The Safety of School Reopening

We are facing school opening again. It is time to re-examine the impact of school closure on the coronavirus pandemic. Have we learned anything from last time? Do we know anything new about the coronavirus which changes what we think about sending our children to school?  I would like to share with you the perspective of a few experts whose work I have been following:

  1. Do children catch coronavirus?

Yes, but less, and it is usually a mild case.  The current evidence suggests that if exposed to a sick close contact, children are half as likely as adults to catch coronavirus. If they do catch it, their likelihood of death or very severe illness is quite low.  It is similar to the risk of seasonal flu (~15 children die each year from flu in the UK, for example). Children under the age of 1 are at higher risk, as are children over the age of 15. There does seem to be a curve in which the older the child, the more adult-like experience of coronavirus they can have, so children over 10 are considered to be somewhat higher risk, but overall the risk is still generally low. https://www.medrxiv.org/content/10.1101/2020.05.20.20108126v2

  1. Do children transmit coronavirus?

Yes, but they are not the superspreaders.  Unlike flu and other respiratory diseases, kids are not the reservoir (meaning they do not acquire it the easiest nor spread it the most).  It has been very hard to study the impact of age on transmission for a few reasons:

First, there are so few known cases of children being the index case (i.e. the initial spreader). This may be because kids were kept at home or outdoors more during isolation, or maybe they are not contracting it as easily, or maybe because they are generally asymptomatic so do not get tested and found.

Second, kids tend to move in groups, so when a cluster of cases in children is found, they were usually exposed to the same index case and we cannot tell whether the kids all got it from same super-spreader or if they passed it between themselves. Similarly, within a family it is hard to know whether it was the adults or children who first contracted it and passed it on.  Even with all the noise, one thing we can say with relative certainty from the data is that children are not the super-spreaders. We can focus our efforts on policies for adults.  https://adc.bmj.com/content/archdischild/105/7/618.full.pdf

  1. Did re-opening schools the first time cause a pandemic spike?

No. Perhaps, dare I say, we can learn something from watching the controversial case that is Sweden. They never closed schools for children under 16. They did eventually close universities, encouraged social distancing and work from home, but they did it late, and it was their being behind the power-curve that caused such a bad first wave.  Once Sweden implemented the adult-centered measures above, the curve of their pandemic came down and mirrored other countries which implemented those measures.  We learn from that curve, very broadly, that closing schools is NOT NECESSARY to get control of the pandemic and bring numbers down.

Similarly, Denmark opened schools cautiously early in the pandemic, and nothing happened. No explosion of cases. Same pattern in the Netherlands, Switzerland, no surge off the back of school reopening.  With regard to Israel’s school re-opening, I extrapolate from these data that it was the rushed reopening of stores, events, etc. which caused the second wave. Since this occurred at the same time as school reopening, they are difficult to separate, but I think that it is clear that countries do not HAVE to close schools to suppress transmission, and opening schools does not necessarily mean we will propagate a second wave. Faust SN, Munro APS. It’s Time to Put Children and Young People First During the Global COVID-19 Pandemic. JAMA Pediatr. Published online September 25, 2020. doi:10.1001/jamapediatrics.2020.4582 (firewall). https://www.theatlantic.com/ideas/archive/2020/10/schools-arent-superspreaders/616669/

What do we gain by closing schools? How many lives do we save? Vs What do we lose?

It appears that for most people there is little increased risk from reopening schools. What is lost is long-term opportunities for our children’s growth and societal mobility and equality.  What is the added risk to an individual family?  For children in school, the risk of catching the virus and having severe disease is similar to catching the flu. This is a risk we generally accept.  For parents exposed by their school-aged children, the population data shows no explosion of cases from opening schools, so the risk is probably similar to the risk of our every-day adult exposures. For the vulnerable individuals in society – e.g. grandparents interacting with possibly asymptomatic schoolchildren – that risk may be somewhat higher and worth thinking about.

What is lost as a family and a society by keeping kids out of school? I think it is important to note that closing schools is not something that can be compensated by the government. If you close bars or stores, the government can assist with wage-loss, retraining and new opportunities. But the social and educational opportunities, especially for children from difficult backgrounds, cannot be replaced by zoom meetings. Lack of education widens the attainment gap – it impacts children’s future –people’s forever –which is a heavy price to pay for something we do not see changing the course of the pandemic.  Since the harms of closing schools are known, and benefits unclear, health-policy experts recommend that schools should be the last thing to close and the first thing to open. https://www.economist.com/leaders/2020/04/30/when-easing-lockdowns-governments-should-open-schools-first

  1. What are we trying to achieve as a country?

The problem is that in Israel we are not sure.  In order to figure out what level of disease is acceptable and which added risks to take as a country, Israel needs to articulate a philosophy or direction for what we are trying to achieve in managing the pandemic. For example, New Zealand wants NO virus. Given their global position, they can keep it out completely.  They will lock down a city to contact trace and stamp it out, then reopen, which is consistent with their goal.  Sweden has a different philosophy.  Their goal is to put in sustainable, livable measures that strike a balance which keeps the health system out of trouble, but allows individuals maximum choice and freedom.

The problem we have run into in Israel is that we have not formulated a strategy, so we are not exactly sure what an acceptable level looks like for us. Which policy responses to choose, or how long they should go on hinge on what we are trying to achieve.  Society fatigues from confusion, lack of shared purpose, and inexplicable and seemingly random rules. This in turn makes it hard to enforce even the important measures, especially as senior members of the government are caught violating the very policies that they promote. The goals of the country must come from the top experts and be clearly communicated with evidence-based and philosophically consistent policies.

  1. Thoughts as a parent.

I am still nervous about sending my child back.  On balance, I believe that the weight of the evidence shows that I can send my children back to school. It would certainly be easier for me to have the children in school, and I would like to believe that its better for them to be having a real educational experience. But I will say that the children seem to have benefited in unexpected ways from their time at home. They learned different sorts of things and strengthened family bonds.

Additionally despite the risk being low, I harbor fear. Fears which I believe are actually grounded in reality, of them becoming one of the thousands of children in the world who end up very sick from corona; of there being yet-unrecognized consequences of asymptomatic infection; of them passing it to my husband or myself or my parents and the stress which that will put on the family; or even simply of them being placed in isolation after exposure and the stress of kids not being able to leave the house for weeks. Times of risk make it feel right to keep the little ones close. While Israel should certainly reopen schools, I wonder on a personal level whether the risks of those unknowns are worth the trade-off of putting them in school.  https://www.cdc.gov/mmwr/volumes/69/wr/mm6937e4.htm

Many of these ideas are discussed in an interview on the Plenary Session Podcast by Dr Vinay Prasad, MD, MPH at UCSF with Dr Alasdair Munro, Pediatric Infectious Disease Specialist, Epidemiologist, and Professor at the Johns Hopkins Bloomberg School of Public Heath: https://podcasts.apple.com/us/podcast/3-15-covid-19-in-children-dr-alasdair-munro-pandemic/id1429998903

About the Author
Dr Roth is a US-trained family physician with specialties in research and global health. She made aliyah five years ago to Ra'anana, and is mother to four young children. Dr Roth currently practices both in Israel and to the US via telemedicine, and directs the Clinical Reasoning Course at Sackler Medical School (Tel Aviv University).
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