Germs in the Family: The Short- and Long-Term Consequences of Intra-Household Disease Spread

This paper studies the short- and long-term consequences of intra-household respiratory disease transmission from older to younger siblings in Danish families. The central research questions are: (1) how do respiratory illnesses spread from preschool-aged older siblings to younger infant siblings during the first year of life, and (2) how does respiratory disease exposure during infancy causally affect younger siblings’ long-term economic, human capital, and health outcomes?

The study uses population-level Danish administrative data covering 1,230,180 children from 37 birth cohorts (1981–2017), linking records from the National Patient Register, income and labor market registers, education registers, and psychiatric care registers. The identification strategy combines birth order variation in respiratory disease vulnerability with within-municipality variation in local respiratory disease prevalence among children aged 13–71 months. The authors construct a municipality-level disease exposure index—cumulative respiratory hospitalizations per 100 children aged 13–71 months in a child’s municipality over their first 12 months of life—and estimate the differential effect of this index on younger versus older siblings, controlling for municipality fixed effects, birth year-month fixed effects, and an extensive set of individual and family background characteristics.

The descriptive findings are stark: younger siblings have 2–3 times higher rates of hospitalization for acute respiratory conditions during their first year of life compared to older siblings at the same age, with the gap largest at ages two and three months. The gap is larger for winter births, shorter birth spacing, and when older siblings attend childcare centers—all patterns consistent with the older sibling serving as a disease vector.

On the causal estimates, moving from the 25th to the 75th percentile of the disease exposure index distribution increases the younger sibling’s acute respiratory hospitalizations in the first year of life by 0.023 (32.9 percent above the sample mean), with effects more than twice as large for exposure in the first six months compared to the second six months.

In the long run, an interquartile increase in first-year respiratory disease exposure reduces younger siblings’ wage earnings (conditional on employment) at ages 25–32 by 0.8 percent and total income by 0.8 percent, and reduces their income percentile rank by 0.3 percentage points. There is no significant effect on labor force participation at the extensive margin. Effects on earnings are approximately twice as large when exposure is measured in the first six months of life. These earnings effects are comparable in magnitude to those from a 10 percent reduction in birth weight or a 9 percent increase in ambient air pollution at birth, and correspond to roughly two-thirds of the adult earnings impact of in utero exposure to the 1918 Spanish Influenza. When the disease index interaction is included, the main birth order coefficient declines by approximately 70 percent, suggesting intra-household disease transmission is an important channel underlying the documented birth order earnings disadvantage.

Additional findings include: a 0.5 percentage point reduction in high school graduation and a 0.6 percentage point reduction in college graduation (interquartile effects); a 0.01 standard deviation penalty in ninth grade Danish test scores; a 20 percent increase (0.016 per hundred per year) in chronic respiratory hospitalizations at ages 16–26; and a 6.1 percent increase (0.5 additional visits per hundred per year) in psychiatric clinic visits at ages 16–26. Breastfeeding mitigates short-term effects, with 15 months of breastfeeding sufficient to entirely offset the elevated hospitalization risk.

Scope conditions: findings apply to second-born relative to first-born children in Danish sibling pairs with at least 11 months birth spacing; long-term estimates are net of parental compensatory responses and any immunity benefits, and thus represent lower bounds of the uncompensated biological impact of respiratory illness in infancy.

Q: What is the magnitude of the birth order gap in acute respiratory hospitalizations during infancy, and what patterns support an intra-household transmission mechanism? A: Younger siblings have 2–3 times higher hospitalization rates for acute respiratory conditions in the first year of life compared to older siblings at the same age, with the gap especially large at ages two and three months. The gap is larger for winter births (when respiratory viruses circulate more), for siblings with shorter birth spacing, and when the older sibling attends a childcare center. Hospitalizations for non-infectious digestive diseases and injuries show no analogous birth order differences, ruling out differential parental healthcare-seeking as an explanation.

Q: How is the disease exposure index constructed and what variation does it exploit? A: The index is the cumulative count of acute respiratory hospitalizations per 100 children aged 13–71 months in a child’s municipality over their first 12 months of life, with the older sibling excluded from the count when applicable. It exploits irregular spatial and temporal waves of respiratory viruses (such as RSV and influenza) across Danish municipalities. The interquartile range of this index captures meaningful variation in community disease burden faced by infants across different places and years.

Q: What is the first-stage relationship between the disease index and infant hospitalizations? A: Moving from the 25th to the 75th percentile of the disease index increases younger siblings’ acute respiratory hospitalizations in the first year of life by 0.023 (a 32.9 percent increase relative to the sample mean), while the effect on older siblings is substantially smaller. The interaction coefficient in the preferred specification implies that one additional hospitalization per 100 community children aged 13–71 months raises the younger sibling’s hospitalization count by 0.012 more than the older sibling’s. Effects are more than twice as large for exposure in the first compared to the second six months of life.

Q: What are the estimated long-term effects on adult earnings, and how do they compare to benchmarks in the literature? A: An interquartile increase in first-year respiratory disease exposure reduces younger siblings’ wage earnings at ages 25–32 by 0.8 percent and total income by 0.8 percent, with a 0.3 percentage point reduction in income percentile rank. These magnitudes are comparable to a 1 percent earnings reduction from a 10 percent birth weight reduction (Black et al., 2007), a 1 percent earnings reduction from a 9 percent increase in ambient air pollution (Isen et al., 2017b), and roughly two-thirds of the in utero Spanish Influenza effect (Almond, 2006).

Q: Does the birth order earnings disadvantage reflect intra-household disease transmission? A: When the interaction between birth order and the disease index is excluded, the regression finds a 1.9 percent birth order earnings disadvantage for second-born children (consistent with Black et al., 2005 range of 1.2–4.2 percent). When the interaction is included, the main birth order coefficient declines by approximately 70 percent, suggesting that disease transmission from older to younger siblings is an important channel driving the birth order earnings penalty.

