While it may seem like forever, the first cases of the deadly respiratory disease COVID-19 were identified less than five months ago, and states just over two months ago began widespread school closures to slow the spread of the new coronavirus that causes the disease.
That means education leaders are grappling with how to safely reopen schools in the coming months amid a still-evolving understanding of how the disease infects and affects children, and how best to prevent them from carrying it to others.
“If the idea is that we’re going to keep the schools closed until we have a vaccine, which is the most likely way that this pandemic will end, then conservatively, we’re talking about another 18 months at the earliest,” said Dimitri Christakis, a pediatrician and the director of the Center for Child Health, Behavior and Development at Seattle Children’s Hospital, in a city that weathered one of the earliest U.S. outbreaks, “but that would mean that kids would spend two years in a distance learning environment.
“Think about what that means for a 5-year-old or 6-year-old. Even a child from a well-to-do family is going to suffer detriments, but for low-income kids, the effects are going to be enormous and carry forward through the child’s entire life. So we can’t take a wait-and-see attitude.”
Here are a few questions to help education leaders think about the virus as they consider reopening school buildings.
1) How can the coronavirus affect your students?
Let’s back up a bit.
COVID-19 comes from a newly discovered coronavirus, part of a family of spiky, spherical-looking viruses also responsible for illnesses from the annoying common cold to the deadly severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Different members of the coronavirus family affect children differently.
Your common everyday cold viruses account for 17 percent of all outpatient respiratory infections among adolescents in the United States, and 6 percent of U.S. children hospitalized for serious lung infections. It’s still unknown how many children contracted the first SARS (COVID-19 is technically SARS-CoV-2) and the Middle East syndrome virus was not prevalent at all among children worldwide during a two-year global study.
Young people, and especially school-age children, seem to be more resistant than adults to the coronavirus that causes COVID-19. Fewer of them have caught the virus, and of those, more than a third have shown no symptoms. Studies have found children to be less likely than adults to show severe breathing problems, and more likely to show symptoms like fever, coughing, sneezing, and stomach upset, in line with other common childhood illnesses.
Only 3.6 percent of all U.S. coronavirus cases so far have been of those under age 18. Of the more than 98,000 Americans who had died from COVID-19 as of May 20, the Centers for Disease Control and Prevention estimates only 176 were younger than 25, including 10 infants through age 4; 14 children ages 5 to 14, and the rest ages 15 through 24. The Pediatric COVID-19 U.S. Case Registry at St. Jude Children’s Research Hospital, which has tracked more than 1,000 new COVID-19 cases among U.S. children this spring, found about 1 in 5 needed to be hospitalized, and none had died as of May 21.
Take all these studies with a grain of salt, though, because children overall have been significantly less likely to be tested for the novel coronavirus because they tend to show fewer and milder symptoms that can be mistaken for other common illnesses. They also have been less likely to be part of large-scale studies exploring COVID-19’s effects, which tend to focus on older and more vulnerable groups—though there is some evidence that black and Native American children and those with existing respiratory problems like asthma may be at higher risk of serious illness than other students.
“The exclusion of children from COVID-19 clinical trials is a tremendous lost opportunity to generate timely knowledge to guide treatment of pediatric populations,” argued Thomas Hwang, a pediatric researcher at Boston Children’s Hospital, Harvard Medical School. Hwang and his colleagues found that of 275 COVID-19 treatment studies started by early April, only 30 have included patients younger than 18. And as more time passes, researchers are discovering some children have longer-term complications from the virus.
2) Are children exposed to coronavirus likely to get a later disease, even if they don’t get sick immediately?
Earlier this month, health experts raised concerns about a severe and at times deadly immune reaction in children and young adults exposed to the coronavirus. Multisystem inflammatory syndrome in children, or MIS-C, has been likened to toxic shock syndrome, in that children’s immune systems seem to go into overdrive after being exposed to the virus.
In more than 200 cases across 20 U.S. states and other countries, children and young adults experienced high fever for several days, stomach pain and upset, red eyes and rashes, and swelling of the hands and feet, as well as the heart and other organs. Most did not have active COVID-19, but did test positive for antibodies to the virus, suggesting they had been exposed to the virus a few weeks before. Some researchers theorize that the same strengths in children’s immune systems that seem to make them less vulnerable to a COVID-19 infection can also make hyper-immune responses more likely.
At least three children have died from the inflammatory syndrome, but unlike COVID-19, MIS-C is treatable with steroids and antibody therapies if identified early and most children recover completely.
3) Can children spread COVID-19 even if they don’t get sick?
For common childhood illnesses like colds and flu, people become contagious around the same time they start to feel sick, making it more likely a sick student will stay home from school. But COVID-19 has spread so quickly in part because people become contagious up to five days before they feel sick, and more than 40 percent of infections have come from people who had no symptoms. Case studies of so-called “super spreaders” during the infection have found one person who is “shedding” virus particles can infect dozens of people in an indoor space like a restaurant or music hall. And a new, not-yet-peer-reviewed study in Germany suggests kids can shed just as much virus as adults.
