[This text has been written by Juliane Chaccour, immunologist and medical editor; Marta Valente, pediatrician at the Centro de Investigação em Saúde de Manhiça (CISM); and Carolyn Daher and Mònica Ubalde from the Urban Planning, Environment and Health Initiative at ISGlobal]
Closing schools has been a fundamental part of non-pharmaceutical interventions in response to epidemics of infectious disease because of the close contact among students that enables disease transmission. In April 2020, school closures affected 1.6 billion children globally. Considering the risks of a second wave of SARS-CoV-2 infections, their role in reducing transmission but also its impact on essential social and community services, needs to be critically assessed.
Children have more and closer social contact than adults and contribute more than adults to community transmission of seasonal respiratory infections, including influenza. However, the relative influence of children on the spread of the new virus is still under discussion. There exists a possibility that their relative influence is smaller because both children and adults are equally naïve to the new SARS-CoV-2, unlike in influenza epidemics, where adults are partially immune to seasonally circulating viruses and transmission is carried to a large part by school-aged children.
In April 2020, school closures affected 1.6 billion children globally
Evidence until now indicates that children and adolescents constitute the minority of cases and rarely develop severe disease. In Sweden, in the first two months of the pandemic and without social restrictions, COVID-19 accounted for only 0.7% of all pediatric admissions, most of those in infants under 12 months of age. CDC data on cases requiring intensive care, only 0.005% of children aged 0-9 who got infected had to be admitted to the ICU, compared to 2-3% of infected adults. Reports of an increased incidence of a Kawasaki-like disease and/or multisystem inflammatory syndrome in children emerged, but nevertheless referred to very rare events. The mortality risk for children also seems very low: In seven countries heavily affected by disease transmission, 44 children have died from SARS-CoV-2, whereas more than a hundred children have died from influenza in the same time frame.
Concerns, however, arise about whether children, once infected, are likely to pass the virus on to peers or adults. Virological studies indicate that symptomatic children and adults might have comparable viral loads but that asymptomatic carriers of the disease seem to have less viral RNA in their secretions. Data from contact tracing of pediatric patients suggest that sick children have rarely passed on the disease to peers or families. Apart from the previously mentioned immunological factors, their presumably small role in the transmission chain could be explained by the different symptomatology of children, lower expression levels of the viral receptor or by their more shielded position during social distancing.
Are school closures effective?
Models from different countries have shown a limited effectiveness of school closures on disease transmission and ICU bed occupancy. Also, an analysis with data from 20 countries concluded that school closures were among the least effective non-pharmaceutical interventions in the current pandemic. The Norwegian Institute of Public Health went so far as to report that school closures had seemed unnecessary in tackling the spread of COVID-19 in Norway, and Iceland is reassessing the restrictions on school functions in case of a second wave, given the available evidence.
An analysis with data from 20 countries concluded that school closures were among the least effective non-pharmaceutical interventions in the current pandemic
From a public health standpoint, schools offer ideal environments for instituting the desired rigid test-trace-isolate and vaccination strategies (including the seasonal flu vaccine) with minimal investment. Even though children enjoy more daily social contact than their parents, their social network is much more homogeneous, predictable and easily restricted. Thus, tracing and quarantining contacts of infected individuals are more workable in the controlled settings of educational centers. School staff, especially teachers, should be on the forefront of testing as they have been most implicated in disease transmission in school settings. In a survey of 687 child care centres in several US states that were kept open throughout, staff had six times the rate of infection than the attending children.
Numerous countries have already partially reopened schools. So far, none of these countries have experienced noteworthy increases in case numbers, although it is premature to fully understand impact. One of the first countries to reopen schools and kindergartens, Denmark published PCR prevalence data by profession around 10 weeks after the re-opening, which revealed that despite more frequent testing, teachers had below average infection rates.
Numerous countries have already partially reopened schools. So far, none of these countries have experienced noteworthy increases in case numbers, although it is premature to fully understand impact
Transmission outside household and healthcare settings has happened mainly in restaurants or bars, workplaces, music-related events, and gyms and yet, all of these have been opened in many countries before schools. Localized low-level outbreaks in those settings are increasingly being considered the “new normal”, while schools are being scrutinized to fulfil zero-risk conditions.
An electronic sign at the entrance to the Loyalsock Township High School and Middle School in Williamsport, PA, USA announces school closures due to COVID-19. Author: Brinacor / Wikimedia Commons.
How do school closures cause harm?
As part of an emergency response to the COVID-19 pandemic, global school closures were warranted without a doubt. As they continue though, they present an unprecedented risk to children’s social protection and wellbeing. Moreover, promoting and safeguarding every child’s right to education, as set out in the Convention on the Rights of the Child, should also be a priority during this pandemia.