Q: Are effects larger for exposure in the first versus second six months of life? A: Yes, consistently across all outcomes. The interaction coefficient for acute respiratory hospitalizations is more than twice as large when exposure is measured in the first versus second six months. Effects on wage earnings are approximately 60 percent larger for first-half exposure, and effects on income rank are two to three times larger. This is consistent with biomedical evidence that infants’ immune systems mature around six months when solid food introduction begins.

Q: What are the effects on educational outcomes? A: An interquartile increase in first-year respiratory disease exposure reduces the likelihood of high school graduation by 0.5 percentage points (0.6 percent at the sample mean) and college graduation by 0.6 percentage points (1.7 percent at the sample mean), with effects approximately 60 percent larger when measuring first-half exposure. A 0.01 standard deviation reduction in ninth grade Danish test scores is also found. A back-of-the-envelope calculation using Danish returns to schooling suggests the reduction in educational attainment can explain approximately half of the estimated earnings effect.

Q: What are the effects on chronic respiratory and mental health outcomes? A: An interquartile increase in first-year exposure increases chronic respiratory hospitalizations (asthma, COPD) at ages 16–26 by 0.016 per hundred per year (20 percent above the sample mean), with significant increases also apparent at ages one to two. For mental health, the same exposure is associated with 0.5 additional psychiatric clinic visits per hundred per year at ages 16–26 (6.1 percent above the sample mean), with effects becoming more significant in the early twenties. Effects on mental health from this paper are smaller than those estimated for more extreme fetal and early childhood shocks such as Ramadan exposure or maternal bereavement.

Q: What does the acute respiratory trajectory look like beyond infancy? A: Elevated acute respiratory hospitalizations persist at age one, then there is a reduction at ages two to three consistent with an immunity formation hypothesis, but this protective effect disappears by age four. There is no significant increase or decrease in acute respiratory hospitalizations at older ages, in contrast to the persistent increase found for chronic respiratory conditions.

Q: What heterogeneity is found in short-term effects? A: Effects on infant respiratory hospitalizations are larger for low birth weight children, for male infants (consistent with the fragile male hypothesis), for siblings with shorter birth spacing, and for sibling pairs where the older child attends childcare. The monotonic decline in effect size with increasing birth spacing is the opposite of what would be predicted if differential parental time investment were the main mechanism, supporting intra-household disease spread as the operative channel.

Q: What is the role of breastfeeding as a moderator? A: Using supplementary data on breastfeeding duration (covering 2009–2016, matched to 7.6 percent of the sample), the authors find that the impact of disease exposure on younger siblings’ infancy hospitalizations declines significantly with longer breastfeeding duration. A linear specification implies that 15 months of breastfeeding entirely offsets the elevated hospitalization risk from higher disease exposure. Second-born children breastfed for less than half a month are particularly vulnerable to acute respiratory infections.

Q: How do the authors validate the identifying assumption? A: Three validation exercises are used. First, results are robust to adding municipality-specific linear and quadratic trends and maternal fixed effects. Second, using family background characteristics as outcomes in the interaction regression, at most two of fourteen coefficients are significant in any specification, and all effect sizes are less than one percent of sample means. Third, using alternative disease indices based on non-infectious digestive diseases and injuries shows no differential effects for younger siblings, ruling out a parental healthcare-seeking confound.

Q: What are the policy implications? A: The authors highlight breastfeeding support policies (paid family leave, workplace lactation accommodations), RSV vaccination campaigns for pregnant women and monoclonal antibody prophylaxis for infants, sick pay regulations, and childcare attendance policies as levers to reduce infant respiratory disease burden. They argue that current cost-benefit evaluations of such policies likely undercount the long-term human capital and earnings benefits. The COVID-19 pandemic illustrates the mechanism: restrictions reduced RSV spread during 2020 potentially benefiting infants with older siblings, while the subsequent RSV surge in 2021–2022 may have exposed later cohorts to above-average disease burden.

Respiratory Disease Exposure Index: A municipality-level cumulative measure of acute respiratory hospitalizations per 100 children aged 13–71 months assigned to each child over their first 12 months of life (or first and second six months separately), designed to proxy for community respiratory disease burden faced by infants from slightly older children, with the child’s own older sibling excluded from the count.

Intra-Household Disease Transmission: The mechanism by which preschool-aged older siblings, exposed to respiratory viruses in group childcare settings, bring home those viruses and infect younger infant siblings who are in a vulnerable stage of immune and brain development, creating a within-family externality in health outcomes.

Differential Birth Order Effect (Identification): The quasi-experimental design exploits the interaction between birth order (younger siblings are more exposed to older siblings’ illnesses) and local disease prevalence variation to identify causal impacts, netting out the main effects of both birth order and local disease environment through municipality and birth year-month fixed effects.

Immunity Formation Hypothesis: The conjecture that early respiratory disease exposure may have a protective effect on later acute respiratory illness through immune system training; supported in the data by reduced acute hospitalizations at ages two to three, though this protection disappears by age four and does not prevent chronic respiratory disease development.

Dynamic Complementarities with Sibling Health Spillovers: An extension of the Cunha-Heckman framework: while standard models incorporate investment complementarities across time periods for a given child, this paper’s findings imply that sibling health spillovers create differential returns to early-life health investments by birth order, since disease asymmetries between older and younger siblings are not incorporated in existing theoretical models.

Net Long-Term Effects: The estimated long-run impacts incorporate not only the direct biological effects of respiratory illness on the younger sibling but also any parental compensatory responses and immunity benefits; thus they represent lower bounds of the uncompensated biological impact, as parental compensation would attenuate the measured sibling difference.