“It’s very easy, for an epidemiologist, which I am myself, or an infectious disease expert, to say … it represents too much of a risk because kids could easily be a vector for disease or are a vector. We don’t know how big a vector, so let’s just keep the schools closed,” Christakis said. “That focuses only on the contagious part of this equation. But there’s so much more at stake that has to be taken into account. We need to have a broad array of the table analyzing what we know. And we by no means know everything to make the best-informed decision.”
It’s hard to tell how infectious children actually are compared with adults, because they haven’t had as much opportunity to spread the disease. A majority of children who tested positive for COVID-19 were living with someone who had the disease first. An analysis of 700 studies found children seemed to have lower rates of transmitting COVID-19 and were very rarely the first case in a new outbreak.
“One of the huge caveats in all this research is that children are the most isolated group in the population, because no one that is under the age of 15 is an essential worker, they’re not much out in the community. … So it’s a big black box right now,” said Erin Bromage, an associate biology professor at the University of Massachusetts Dartmouth who teaches on the ecology of infectious diseases.
An April study in China found children under 15 about a third less likely to contract the coronavirus than older people, but predicted that when schools open they would be exposed to three times as many people, putting them at the same risk as adults. Some children in France and South Korea have contracted COVID-19 since schools in those countries reopened, but it was not clear that all students in the outbreaks had actually gotten the virus at school.
In Australia, for example, officials tracked what happened to nine students and nine staff members who were confirmed to have COVID-19 and were exposed to other students and staff at 15 schools. While 735 students and 128 staff members came into close contact with the students while they were contagious, the researchers found only one elementary school student and one high school student may have contracted the virus from school. No teachers became ill from school.
Siouxsie Wiles, a microbiologist and expert on “superbug” diseases at the University of Auckland, told the Sydney Morning Herald that the cluster of infections could have been driven as much by parents gathering and chatting at drop-off and pick-up as by teachers and students passing the infection in class.
All that means school leaders and teachers will need to be alert to gatherings of parents, not just students, and act on even mild symptoms, according to Danielle Dooley of the National Children’s Hospital in Washington, D.C.
“Right now, there’s not even a baseline [of child infection rates]. If we want to reopen things, people have got to have access to testing that is coordinated and easily accessible if you start developing symptoms. So that you can know really rapidly if you have the disease and then can set quarantine,” she said.
Yet she noted that schools will still need to set up procedures for when and how often to test students, keeping in mind that a third of infected children may have no symptoms and at least 40 percent of COVID-19 infections have been found to come from carriers with no symptoms.
“There’s just a lot of questions that are unanswered about that, and I think you’d get into a lot of resource issues too, on whether all schools could actually do [ongoing testing],” Dooley said.
There have been no studies so far about how often and how widely schools would need to test students, either for a fever or for the virus itself, for such a screening to be effective, Dooley said. While some coronavirus tests now can return results in 15 minutes, they can only be run one at a time, making them impractical for schools to use on every student daily, but more useful to stop an emerging outbreak as students start to develop symptoms.
Bromage agreed, noting that schools will also need to push a massive culture change among parents: “We absolutely need to be keeping symptomatic kids out of school. That’s going to be a big one that parents need support on, to not give kids a dose of Tylenol to bring their fever down or a cough suppressant and send them to school sick. That’s about as bad as we possibly can do. Everybody needs to be on board with this, to understand that a child that is sick cannot be in school.”
4) How can schools limit infections?
Schools can be a hot spot for the coronavirus, but that seems to have less to do with how infectious children are and more to do with the structure of the schools themselves, which in many places have narrow travel spaces, inadequate ventilation, and crowded classrooms.
Why is that important in a school? Because it’s easy to think about the risk of shared objects and surfaces, which we can see students touch (or, in the case of the youngest, put into their mouths or noses). It’s harder to think about the air students and teachers sit in, breathe in, speak in—even when no one is sneezing or coughing.
Erin Bromage, a biology professor and comparative immunologist at the University of Massachusetts Dartmouth, noted that the risk of infection goes up the longer people sit and speak together in an indoor room, even if they are socially distanced. A single uncovered cough can spread viral particles across a room; Wiles, in New Zealand, noted that several prior outbreaks of COVID-19 were traced back to indoor areas that included loud talking or singing.
A sick student running around outside on the playground may be less likely to spread infection than that same student sitting in a classroom—particularly if he happens to be sitting near an air conditioner uptake vent.
“The data that does exist suggests that outdoors is much safer, certainly from a viral transmission standpoint, than indoors,” said William Massey, assistant professor for public health and human sciences at Oregon State University. “And if we think about the school environment, being outside on the playground, whether it be for recess or for outdoor class periods, is going to be a reduced risk as compared to being on the bus, sitting indoors in a classroom, touching the doors.”
That may run counter to plans in many districts to cut out recess or other outdoor times to limit potential virus transmission on equipment and prevent students from getting too close to each other. But the American Academy of Pediatrics recommended that careful hygiene practices, including regular handwashing and cleaning equipment, and mitigate the risk. And new research suggests time in the sun may be helpful for killing the virus on surfaces.
“If we deprived [students] of those things [like recess], we’re also depriving them of health and learning opportunities. And so I think we can get creative with solutions to minimize and mitigate transmission risk, but also ensure that we’re giving our children what they need,” Massey said.