Schools fulfill an important function as equalizers of social inequalities by covering different socioeconomic levels in neighborhoods. Access to resources and services to buffer the losses imposed by the restrictions are not borne equally among different groups in a non-inclusive digital learning scenario, exacerbating already existing inequalities. Deprived of face-to-face teaching, children incur a qualitative and quantitative loss of education, and children in disadvantaged families will suffer the impact of months-long interruption of normal life all the more severely, while being hidden from view entirely. Some children suffer harms to welfare, nutritional problems or disturbances in their social development from prolonged isolation. The increased unsupervised online presence of underage children also puts them at a risk of grooming and abuse. The American National Center for Missing and Exploited Children (NCMEC) has reported a 400% increase in abuse complaints in the month of April compared to the same month in 2019. The increase in social inequalities and other potential adverse consequences need to be taken into consideration to improve epidemiological surveillance and provide a fairer impact evaluation.
Schools fulfill an important function as equalizers of social inequalities by covering different socioeconomic levels in neighborhoods
Beyond the relationships and experiences related to its academic objectives, a school environment is of vital importance to promote the health and well-being of children. Schoolyards are open-air spaces that reduce stress, promote play and foster experimentation, creativity and critical skills in children. Schools are also important contact points for other social services such as meals, psychological support, health interventions such as dentists and vaccinations, enrichment activities and afterschool programming that have all been partially or entirely suspended as a consequence of the pandemic.
Interrupting education services also has serious, long-term consequences for economies and societies. As economies are gradually reopening, schools and kindergartens are envisaged to be operated at less than full capacity for many months and remain vulnerable to further interruptions due to preventative school closures as a response to localized outbreaks in other settings. The Institute for Economic Research in Germany, where schools opened in a phased approach in early May, reckons that school closures will cause the affected German children a lifelong income loss of 3-5%, and McKinsey estimates a long-term 0.8-1.3% reduction in US GDP as a direct consequence of interrupted in-person learning. Already, eight million Spanish families (1.7 million of those headed by only one parent) are struggling to combine childcare and professional responsibilities. Many families might opt to preserve the salary of the main earner, most often the man, while balancing childcare duties. This dynamic would risk reversing decades of gains in gender equality. Alternatively, some families may return to resort to grandparents as caretakers, which might expose this vulnerable age group to an increased risk of infection. Parents are disproportionately disadvantaged in their productivity while working from home, leading to income loss and increased stressors to mental health due to combining homeschooling, childcare, home duties and formal work. Respecting healthy routines for adults and children is a profound challenge under the current conditions, and families suffer from tension and conflicts brought about by the “new normal”, which in turn has repercussions on the treatment of children.
Author: Gajendra Bhati / Pexels
Time to be proactive
These reflections are being backed by pediatric societies like the British Royal College of Paediatrics and Child Health and the American Academy of Pediatrics which both issued statements supportive of in-person instructions. Contrasting outbreaks of Covid-19 in Israeli schools without prevention measures with relatively safe environments in Ireland, France, Singapore and Australia reminds us of the importance and feasibility of a measured and careful approach to school reopening. The return to schools and kindergartens must sensibly rely on enforced hygiene protocols and organizational changes that effectively reduce the size of children’s social networks but not the quality of their social interactions. Additional modifications such as changing protocols to increase ventilation and modifying schoolyard interactions are all possibilities that other countries are implementing and should be evaluated. Some places, like Denmark emphasize the benefits of the outdoor learning model by incorporating green areas as learning spaces while maintaining physical distancing to minimize risk of transmission. Schools should also encourage parents to let their children walk at least some of the way to school to avoid parent gatherings at the school gates.
Meanwhile, research on transmission of COVID-19 by children and in school environments needs to add to a solid evidence base informing future policies for different adaptation scenarios. This should encompass disciplines beyond virology and epidemiology to allow for a comprehensive analysis of the risks and benefits of interventions aimed at reducing disease transmission among children.
Research on transmission of COVID-19 by children and in school environments needs to add to a solid evidence base informing future policies for different adaptation scenarios
The economic, societal and health cost of marginalizing children is too high to delay gathering strong evidence supporting interventions targeted at interrupting transmission in children. Sidelining schools seems inconsistent with the available evidence and regrettable in the face of the significant negative impact it has on social, economic and health aspects. Basing continued or intermittent school closures on a perceived threat to the health of the community undermines the decision to give precedence to workplaces, bars, restaurants, fitness studios, and other public areas that are known to have contributed substantially to transmission and are frequented by adults at a higher risk of disease. Faced with a likely second wave of infections, we need to re-examine the priorities for a functional society and find proactive ways to make these priorities happen.
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