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COVID-19: Sending Children Back To School

Medically reviewed by Susan Kerrigan, MD and Marianne Madsen

To school or not to school? That is the question on everyone’s minds as some countries start to relax restrictions after the long COVID-necessitated absence. 


Frazzled parents, anxious teachers, and eager children are already looking forward to the day when schools will reopen, but it’s not an easy road. Over three-quarters of the world’s roughly 1.5 billion schoolchildren have been barred from the classroom, according to UNESCO. Out of the total population of students enrolled in education globally, UNESCO estimates that over 89% are currently out of school because of COVID-19 closures.

The current plan in the USA is that schools are to remain closed in almost all 50 states for the rest of the 2020 academic year–whether that is weeks or months. Worldwide, administrators are trying to figure out how to get kids back while COVID-19 is still an issue, with options including everyone wearing masks, staggering start times, and canceling assemblies and sports. But teachers are skeptical that schooling with social distancing rules is even possible.

However, the costs of keeping schools closed needs to be weighed against the tremendous costs of lost learning. In the past, schools have struggled to remain open during wars, famines, and even storms. The extent and length of school closures now happening in the developed world are unprecedented. The costs are horrifying. Most immediately, having to take care of children limits the productivity of parents. But in the long run, that will be dwarfed by the amount of lost learning. Those costs will fall most heavily on those children who are most in need of education. Without interventions, the effects could last a lifetime. Children are also at risk of psychological distress at times of crisis as well as increased risk of violence, abuse exploitation, and neglect. 


Stellenbosch University in South Africa recently published an in-depth policy brief which states that the question of when and how children should return to school depends on 3 main points:


1. Risk to children of disease and death

2. Transmission of virus from children to adults

3. Social and economic costs of keeping children at home

Risk to children of disease and death


According to Dr Kirsten Perrett, “Most of the time with respiratory viruses such as influenza, children are actually more susceptible to infection and severe disease, but this is not the case that we’re seeing with COVID-19.”


“Those children who did contract the virus overseas have only had mild symptoms such as fever and upper respiratory symptoms,” he said.


So far, serious complications in children have been rare, but that is not the case for adults–particularly older adults.


Fatality rates from COVID-19 by age show that for COVID-19 (unlike many other diseases like influenza and malaria) the risk of dying if infected is negligible in children. Recent data from South Korea, Spain, China, and Italy show a 0% case fatality rate in children 0 to 9 years. South Korea, Spain, and Italy have also seen a 0% case fatality rate in the 10-to-19 year age group, with a 0.2% case fatality rate in the 10-to-19 year age group in China. The USA CDC reported on May 1, 2020, that there were 9 deaths among children aged 0 to 14 years (0.02% of their total deaths). Sadly, South Africa reported the death of a 2-day old newborn from COVID-19 (the mom was also positive), making this the only fatality (0.3% of total deaths in South Africa) in the 0-to-9 year age group in South Africa, with no deaths in the 10-to-19 year age group.


Large studies from Italy, Japan, the Netherlands, Switzerland, South Korea, Iceland, and Germany all show very low infection rates in children under 10 years, with one study from Vo in Italy–which screened 86% of their population–detecting zero infections in children tested under age 10 years. A summary by Munro of the five studies (done in China and Japan) concluded that children are significantly less likely to acquire COVID-19 infection when exposed to it than are adults.

Kawasaki disease is a rare autoimmune disease preempted by a virus (not necessarily COVID-19, but any virus), and there have been recent reports of Kawasaki linked to COVID 19 in children. Without going into too much detail, this is something that doctors are watching out for, but is extremely rare, despite the media’s over-reporting of it. Most (of the few) children who have been treated for Kawasaki disease from COVID-19 have recovered from it.


In a nutshell, children are far less likely to contract COVID-19 and to suffer severe disease if they do get it.


Transmission of COVID-19 from children to adults


Evidence from around the world is consistently showing that although children were initially thought to be super spreaders (based on the influenza model), this assumption was incorrect and, in fact, children are rarely the primary sources of infection in a household or population.

The concern was similar to concerns over influenza and the 2003 SARS epidemic–that children might have asymptomatic infection and unknowingly drive household and community transmission. Data from studies done in China, the French Alps, New South Wales, and the Netherlands all suggest that COVID-19 is mainly spread between adults and from adult family members to children. Tracing studies from US, Australia, Germany, the Netherlands, China, South Korea, and Singapore all support the hypothesis that children are NOT the primary spreaders of the virus.

Social and economic costs of keeping children at home


The social isolation of extended lockdown can create anxiety, depression, inactivity, and other problems in children. The longer children stay out of school, the more difficult it is to get them back to their previous levels of knowledge. In addition, it is hypothesized that during the summer break, children lose 20 to 30% of their accumulated knowledge and skills. This can be extrapolated to our situation. Girls are at increased risk of abuse and teen pregnancy, and these factors also need to be accounted for. Sadly, the increase of “stay home, stay safe” protocols have led to an increase worldwide for domestic abuse, both of adults and children.


Should governments choose to refrain from reopening schools, children’s education will be interrupted even further, and their families and communities will be placed under further stress by health and economic burdens. Even though children’s health appears less impacted by COVID-19 than older adults, each family needs to weigh the risk-to-benefit ratio for themselves and make a decision. The evidence changes in this pandemic weekly. Let’s hope that it continues to emerge in this positive light, so we may soon send our children back to school with increased confidence.

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