Medicine to produce health must examine disease; and music, to create harmony must investigate discord. —Plutarch The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus is endemic and now joins a list of viruses such as respiratory syncytial, influenza, parainfluenza, and metapneumoviruses that complicates the lives of children. At the beginning of the pandemic health systems were overwhelmed and century old drastic public health measures including isolation and physical and social distancing were instituted (1). As bedside clinicians were cloaked in protective gear, treating patients, and learning in real time, epidemiologists and laboratory scientists were searching for associations aided by generous research funding and unprecedented sharing of data. This produced some of the most comprehensive science we have seen. Alongside these advances, confusion and fear fueled a tsunami of misinformation on social media (2). Public health measures relying on sound data served to decrease the burden and improve outcomes from disease while reducing the disparity between populations. In COVID-19, rapid evolution of the virus, changes, and introduction of therapies (from hydroxychloroquine/azithromycin to dexamethasone to monoclonal antibodies to tocilizumab/baricitinib), and supportive care measures have provided great challenges in deciphering true associations from confounding variables (3–6). Nonetheless, many epidemiologic evaluations have attempted to elucidate variant-to-variant, epoch-to-epoch differences in outcomes in critically ill children (7). These studies have also attempted to consider the impact of vaccination rates among children, prior exposure of virus for passive immunity, and the presence/absence of public health measures in order to trend the viruses’ impact upon pediatric critical care resources and patient outcomes. Understanding these trends, including comparisons to other viruses such as influenza, are important to inform risk assessment and advise public health measures including potential resource allocation. Early reports that children were relatively unaffected in COVID, and that the virus was “just the flu” by “social media experts” have been disproven (8–10). Children have demonstrated varying outcomes with acute COVID, multisystem inflammatory syndrome, and long-term COVID sequelae (11). The evolution of the original SARS-CoV-2 wave to Delta to the Omicron variant is accompanied by an apparent increase in contagiousness with concern that increased numbers of sick children could have worsened outcomes. Thus, understanding how the variant evolves, its virulence, and the outcomes of those afflicted is important for public health measures including the use of protective gear, the deployment of vaccinations, and the relevant preparation for delivery of acute care. In this issue of Pediatric Critical Care Medicine, Ross et al (12) compare two 3-week epochs (March 2020 and January 2022) to evaluate the clinical evolution of disease by predominant original strain to omicron in a multicenter, retrospective cohort study in North America. The group set out to further define characteristics of disease severity across these variants including rates of PICU admission, mechanical ventilation days, length of stay, and mortality. With a cohort of almost two hundred omicron patients compared with twenty-eight children with the original strain, the authors’ main findings are that younger children are more afflicted in the omicron cohort and that there is a seven-fold increase in PICU admissions. This finding contrasts to other studies that have compared the original to D614G to delta to omicron variant outcomes and subsequently shown that the PICU admission rate gradually decreased over these waves (from 31.0% to 17.8%) (13,14). However, the authors in the present study failed to identify “any” association between epoch period and baseline comorbidity profile. These findings are surprising because increases in mortality or need for mechanical ventilation were not seen. While the presence of better outcomes is gratifying, this report cannot answer whether less mortality and less need for endotracheal intubation reflects practice/policy changes in each of the nine PICU centers or may be due to the vaccination status of patients; regardless of the fact that the patients are younger (12). For instance, a lack of difference in endotracheal intubation between the epochs may be reflective of practice changes in intubation strategies, where less severe patients were intubated earlier in the pandemic with fear of aerosolization and spread to healthcare workers. The study by Ross et al (12) does not provide any data about “disease severity” or “risk of mortality” and hence cannot shed light on this issue. Finally, the authors do suggest that hospitalization rates may overestimate trends in virulence severity from disease, especially as routine universal hospital admission screening cannot differentiate whether SARS-CoV-2 is the cause for, or an incident finding of, the admission. This problem is inevitable with COVID-19 epidemiology because most estimates of the disease impact are biased by a combination of testing and attribution (determining who has disease vs incidental infection and indirect effects). Unlike in the first wave where the SARS-CoV-2 virus was the primary driver of morbidity, the more contagious omicron variant may only lead to an incidental positive test with another driver of morbidity, i.e., potentially respiratory syncytial virus, rhino enterovirus, or bacterial pneumonia in origin. These nuances cannot be explored because the study (12) is underpowered with inclusion of only twenty-eight subjects in the first wave and hence limits its ability to infer causal findings versus drawing loose associations between the epochs (6). The shift of disease from older children to younger children may simply be coincidental or related to the inability of thus under 5 years of age to receive vaccination? Pediatric COVID vaccination first became available to adolescents 12 through 15 years old in May 2021 followed by October 2021 for children 5 through 11 years old. These groups correlated with the delta variant and preceded evidence of omicron as the predominant circulating U.S. strain. Most interestingly, among persons 0–17 years old in Summer 2021, US COVID-19–related emergency department visits and hospital admissions occurred in the states with the lowest compared to those states with the highest vaccination rates (some 3.4 and 3.7 times greater, respectively) (15). Mask wearing commenced in the United States after May 2020 and likely waned as schools went back during the fall of 2021. Thus, both comparison populations likely were exposed to virus during two epochs where use of masks to prevent community spread measure were sporadically “used.” However, the main public health containment differences between the two epochs are the stay at home versus schooling in eligible students and the “presence or absence of vaccination” in the same cohort. Thus, the lack of difference in endotracheal intubation, mortality, and decreased severity of illness is an important finding as it may lend support of public health measures to improve vaccination rates, especially in younger children. Given that in both epochs that mask wearing was not mandatory, it questions if increased efforts to dialogue with the public for mask wearing should continue also? Increasing these efforts for improved vaccination rates may have more benefit and greater acceptance. As William Foege, the former director of the Centers for Disease Control and Prevention states: “The science on which public health decisions are based is epidemiology, or the study of the distribution of diseases, health problems, or risk factors in the population and action taken to alleviate those problems. The science of demography augments epidemiology and studying population problems.” Pandemics and their effects are not static, and hence continuous surveillance is extremely important to inform public health measures as well as investment in acute care and rehabilitation efforts. Thus, the study by Ross et al (12) is important, but in view of its limitations and the changing landscape of the virus, it is certainly not the last word. In the meantime, we should continue advocating for measures such as increased vaccinations and be resolute to continue advancing our knowledge in providing the highest clinical care and conducting the most rigorous research.