By Michael Ainscough, MD, MPH
We could probably all agree the most important factors are our children’s health and safety. Attending classes at school is important, but what are the risks?
Schools could open, but if parents don’t feel comfortable sending their children back then they won’t go. Some parents have already made the decision to homeschool their kids this fall. Some parents had enough of that last spring and plan to send their kids back to school, assuming they open.
As schools contemplate reopening amid rising COVID-19 cases across the southern states, an awkward truth is emerging: Adults are the problem, not our kids. A growing body of research suggests young children are unlikely to transmit COVID-19 virus. They get it from adults.
To assess the risks, this article discusses two questions: 1) to what extent do children catch the virus and 2) to what extent do they transmit it to others?
FDA Commissioner Dr. Scott Gottlieb said last week that the “data clearly shows children are less likely to become infected and less likely to transmit infection. But we need to recognize we don’t fully understand all the risks, and while kids are less vulnerable, less risk doesn’t mean no risk.” Few things in life are 100% risk free.
In an article for pediatric health care providers published in late May, the CDC wrote that 2% of confirmed coronavirus cases in the US were among people 18 years old or younger. From California data, children represent a small fraction of confirmed cases. About 1.8% of cases are in children younger than 5, and 6.5% of cases are in people aged 5 to 17. In contrast, 33% of cases are among people between the ages of 18 and 34 years. The remaining 59% of cases are older than 35 years.
Older children in high school start to have similar risk of infection as adults, although the risk of complications is still much lower than in the elderly or other vulnerable groups.
“Relatively few children with COVID-19 are hospitalized, and fewer children than adults experience fever, cough, or shortness of breath,” the CDC said, noting that “severe outcomes have been reported in children including COVID-19 associated deaths” and those hospitalized were most commonly infants and children with underlying conditions.
Most children don’t get as sick as adults, and serious complications are rare. CDC’s Director Redfield said “in general, this virus does not cause significant illness in children.” Recent cases of a rare but dangerous complication called multisystem inflammatory syndrome in children (MIS-C)” – with delayed symptoms such as fever, abdominal pain, vomiting and diarrhea – have been reported. A recent CDC review of 186 cases found that most cases of MIS-C were after the early severe outbreaks in New York, New Jersey, and Michigan.
Evidence from China, Europe, and the US has indicated that children tend to have milder cases. In a study published last week, researchers in China report that even among children hospitalized with confirmed COVID-19 infections, their illnesses were mild compared to adults’ experiences.
In that study, a research team documented the cases of 34 children, ages one month to 12 years, admitted in Jan and Feb 2020, to one of four hospitals in China. The patients, 14 boys and 20 girls, all had a confirmed infection. The most common symptoms were fever (76%) and cough (62%), and vomiting and diarrhea were each present in 12% of subjects.
On Thursday, the British medical journal Lancet estimated that 1.5% of children infected with the virus required Intensive Care Unit admission. Of the 78 children needing ICU care, 22% had pre-existing medical conditions that put them at risk.
For months we’ve kept children carefully isolated for fear of spread. We’ve assumed this new virus acted just like the flu and common cold – classrooms full of kids would be incubators for disease.
Dr. Anthony Fauci, Director of NIAID, said on June 30, “We don’t really know, exactly, what the efficiency of spread is” among children. There are no large American studies because our schools have been closed since March. But recent international research and reports suggest young children aren’t responsible for most COVID-19 transmission.
Based on recent findings, school-based transmission could be a manageable problem, particularly for elementary school aged-children who appear to be at the lowest risk of infection, according to a recent commentary in the Journal of Pediatrics.
“The evidence suggests that children are less likely to become infected, less likely to develop severe disease and less likely to transmit the virus to other children and adults,” said pediatrician Dr. William Raszka Jr. of the Univ. of Vermont School of Medicine.
If confirmed, this is good news for teachers, whose classrooms can feel like big Petri dishes. But still more data must be collected to prove that kids are not very good spreaders of the virus.
According to studies by Dr. Naomi Bardach at UCSF Dept. of Pediatrics, transmission in elementary school seems lower than in high schools. There’s limited data on middle-school and preschool children. Most importantly, “staff and teachers, as adults, are more likely to transmit it to each other,” she said.
The American Academy of Pediatrics, a traditionally conservative group of doctors – says that kids belong in school. While COVID-19 risk can never be eliminated, students should be “physically present in school” as much as possible, because there are known emotional, social and educational risks to keeping children at home.
As evidence that children are not the agents of spread, pediatricians point to large “contact tracing” data sets from around the world. They show that a household’s COVID-19 infection rarely starts with children. On the contrary, grownups bring it into the home. And children rarely share it with others.
