices.

Unger: Absolutely. Well, last question, Dr. Carroll, we head into Halloween and the rest of the holiday season. What is your number one thing that patients need to hear from their physicians right now?

Dr. Carroll: I just think, again, we cannot undersell the value of the vaccines. They make a huge difference. They make it less likely that people get infected. If they do get infected, they make it less likely they will get sick. It's how you not only protect yourself but it's how you protect others. And especially those who cannot protect themselves. Continuing to make that message known and continue the drum beat and keep pushing for as many, many people to get immunized as possible. That's how we'll really change things.

Unger: It is the present. That's good for you and everybody else around you.

Dr. Carroll: Yep.

Unger: Thank you so much, Dr. Carroll, for joining us today, it's always a pleasure to talk to you. That's it for today's COVID-19 Update. We'll be back soon with another segment. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. 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.

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