Even a global pandemic can’t take away this joy of summer: fresh, juicy, sweet berries!

Photo by Edwin Hooper on Unsplash

Life was turned completely upside down in March, 2020 when schools closed. As a self-employed mother, I wondered, was I supposed to let my business tank and take care of my daughter at home just to protect our household from COVID-19? Here we are six months later and parents of school-aged children have been slugging it out: working at home, teaching children at home, caring for children at home, and dealing with an infinite number of other emotional, mental, physical, financial, and spiritual complications, thanks to COVID-19.

In August, I found increasing numbers of my friends were sending their kids back into day care and back to school. With a high-risk family member in my home, I just couldn’t do it. I wasn’t so much worried that my child would have serious problems from COVID-19, but that she would bring the illness home to us. We wanted more than anything to send her back to day care. She was bored, stir-crazy, and missed her friends terribly. But I needed to weigh the evidence myself and here is what I found out.

 

Key Takeaway Points

  • Adults are the primary drivers of illness, not kids.
  • Age matters a lot.
  • Kids under 20 years old are half as likely to get COVID-19 than adults.
  • Very young children < 9 have a harder time catching it and spreading it.
  • SARS-CoV-2 and its coronavirus cousins, SARS and MERS, show the same age-related effects.
  • Closing schools has significant social, educational, economic, and health ramifications.
  • Closing schools does not significantly reduce COVID-19 transmission because “children may not be a major reservoir or vector of infections.”1
  • Since March, outbreaks in day cares have been surprisingly uncommon.
  • For COVID-19, school closures are likely to be much less effective than for influenza-like infections.2
  • The SARS outbreak didn’t show school closures to be widely helpful.3
  • Evidence from around the world suggest child cares and elementary schools are low risk and can open with precautions.
  • Teenagers are still a concern; they might spread it more like adults.
  • Kids may be more likely to get COVID-19 from their caregivers or teachers, than to give it to them.
  • We have a gap in our knowledge about kids because we don’t have good testing data on them, especially those without symptoms.
  • The spread of the virus in the larger community is a major determinant of COVID-19 in schools.
  • Even if kids go back to school in a limited capacity, other social activities need to be severely restricted.
  • We still need to upscale testing, contact tracing, and isolating in order to successfully open schools and keep them open.

 

Reality Check: The Risks for Kids

 

From the get go, the COVID-19 numbers in kids have been nearly too good to be true, right?

 

There aren’t many cases in kids, they don’t get that sick, and the risks for serious disease are low. The risk of death is extremely, extremely low. This has led some COVID-19 researchers to say, children “may not be a major reservoir or vector of infections.”1

 

As of May, 2020, children younger than 18 years made up only 1.7% of the US COVID-19 cases, 1% of cases in the Netherlands, and 2% of a large cohort in the UK.4 Of COVID hospitalizations in 23 states and NYC, children made up only 0.5% – 3.7%. Yes, kids can get very sick, it’s just a small percentage that do. Underlying health problems increase the risks that a child will have serious symptoms. The worst-case scenario, death, is extremely unusual in children. As of September 3, 2020, eighteen states reported zero child deaths. Of 42 states and NYC, children made up only 0% – 0.3% of all COVID-19 deaths. The risk of death is extremely low, but a friend pointed out to me, it can still happen. She knows someone who lost a child to COVID-19.

 

More kids are getting COVID-19 right now in the US, although they still make up less than 10% of total cases. In late May, about 5% of US cases were in minors. By August 20th, it had risen to more than 9%. From August 20 to September 3rd, there was a 16% increase in child cases. When kids were tested, 3% – 17.3% were positive for COVID-19. Hospitalizations and deaths have increased, also. It may be due to the increasing spread in the community, the relaxing of precautions over the summer, or schools reopening.

 

In France, they also report that children have a low incidence of the virus. Their infections are mild and they recover more quickly than adults. In many cases of children diagnosed with COVID-19, it seems that they were part of a larger familial cluster of the virus. That means they were probably getting it from their family members. Authors said, children “may not be a major reservoir or vector of infections.”1

 

