Returning Students to School Amid COVID-19

Jill Simons, MD on August 4, 2020

Recently the Department of Education hosted a webinar to discuss one of our nation’s most pressing issues: how we can safely get students back to school in the fall. It is all everyone is talking about right now, “What is going to happen with school this fall? What plans am I going to need to make? Is it safe?  

We all realize that we need to be a part of the solution and recognize that this will not be a one-size-fits-all plan. This is a grand, diverse country made up of children and families with many unique needs and circumstances. It should be our goal to have all children return to in-person education, whether that be public schools, private schools, or home school co-ops; and to do so safely.  

In order to make these decisions, it is critical to review the science and statistics of how COVID-19 has affected children thus far. Understanding the facts and what is at risk will allow us to make informed, confident decisions about school this fall. We can then better prepare our children for school that will be familiar, but different.   

Speaking as a pediatrician, my priority is children, but pediatricians like me recognize that you can’t care for children without the collaboration of families, schools, and communities. In addition, many people, such as teachers, bus drivers, and custodians, play vital roles in children’s education, and it is important to keep them safe as well. Making decisions that are best for children means we must also make decisions that are best for the people who care for them. 

There have been a very low number of cases of children with COVID-19. 

As of July 16, there have been 241,904 total cumulative child COVID-19 cases reported — 8% of all cases in the United States. Of all the children with COVID, about 2% need hospitalization.  Hospitalizations are most common among children less than one-year-old and those with underlying conditions.1

There has been a total of 66 pediatric deaths due to COVID-19 since the start of the pandemic.  To put this into perspective, Influenza killed 185 children in the U.S. last year.2

We know that while kids can get severely ill, most children with COVID-19 have symptoms that are milder than in adults. Kids can have fever, cough, runny nose, and sore throat. They can also have abdominal pain, diarrhea and vomiting, and very little respiratory symptom, which is a pattern we don’t see as much in adults with COVID. Children can be also be asymptomatic.

The number and severity of COVID-19 cases varies greatly depending on the state or region. This is why it is absolutely necessary to work closely with local health departments and officials when we discuss plans for in-person education.3

We must also consider the impact of a condition that can occur with children who get COVID-19 called Multisystem Inflammatory Syndrome in Children. While serious, it is extremely rare. As of July 15, only 342 cases have been reported in the U.S., causing 6 deaths.4   

The severity of COVID-19 is often less in cases involving children.

In addition to relatively low numbers of children having COVID-19, the other good news is that we are noticing that children, especially those under 10 years old, are not as likely as adults to become infected or transmit the disease. This is true even when the child is living with someone who has COVID-19. It is often revealed that the adult in the household is the one who spread to the child – or despite the entire family being exposed, only the adults became positive for COVID-19 and had symptoms.

We don’t know why children tend to have milder symptoms and seem to be infected at lower rates. Perhaps it is because children don’t have as severe of an infection and so they are not coughing as forcefully and not spreading as many viral particles. Another reason may have to do with receptors, called ACE-2 receptors, in our nose, that the virus attaches to. Studies have shown that children under 10 do not have as many of these receptors as adults.5  

Children are not super-spreaders for the virus causing COVID-19.

While other viruses, like influenza, are greatly spread by children, the spread of COVID-19 by children seems to be much less. We can look to other countries for more data; those that kept their schools open, or as they have started to re-open up their schools. 

Looking at Sweden and Finland, two very similar countries that chose to treat the pandemic very differently, we observe noteworthy results. On March 17, Finland closed its schools, but Sweden made the decision to keep them open. The incidence of COVID-19 among school aged children was approximately the same. This demonstrated that schools did not play a significant role in the spread. Another important revelation from this study is that the teachers had no greater risk of contracting COVID-19 than adults in other professions.6 

Another study from Australia studied 9 students and 9 staff who were infected with the virus. Those 18 people were spread across 15 schools and had close contact with about 900 others in the schools (735 students and 128 staff). Only two secondary infections resulted: one student in primary school (who was thought to be infected by a teacher), and one high school student potentially infected via exposure to two infected school mates.7  

There are many more studies and they are coming out almost weekly that are showing similarly low transmissions when children are involved.

There is a risk to not sending students back to school.

We’ve now reviewed some of the data about how COVID-19 affects children, the numbers of children infected, and how children do not seem to play a large role in the transmission of the infection. After looking at the risks of COVID-19, and, considering whether or not it is worth the risk to send children to school, let’s look at the other side—the risks of not sending kids to school. This is where we really take into account the “whole child” and everything, and everyone, that factors into the child and their wellbeing.  

We all know school is more than just a place for academic learning. Schools provide safe places to play, interact with other kids, exercise, sing, dance, and create. Many children also receive important health services such as diabetes and asthma management, eye screening and even glasses, physical therapy, occupational therapy, and speech therapy. Kids with learning disabilities further get the services they desperately need in order to learn. 

Schools also provide a significant amount of mental health services for children, and those services are needed now more than ever. We know that suicide is the second leading cause of death among 10-24-year-olds.8  

Schools provide nearly 30 million children with daily low cost or free lunch, in addition to providing breakfasts and other meals. It is estimated 1 in 7 children live in a food-insecure household, a number that is sure to have increased over the past few months.9 

Another way for children and their families to be more secure is for parents to be able to have a job. School provides a steady, reliable source of child-care that enables them to do so.  Remember, even if a family is able to find child-care for while they work, that does not mean that that caregiver will be able to also provide help with virtual education. And finally, while the technology for virtual learning can be great, there are still millions of children that don’t have access to the internet, or schools that don’t have the laptops or tablets that are needed to connect the teachers to their students.

