SCHOOLS across England and the US are about to reopen their doors to students who have been at home for months thanks to the coronavirus pandemic. What is the best way to keep children, and school staff and parents, safe?
Many of these schools closed towards the end of March as cases surged in both the UK and the US. Given how little we knew about the coronavirus at the time, closing schools was the right thing to do, say the researchers contacted by New Scientist.
But we have learned a lot about how the virus spreads and who is at the greatest risk since then. While many questions remain, keeping children out of school is likely to be more harmful to them, and to society, in the long run.
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Back in March, many decisions about the coronavirus were based on what was known about other respiratory viruses, like the flu. “Kids are the main sustainers of transmission of influenza,” says Benjamin Linas at Boston University. “But covid-19 is not influenza.”
Unlike with flu, children seem far less likely than adults to have symptomatic or severe cases of covid-19. In February, a found that only 1 per cent were in children under the age of 10 (JAMA, ). Similar trends have been seen in other countries since, including the US.
Children aren’t immune, and some do appear to develop a which can be fatal, but this seems to be extremely rare. In one recent study, Olivia Swann at the University of Edinburgh, UK, and her colleagues followed the outcomes of 627 young people under the age of 19 who had been admitted to UK hospitals with confirmed cases of covid-19. Six of the children died, all of whom had other conditions (BMJ, ). Half of the deaths were in very premature babies with heart problems and sepsis, for example.
“If we knew in March what we know now, I would say we shouldn’t have closed primary schools”
It isn’t clear why children seem to be less likely to get very sick with covid-19. “The theory – and it’s just a theory – is that, because children have had less exposure to coronaviruses, their immune systems may be less activated [by the coronavirus],” says Dimitri Christakis at Seattle Children’s Research Institute. Overreactions of adult immune systems – known as cytokine storms – are thought to be a common complication in severe covid-19 cases, and severe reactions are rare in children.
Children seem to be less likely to transmit the virus than adults, according to the data we have so far. While schools closed for most young people in England in March, they remained open for the children of key workers and those with special educational needs. In June, schools reopened for children aged 5 to 6, 10 to 11, and for older teens and those attending nursery. By the end of June, 1.6 million children were attending educational settings.
Only 70 of these children have tested positive for the virus, according to a (PHE). These cases tended to occur in areas experiencing high levels of the virus in the community, say the authors of the report.
There are also concerns that school staff members and children’s families might be put at risk when schools reopen. The PHE report identified 198 confirmed cases in school staff, one of whom was hospitalised. Over the period, one teacher died following an infection, but this person caught the virus from a household member, rather than in school, the report states.
Adult transmission
Evidence suggests that adults might be more likely to spread the virus than children, particularly younger children. A large study from South Korea, which traced the 59,073 contacts of 5706 people with covid-19, to others.
While such findings are far from conclusive – asymptomatic cases could still be missed, for example – it appears that adults are more likely to be spreading the virus in schools than young children. In England, seven outbreaks in which two or more people were infected occurred in early-years settings in June, and all were triggered by an adult staff member, according to the PHE report.
No one knows why young children might be less likely to spread the coronavirus, but there are many hypotheses. It might be because children are less likely to have severe symptoms. “Even when they’re symptomatic, they tend to expel less because they don’t sneeze or cough as vigorously,” says Christakis.
Others have suggested that height plays a role. In theory, any virus that is expelled by a small child is more likely than virus expelled by an adult to fall directly to the ground before coming into contact with another person.
Christakis is among a group of researchers who believe education settings for young children should have been the first to reopen. “If we knew [in March] what we know now, I would say we shouldn’t have closed primary schools,” he says.
“153
students contracted the virus in a reopened school in Jerusalem”
Before schools reopen, however, many epidemiologists believe it is key to have coronavirus cases in the community under control, and effective test, trace and isolate programmes in operation.
It takes between about eight and 10 days in the US to get a result from a coronavirus test, says Linas. Parents can’t be expected to keep their children home for up to two weeks every time they get a runny nose, he says. “The fifth time that happens, are you going to do it? I’m probably not, and I’m the infectious diseases doctor,” he says. “It’s going to be a major problem if we don’t have [rapid, accessible] testing.”
Without better testing, disruptions may be common. A UK government policy released on 28 August could require an entire year group in an English school to students test positive.
And community transmission should be kept low. There are no established criteria for how low, but low levels of transmission are generally considered to have been achieved when an area has fewer than 10 cases per 100,000 people, or when less than 5 per cent of those tested for the virus get a positive result. “There are several examples of countries that have reopened schools successfully, and I believe that nearly all the success stories are in countries that had low community prevalence when they opened,” says Julie Donohue at the University of Pittsburgh in Pennsylvania.
