With reopening well underway in some states — and reopening plans now taking shape in states that remain locked down — America’s harried, anxious parents are suddenly being asked to consider whether they feel comfortable sending their children back to school.
Late last month, President Trump told governors to “seriously consider” and “maybe get going on” school openings “because a lot of people are wanting to have [them]” and “young children have done very well in this disaster that we’ve all gone through.”
Then on Wednesday, Trump reiterated his belief that schools should reopen after Dr. Anthony Fauci, the nation’s top infectious disease expert, cautioned the Senate about the unknown effects the coronavirus has on juveniles in light of recent reports about a multisystem, COVID-triggered inflammatory disease that has killed three children.
“They should open the schools, absolutely,” Trump told reporters. “I was surprised by his answer. To me it’s not an acceptable answer, especially when it comes to schools.”
“Now where you have an incident, one out of a million, one out of 500,000, will something happen? Perhaps,” the president continued, referring to the rare yet tragic complication. “But, you know, you can be driving to school and some bad things can happen too. We’re going to open our country. We want it open.”
Trump is probably right that cases of the Kawasaki-like disease are too few and far between — for now — to change most policymakers’ minds about the safety of returning to school. He is also right that children have “done” better than adults overall: Confirmed COVID-19 cases among minors are uncommon (2 percent of the U.S. total) and significantly less likely to be severe. As of May 6, there were 10 deaths in children 14 and younger and 48 deaths in those between the ages of 15 and 24 — though some early research suggests that asymptomatic coronavirus infections might be more prevalent among children than the confirmed case count would indicate.
Either way, reopening schools would not only help kids start learning — and, in many poor districts, eating — again. It would also help parents get back to work. Other countries and regions, including Australia, Hong Kong, Japan, Taiwan, Germany, Denmark, France and Belgium, are already doing it.
As a result, administrators nationwide have been contacting families and asking for feedback. “We are exploring opening our doors to a reduced number of students on July 1st, with new protocols in place to minimize health risks,” one California preschool emailed earlier this month. “We’d like to gauge from the community who among you would be interested in returning on July 1st ... PLEASE EMAIL ASAP to let us know.”
The immediate, instinctive answer — as any preschool parent will attest — is a resounding yes. Working from home while caring for young, cooped-up children is somewhere between challenging and maddening.
But the real risk of sending kids back to school isn’t to the kids themselves. It’s to everybody else. What parents are actually being asked to assess when administrators request “feedback” on reopening is whether that risk — the risk that children will wind up spreading the coronavirus to teachers, parents, grandparents and beyond — is one they’re willing to take.
In other words: What role do children play in the pandemic? Do they pass the pathogen to adults and continue the chain of transmission?
The trouble for parents is that even the experts don’t seem to know the answer to that question.
Consider two headlines from the last week or so.
“New Studies Add to Evidence that Children May Transmit the Coronavirus: Experts said the new data suggest that cases could soar in many U.S. communities if schools reopen soon” — New York Times, May 5
“Coronavirus: Reopening of schools ‘unlikely to cause huge problems,’ disease expert says” — Yahoo News U.K., May 13
It’s almost impossible to reconcile those claims. Both cite experts. Both are current. One says “cases could soar” if schools reopen. The other says they won’t.
So what does the actual data say?
Like so much else with COVID-19, it’s complicated. The Yahoo News U.K. report leads with remarks by Matt Keeling, a professor of populations and disease at the University of Warwick, who told the outlet that because “children are not suffering substantially from this pandemic,” any “phased opening of school is unlikely to cause huge problems.”
Keeling’s remarks were a response to a brand-new summary of the international evidence on immunity and the spread of the coronavirus by children published Wednesday by the U.K.’s Health Information and Quality Authority (HIQA), which claims that “children are not, to date, substantially contributing to the household transmission of SARS-CoV-2.”
And the HIQA summary is based, in turn, on seven international studies: “five that investigated intra-familial and close contact transmission, one that examined transmission of SARS-CoV-2 in schools and one that was a mathematical modelling study estimating age-specific transmissibility of SARS-CoV-2.”