Photo by Allen Taylor on Unsplash

It’s a mystery why young kids seem to have a protective forcefield when it comes to COVID-19. Kids may be less likely to get infected because their immune systems are already primed to other coronaviruses. Or maybe immunity to other colds and flus have given them resistance to the virus2. Children have more ACE2 receptors, which may help them suppress inflammation – the major threat — from SARS-CoV-2. Children older than 4 years tend to be hardier to pathogens. They have lower rates of symptomatic diseases and death across the board, to any number of pathogens.2 Kids’ innate immune systems may be better primed than adults to fight off all of the novel pathogens they encounter in early life.5 Children were similarly protected from SARS and MERS, COVID-19’s cousins. Kids were less likely to get infected and less likely to have severe symptoms or death, compared to older adults.6

 

Even when kids get it, they may not spread the virus effectively because they don’t have many symptoms. Kids that aren’t coughing and sneezing are less likely to spread the virus. However, studies show that similar to adults, they do carry significant amounts of the virus, when they have it.1

A complication of COVID-19 that affects children, similar to Kawasaki disease, was reported in small clusters in the UK, Italy, and the US. Multisystem inflammatory syndrome in children (MIS-C), as it is now called, is a rare but severe condition that shows up 2-4 weeks after the onset of COVID-19 in children and adolescents. Symptoms include shock, cardiac involvement, gastrointestinal symptoms, high markers of inflammation, and a positive test result for SARS-CoV-2. There are treatments for Kawasaki disease and most children recover completely if they are treated early.7 The risk of death is low. By July 29,  a total of 570 patients with this condition in the US had been reported to the CDC. No cases were reported in China.7  While Kawasaki disease is alarming, it is extremely rare and it’s important to remember that the vast majority of children are minimally affected by SARS-CoV-2 infection.4 One pediatrician advises parents, “don’t worry about it, but be aware of it.”

 

 

Your Child’s Age Matters

People under 20 years old are half as susceptible to contracting the virus than those older than 20. Further, age determines if you get symptoms. In people 10-20 years old, only 21% get symptoms, but 70% of elderly (older than 70 years) get symptoms.2 This is confirmed by other studies; one showing that children and adolescents had 43% lower odds of being infected from a positive case. The data keeps building… Population studies in Iceland, Italy, South Korea, Netherlands, California, and a hospital study in the UK suggest kids 0-18 years old are less likely to be infected.8 The opinions aren’t unanimous, however. One study said that kids could pick it up as easily as adults in the same household.9

Kids aged 0-9 years old appear to be very, very safe. COVID-19 transmission is low in this group and infection rates are low, too.10 Their symptoms are usually mild or absent, meaning that they aren’t as contagious even when they do get it. Kids 0-9 years old make up fewer of the cases than those aged 10-19 years old. Of all cases in children, very young children make up only 20-40%, while kids ten and older make up 60-80%. One pediatric case of COVID-19 had a large number of contacts in school but didn’t transmit the disease to any other students.8

 

The evidence is mixed for teenagers. Kids 10-19 make up a larger proportion of total child cases, over 60%. While they are much less likely to pick up the illness than an adult or elderly person, we still need to exercise caution with them.  Until we know more, think of teenagers like you would adults: they are more likely to catch it and to spread it. Young children show lower levels of COVID-19 blood antibodies than adults, while adolescents have similar levels of COVID-19 blood antibodies to adults. I would like to see a break down of the ages in this group. I suspect kids 10-12 years old have less problems than those 16-18 years old. But state health departments aren’t collecting the data that way.

 

One outbreak in a French high school showed that 40.9% of students and staff were infected by school contacts. There was no difference in infection rates between the staff and students. This suggests that high school kids 15-17 years of age have similar disease characteristics to young adults.8 However, in a German community with low numbers of COVID-19 cases, teenagers that returned to high school did not spread the illness very effectively at all.

 

In New South Wales, nine students and nine staff were confirmed with COVID-19 from 15 schools (10 high schools and 5 elementary schools). The 18 positive cases were considered to have close contact with 735 students and 128 staff, but only two people were infected. One high school student was infected after contact with two student cases. And an elementary student was infected by a teacher.8

 

I would view college students as having similar ability to spread the virus as adults. Given their young age, they may have some mild protection from picking up the virus (like kids do under 20 years old). However, like high schoolers, they may spread it as effectively as adults.

 

 

Young Kids Are Less Likely to Get It, But They Still Can

 

While children do not drive the spread of COVID-19, they can certainly be infected. There have been cases of transmission among kids. A significant outbreak at a summer camp in Georgia led to COVID-19 infections in 56% of staff, 44% of 11 – 17 year-olds, and 51% of 6-10 year-olds. It’s unclear whether the kids were transmitting it to the adults or vice versa, but the infection rates were very high – and second highest among the youngest children (10 and under). The outbreak at the Georgia camp could have been explained by a weak testing algorithm, the lack of fresh air, exuberant cheering and singing, and relatively large groups of 15 in each cabin. These problems were averted by four camps in Maine who used a multilayer set of precautions to effectively prevent the spread of the illness among campers and staff.