In-person education should be the goal.

When looking at the big picture, it is becoming pretty clear to me that for a majority of children and their families, in-person education should be the goal. We must still provide virtual or low risk options for those children and families who need it, but we simply cannot abandon the most vulnerable children who rely on schools for much more than education. 

What does it look like to reopen schools safely? Again, this is not a one-size-fits-all solution and schools will need to work with local health authorities to determine the current needs and risks in the community. As the CDC guidelines recommend, schools are planning different scenarios, having in-person, virtual, and hybrid plans at the ready. This allows them to be nimble, react to changing conditions, as well as have options for at risk individual students and teachers. 

When in-person education is in place, by using layers of prevention and protection, the

risk of students and teachers getting and spreading the virus can be minimized significantly. Outbreaks, if and when they happen, can be localized and have a limited impact on the entire school.  

Here are just a few examples of the ideas that schools are planning and discussing:
  • Grouping kids into cohorts, or “pods” to minimize exposure. If there is a case of COVID-19, that student’s pod of classmates and teacher can be quarantined by switching to at home virtual learning, avoiding entire school closures.

  • Decreasing the number of students physically present in school each day by having half the students there Monday and Tuesday, disinfecting the school on Wednesday, then having the other half attend Thursday and Friday. This will be supplemented with virtual learning when students are not physically present.

  • Having kids stay put in classroom and teachers rotating between rooms.

  • Students staying in the classroom for lunch, rather than traveling to the cafeteria.

  • Increasing student time outside, even here in colder climates, getting fresh-air-breaks and movement can be a beneficial learning environment.

  • Students and teachers wearing masks.

  • Spacing desks six – or at a minimum three – feet apart, or putting up plexi-glass dividers

  • Working with families via temperature checks, encouraging staying home if ill, and communicating stay-at-home policies if a student or family member is ill or has been exposed to someone with COVID.

Our kids have a critical role in this massive team effort. It is important to talk to your children, in developmentally appropriate ways of course, about the pandemic, specifically how it relates to them, what it is and why we have to do these extra things. A few things to keep in mind: it is important to acknowledge with your children that this is not how we wish school was, but then focus on the positive; be glad we are able to be back at school and see our friends and teachers.  Explain that if we all work together, we will be able to be together again like before, that much sooner. Children are also naturally empathetic and tell them that by doing their part, they can help others who are at more risk of getting sick. There are many practical things too such as finding a mask that your child feels comfortable in, one that they pick out or help design; practicing wearing it, and how to safely take it off; and practicing social distancing.  

A solution will take innovation, vigor, and creativity.

Early in the pandemic, when the news was nothing but horrific scenes from Italy and of overcrowded hospitals, I remember feeling so overwhelmed with hopelessness. Then, we began seeing the U.S. brace for the spread, building huge hospitals seemingly overnight, mobilizing large naval hospital ships; hearing stories of private citizens sewing masks. Even my 90-year-old mother sewed masks. We began hearing daily reports about scientists, and companies researching, working day and night, racing to find treatments and a cure.  Companies went virtual. Breweries switched to making hand sanitizers. Restaurants fed health care workers. We picked up groceries and medicines for our elderly neighbors. We reinvented ourselves and it brought out the best of us.

It is this same vigor and courage that is needed now. Let’s be an example to our children of how we face challenges. Let’s put our creative minds and our spirit of ingenuity to work. Let’s all work together: students, families, teachers, schools, communities, local health departments, mayors, governors, and with the full resources from the federal government, lets make the return to school and do so safely, because we must. This is the time for us as Americans to work together, and with God’s grace, do what is best for the children of this great country. 

References

1.  Children and COVID-19: State-Level Data Report. A joint report issued by the AAP and the Children’s Hospital Association.  https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/

2.  CDC Weekly U.S. Influenza Surveillance Report. 2019-2020 Influenza Season Week 28, ending July 11, 2020. Influenza-Associated Pediatric Mortality. https://www.cdc.gov/flu/weekly/index.htm

3.  Children and COVID-19: State-Level Data Report. A joint report issued by the AAP and the Children’s Hospital Association. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/

4.  Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome (MIS-C).  Health Department- reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. July 15, 2020. https://www.cdc.gov/mis-c/cases/

5.  Bunyavanich S,Do A, Vicencio A. Nasal gene expression of angiotensin-converting enzyme 2 in child and adults. JAMA May 20, 2020 [Epub ahead of print]

6.  Covid-19 in School Children. A Comparison Between Finland and Sweden. Folkhälsomyndigheten. Public Health Agency of Sweden.
https://www.folkhalsomyndigheten.se/contentassets/c1b78bffbfde4a7899eb0d8ffdb57b09/covid-19-school-aged-children.pdf 

7.  National Centre for Immunisation Research and Surveillance. COVID-19 in schools – the experience in NSW. April 26, 2020. http://ncirs.org.au 

8.  National Institute of Mental Health. Mental Health Information. Statistics. https://www.nimh.nih.gov/health/statistics/suicide.shtml

9.  United States Department of Agriculture. Economic Research Service. National School Lunch Program.  https://www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/national-school-lunch-program/