None of these studies found substantial household or school transmission. A case series of 10 young patients admitted to children’s hospitals in China found one 3-month-old infant who may have infected both parents. A similar study of 74 children with COVID-19 admitted to two hospitals in China reported no evidence that the virus was transmitted from these 74 children to others. A Chinese analysis of public health data on roughly 1,000 patients reported no cases of infection by an “index patient” 15 or younger and only three cases of infection by someone under 18. An investigation of a cluster of cases in the French Alps followed one infected child who visited three schools and attended one ski class while symptomatic; ultimately, researchers tested 73 of the child’s 173 identified contacts and found one additional case of COVID-19. An Australian report released on April 26 examined the spread of SARS-CoV-2 from 18 confirmed cases (nine students and nine staff) to 863 close contacts (735 students and 128 staff) in 15 schools. It found one child who was likely infected by a peer and another who was likely infected by a teacher. Finally, a Chinese modeling study estimating age-specific transmissibility concluded that SARS-CoV-2 has “high transmissibility among adults aged 25 years or older, but low transmissibility among children … younger than 14 years.”
So far, so good. The problem, however, is that the HIQA summary also characterized five of these studies as “low to moderate quality”; the other two, it noted, had not been peer-reviewed.
What’s more, HIQA didn’t include all the relevant research in its report. Some of that work supports the U.K. agency’s takeaway that children are not “substantially contributing” to transmission; researchers in Norway and Iceland, for instance, were able to find only “five documented cases of likely spread of disease from children.”
But other research lends support to the New York Times’ far less sanguine conclusion. The first study cited by the Times (and not by HIQA) was published April 29 in the journal Science. In it, an international team analyzed data from two cities in China — Wuhan, where the virus first emerged, and Shanghai — and found that children were about a third as susceptible to coronavirus infection as adults were. But they also found that when schools were open, children had “about three times as many contacts as adults, and three times as many opportunities to become infected, essentially evening out their risk.”
Based on their data, the researchers estimated that closing schools is not enough to halt an outbreak, but it can “reduce the surge by about 40 to 60 percent and slow the epidemic’s course.”
“My simulation shows that yes, if you reopen the schools, you’ll see a big increase in the reproduction number, which is exactly what you don’t want,” the team’s mathematical epidemiologist told the Times.
The second study cited by the Times was published earlier this month by Germany’s best-known virologist and coronavirus expert, Christian Drosten. His team tested 47 infected children between the ages of 1 and 11 — 15 had an underlying condition or were hospitalized; the rest were mostly free of symptoms — and found that the asymptomatic children harbored just as much virus as their symptomatic peers, or adults. In fact, sometimes their viral loads were higher.
“In this cloud of children, there are these few children that have a virus concentration that is sky-high,” Drosten concluded, noting that there is a significant body of work suggesting that a person’s viral load tracks closely with their infectiousness. “So I’m a bit reluctant to happily recommend to politicians that we can now reopen day cares and schools.”
And so for American parents — and policymakers — the right response is probably to wait and see. All of the existing (and conflicting) studies on kids and transmissibility are small-scale and preliminary. With testing still anything but universal here — and with children usually showing mild symptoms, or no symptoms at all — determining which kids are infected is hard enough; determining which kids may be spreading the virus would be even harder. In Germany, students are already self-administering tests in schoolyards. The U.S. is a long way from being able to do that.
It may be that asymptomatic kids pass the pathogen to teachers and relatives without anyone ever knowing; the Robert Koch Institute of public health, Germany’s equivalent of the Centers for Disease Control and Prevention, recently found that children get infected in roughly equal proportions to adults, even if they don’t show signs of sickness.
Hopefully, a new study by the National Institutes of Health will help answer some of these questions. The project, called HEROS, has already started to enroll participants; ultimately, it will follow 6,000 people from 2,000 families and collect information on which children get infected with the virus and whether they pass it on to other family members.
Until those results are released, Americans would do well to remember the remarks Fauci delivered Tuesday before the Senate — the same remarks Trump later objected to.
“We really better be very careful, particularly when it comes to children,” Fauci said in response to Sen. Rand Paul, who called keeping schools closed “a huge mistake.”
“You’re right in the numbers that children in general do much, much better,” Fauci added. “But I am very careful and hopefully humble in knowing that I don’t know everything about this disease. And that’s why I’m very reserved in making broad predictions.”
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