Image by Gerd Altmann from Pixabay

 

When the cases of COVID-19 are high in the community, more children will get infected. Kids are more likely to get COVID-19 when an adult in the home or a teacher has it.

The Harms of School Closures

 

School closures are not without a heavy cost. Parents who have lost childcare report higher rates of stress and anxiety. Children who have lost child care are more fearful and fussier. School closures carry economic harms to working parents, to healthcare workers, and other essential workers who are forced from work to childcare. Society loses productive working parents. Vulnerable grandparents helping with childcare could be put at higher risk of infection. This is nothing to say of single parents or caregivers who experience all of these difficulties, but magnified, when they lose the childcare resources that they depend on.3

 

Children lose education, children’s welfare suffers- especially the most vulnerable students, and children who rely on free school meals lose important nutritional support.3 Learning at home may lead to losses of learning upwards of 9-12 months. Childhood development, physical and mental health may be harmed due to social isolation and there may be increased exposure to violence at home.10 At the national level, 16% of the workforce are primary caregivers for children. It’s even higher, at 30%, in the health and social care sectors. Just an 8-week school closure has been estimated to cost 3% of the gross domestic product in the US.3

 

What is the Evidence to Support Closing Schools?

 

So far, there isn’t strong evidence to support school closures to prevent transmission of COVID-19. Because kids do not play a large role in the transmission of the virus, closing schools doesn’t pack much of a punch.3  One of the big reasons that countries worldwide jumped quickly to close down schools and day cares is because school closures are effective in flattening the curve of influenza. Children play a big role in spreading flu. Not the same for COVID-19. Children do not play a big role in spreading it. Because kids are half as likely to get it and have a low rate of symptoms, school closures may not limit transmission very much.2

 

“For COVID-19, school closures are likely to be much less effective than for influenza-like infections.”2

-Dr. Nicholas Davies, et al.

 

This is similar to what we saw for children in the SARS-CoV epidemic. SARS, a cousin of SARS-CoV-2, didn’t appear to be particularly transmissible in school children.11 Data from the SARS outbreak in mainland China, Hong Kong, and Singapore suggest that school closures did not help control the epidemic.3 SARS researchers questioned the necessity and utility of closing schools. They said contact tracing was more effective in lowering SARS case numbers.12 Models of SARS confirmed that school closures didn’t do much to delay the epidemic.2

 

Most sources think the contribution of closing schools alone would be small, perhaps only reducing 2-4% of COVID-19 deaths, much less than other social distancing measures.3 However, one source estimated school closures could reduce the peak by a whopping 40-60% and delay the epidemic.13 In a subsequent article, the same authors explained that the impacts of school closures were dependent on the frequency of other social activities. When all social mixing was eliminated during lockdown, closing schools led to a 77% decrease in the spread of the virus. When social interactions were at pre-pandemic levels, school closures only reduced the spread of the virus by 5%.14

 

School closures decrease the number of contacts within the population and reduce the spread of the virus. They also serve to keep parents at home, so they don’t spread the virus.10 Epidemiological modeling of various school reopening strategies in the UK showed that they still needed to increase testing, tracing, and isolation of symptomatic cases in order to successfully open schools without another large wave of infections. They even accounted for children being 50% less likely to acquire the illness than adults. Without testing, contact tracing, and isolating, researchers predicted that reopening UK schools in September would lead to a COVID-19 peak in December, 2020 and intermittent school closures.10

 

What Happened in Other Countries When Schools Reopened?

 

A strong pattern of good news is emerging from all over the world about early learning settings: day cares and elementary schools reopened without significant outbreaks.

 

Image by Gerd Altmann from Pixabay

Denmark reopened day cares and schools for children between two to 12 years old and saw no increase in COVID-19 infections. Finland didn’t see a spike in cases after reopening schools. 22 European countries opened kindergarten and primary schools without any significant upticks in coronavirus infections among children, parents, or staff. Many of these countries are taking significant precautions, such as these. France’s education minister actually said it was more of a risk keeping children at home. However, they opened schools in a strategic way that took into consideration community spread of the virus.