This might go some way to explaining why reopening schools has been something of a disaster in parts of the US. Some schools in Indiana were closed days after reopening as students and staff members tested positive for the coronavirus. Given that cases in the state were rising in August, this outcome was to be expected, says Linas. “If you look around the school, you’ll have the same transmission as you have outside in the community,” he says. “It was a mathematical certainty that that was going to happen.”
Controlling community spread isn’t enough to prevent school-based outbreaks, as cases in Jerusalem have shown. One school, which reopened in May following closure in March, experienced an outbreak that affected 153 students and 25 staff members, for example.
A lack of effective mitigation strategies might have contributed to this outbreak, says Donohue. School reopening requirements included improved hygiene, the wearing of face coverings and social distancing, but a heatwave led to schools dropping face covering requirements, and using continuous air conditioning, which has been linked to virus spread in other settings.
Norway, on the other hand, is often held up as a success story. There, schools were closed in March, but began to reopen a month later, under a range of mitigation strategies. Children were taught in cohorts of no more than 15 individuals, and encouraged to regularly wash their hands and maintain a 1-metre distance from each other. Outdoor activities and learning were encouraged.
These case studies only hint at what might help keep transmission of the virus in schools low. Based on what we have learned about how the virus spreads, it makes sense to teach children in small groups, where they are able to maintain a degree of distance and are exposed to fewer people. Without increased budgets and staffing, that may require children to spend only part of the day at school, leaving parents to find childcare for more of the day and potentially exposing the children to more people, which defeats the purpose.
Staggered arrival
It also makes sense to minimise the opportunity for crowds to form. That means staggering the arrival and departure times of students, and possibly allowing students to eat at their desks rather than in a busy cafeteria. Large halls can be utilised for socially distanced learning instead. Many schools are putting such measures in place.
“Those strategies can go beyond the walls of the school building into community spaces that are not necessarily being used right now, such as churches or public libraries or gymnasiums,” says Donohue.
Different strategies might be appropriate for different age groups. Home learning, mask-wearing and physical distancing will be more difficult for young children, but might help minimise the risk of virus spread in older pupils, for example (see “Should children wear face coverings in school?”).
Staff members who teach or work with older children could be provided with hospital-grade face masks, and potentially plexiglass shields, say researchers contacted by New Scientist. The problem is that it isn’t clear how effective any of these strategies may be to prevent transmission in schools.
Janet Sinsheimer at the University of California, Los Angeles, and her colleagues are one of several groups attempting to predict what might work best using mathematical models and computer simulations. The team assessed the impact of two broad types of strategy: to reduce the number of people each child interacts with on a daily basis, and to reduce the rate of transmission through strategies such as mask-wearing and distancing.
“Reducing class density has, in our models, a bigger impact,” says Sinsheimer. “But both policies can make a difference.”
“1.6 billion
Number of students affected by school closures globally”
Ideally, researchers would do randomised, controlled trials to learn what works, says Donohue. While the idea of experimenting in schools might not be popular, it is essentially already happening, she says. There are about 13,000 school districts in the US, each of which is developing its own guidance for schools. “There will be 13,000 approaches to these critically important decisions,” says Donohue. “There is already experimentation going on, it’s just not random – and we’re not necessarily learning from that.”
What is clear is that, even if the risks can be reduced, they will still exist. “There will not be a time in the foreseeable future that we will be able to say: there’s no covid-19 in this building,” says Linas.
Around the world, it is estimated that almost 1.6 billion children have been affected by school closures. Education isn’t all they have missed out on.
Many children from low-income families rely on school meals for food. Children with extra developmental needs are often provided with expert care that parents alone can’t reasonably be expected to provide. Many healthcare programmes are delivered through schools. And some 20 per cent of child abuse and neglect cases are reported by school officials in the US. “When schools don’t have eyes on kids, that’s going unreported and unaddressed,” says Donohue.
The impact of missed education could be lasting. “If a child is not reading at grade level by the third grade, they are four times less likely to graduate high school,” says Christakis. “And low-income children are six times less likely.”
Donohue points to past studies on the impact of school closures triggered by wars and teachers’ strikes. “We see the effects 30 years later, on children of all ages who miss school,” she says. “Even a couple of months of missed school can translate into a reduction in earnings of somewhere between 2 and 3 per cent.”
All of those contacted by New Scientist stressed that schools should prepare to make up for the lost months of education, offering more tuition as well as mental health support. Many suggested lengthening school terms, and keeping schools open during what would usually be holidays for the next year or so. “Otherwise we are doing a disservice to an entire generation of school children,” says Donohue.
“It starts with recognising that this is a real problem,” says Christakis. “Kids are paying a huge price. It’s not just that they are missing school, their lives are being significantly affected as well.”
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