A 9-year-old British boy contracted the virus at a chalet while skiing in the French Alps. But he did not pass it on, despite coming into contact with more than 170 other people, including his siblings and over 112 pals at three separate ski schools, according to a study by England’s Centre for Evidence-Based Medicine.
Of 68 sick Chinese children admitted to a children’s hospital, 96% were found to have been sickened at home by adults, researchers reported in July’s issue of the journal Pediatrics.
In an Australian high school, 863 pupils and teachers had close contact with 18 sick students and staffers — but just two, or 0.23%, became infected.
Swiss researchers analyzed data on 39 children younger than 16 and found that in nearly 80% of cases, the illness came from an adult in the house, according to a May study in the Journal Pediatrics.
Research from the Netherlands also found that the virus is mainly spread from adult family members to children.
It’s possible that we simply haven’t seen transmission among U.S. children because they’ve been stuck at home. But if children are driving the spread of the virus, we should have seen big spikes in countries where they’ve already returned to school, such as Germany and Denmark. We haven’t.
New York City’s YMCA emergency childcare centers have cared for 40,000 children between the ages of 1 and 14 at 1,100 separate sites and seen no clusters. Israel suffered a school outbreak, forcing closure, but it occurred in a high school. Hong Kong suspended schools last Friday, but it was largely pre-emptive because the city is experiencing a resurgence in cases.
Last week the CDC recommended that schools take measures that include spacing students’ desks six feet apart, staggering class times, isolating lunches, and teaching kids basic hygiene measures. The CDC also recommends that children 2-years-old and above wear masks in public when socially distancing is difficult. CDC guidance changes nearly every week. One pediatrician says to require facemasks for high school students, but they are not needed for elementary school kids.
We still don’t know why COVID-19 is much more common in adults than children and why kids aren’t superspreaders. A recent study found that younger children have less of a receptor in their airways called ACE2 enzyme, which the virus needs to enter cells. Abundance of this receptor is lowest in 4- to 9-year-olds. It is higher in 10- to 17-year-olds, although still lower than in adults.
On July 12, NBC’s Dr. John Torres asked five pediatricians if they would let their own children go back to school. All five said “Yes” without reservation. The pediatricians said “The benefits of being in the classroom far outweigh the risk of disease.”
Most transmissions of COVID-19 occur from adults to adults, and adults to children. The younger you are, the less likely you are to transmit the disease. Note: In all of my reading this week, I have not seen a comment on teachers and staff to wear masks, but that should be required.
In the end, it doesn’t really matter what the science says… it only matters what Governor Pritzker says. Like with state-wide lock-down mandates, Illinois will likely be a “one-size-fits-all” for schools opening or closing. The state will provide a playbook. If school is open, it will be safe. The lever is being pulled by the Governor. He could give the go-ahead signal in August, and then, if there are outbreaks in Chicago schools, he could close all schools in Illinois and direct remote leaning again.
Parents must make sure their children are well before sending them to school, and especially this year keep them home if they show any signs of illness.
With the current relatively low case rate of virus in Washington County combined with the transmission data published in recent reports, parents should feel relatively confident that their kids will be all right attending school this fall. All bets would be off if there are outbreaks in our communities. It becomes even more important for adults to be responsible to avoid exposures.
The epidemic has been going on for five months. Washington County has reported 25 positive cases – all adults. No children. There shouldn’t be much child-to-child transmission of COVID-19. If there are ongoing cases in the community, it is likely that cases will occur in students or teachers, and the school must have a contingency plan. If cases are detected, intervention should be quick to limit the spread.
A large concern at schools is how adults congregate. Schools should have some methods of physical distancing in the staff rooms and on school grounds to limit transmission of virus between adults. Prevention efforts fail if kids social distance, yet school staffs closely mingle in break rooms. Parents should not enter school grounds. Adults should do everything possible to prevent any transmission of disease to the kids. Social distancing, face masks and hand washing remain the best ways we have to reduce spread.
The onus is on adults, especially teachers and school staff, to refrain from social gatherings and travel to hot spots, because they are more likely than the kids to bring the virus to school. For our schools to be virus free, it will take cooperation of the whole community. This is a true issue of basic public health. It will be difficult for adults to refrain from travel to hot spots and avoid exposures at social parties. “Adults” can mean anyone who drives a car. Kids don’t travel to infection areas. Adults do. If an adult goes to St. Louis, Florida, Texas or Arizona, gets exposed to virus, brings it back home, and then goes to a party with friends… it’s over. Don’t blame the kids. Be responsible. If adults keep COVID-19 out of our communities, it won’t get into the schools. It’s that simple.
This unsolicited article is my public health assessment based on recent literature review.