 

Five countries (Germany, Sweden, U.K., Italy, and France) reopened schools, especially because their flattened curves made it more possible. In May, 2020, France reopened schools but there were some COVID-19 cases (70 to be exact, in children or staff) that led to school closures. Take into consideration that 1.4 million French children, or more than 99%, returned to schools without issue. And many of those cases were attributed to community spread, not from the schools.

 

In Saxony, Germany, a study of 13 high schools (8th to 11th grades) which reopened from May to July, 2020 did not develop into silent hotspots of SARS-CoV-2 transmission. Teachers and students did not seem to transmit the virus easily, nor to family members. Nearly half of the cases were traced back to household members that were positive. In a community with low COVID-19 prevalence, authors recommended social distancing, tracing, testing, and isolating as equally effective to school closures, but less harmful, when trying to stop the spread of the virus.

 

Image by tragrpx from Pixabay

Taiwan reopened schools in late Feb 2020 and had no outbreaks, however they had a rigorous intervention plan at the government, school, and citizen levels, which isn’t found in the US. The country had few cases to begin with, and their numbers declined from there due to the country’s rapid implementation of mask requirements, robust case quarantine, and contact tracing methods using phone apps. Unfortunately, we can’t learn much from Taiwan about our own risks when reopening schools in the US. We have lots of community transmission and poor contact tracing. It is a nice reminder that if we were to take on those rigorous measures, we could keep schools open successfully.

 

 

What About US Schools and Day Cares- Have There Been COVID-19 Outbreaks?

 

To help with social distancing, children at Valley of the Sun YMCA sites in Arizona were taught to make “airplane arms” when standing in line.

Unpublished anecdotal reports from the YMCA and New York City’s Department of Education suggest that they maintained childcare for approximately 50,000 children at over 1200 sites since March 2020 and had no known clusters or outbreaks. They were taking all of the recommended precautions, even before recommendations were officially published by the CDC. Some parents and staff members tested positive, but there were no records of having more than one case at a site. This is a dramatic finding considering that most of these were children of essential workers!

 

Outbreaks in day cares have been surprisingly uncommon.

 

There is a crowdsourced database of day care and school outbreaks here. Analysis of this highly limited dataset by Brown University economist, Emily Oster found that of 916 day care centers, serving more than 20,000 children, just over 1% of staff and 0.16% of children had confirmed positive coronavirus infection.

 

It seems pretty clear from the dataset that staff are more affected than children. For example, in a child care outbreak in Los Angeles County, August 2020, they reported 112 cases of COVID-19 in staff and 54 in children. While kids are not thought to drive the spread of illness, surely they participate in outbreaks like this one. But the adults seem to bear the brunt of illness. In June, out of a total of 270 child care centers in Texas, 226 employees and 113 children had been infected. No one wants to hear about positive COVID cases, but really, these are extremely low numbers considering how many kids are being cared for and how easily kids can spread colds!

 

When analyzing COVID-19 outbreaks in day cares or schools, experts believe community transmission of the virus is more a determinant of an outbreak. Parents in the household of a child with COVID-19 may also be positive. In an analysis of Ohio outbreaks in childcare centers using contact tracing, 75% of cases were determined to be from community spread.

 

In Iceland, a genealogy database called deCODE Genetics tested 15.5 % of the general population for COVID-19 and sequenced the virus’ RNA, which allowed them to map its path of infection. As the virus is passed around, it acquires random mutations. The leader of deCODE, Kari Stefansson, a neurologist, said, “One of the very interesting things is that, in all our data, there were only two examples where a child infected a parent. But there are lots of examples where parents infected children.” This further supports the notion that kids are more likely to get it from their parents, than to give it to their parents. However, schools were closed early in the pandemic. If schools had been open, would this study have detected more transmission from kids to adults?

Epidemiologist Daniel T. Halperin echoed this finding. He said, “Remarkably, contact tracing studies in China, Iceland, Britain and the Netherlands failed to locate a single case of child-to-adult infection out of thousands of transmission events analyzed.””

 

Dr. Joshua Sharfstein at the Johns Hopkins School of Public Health has a cautious, balanced view of the optimistic findings about kids and coronavirus: “These experiences illustrate that it’s possible to bring kids together without a guarantee of an outbreak or a serious situation developing.” On the other hand, they don’t guarantee the opposite, he says.

 

There Are Still Many Unanswered Questions

 

Have you noticed that we can’t say anything about COVID-19 without a disclaimer? Same goes here. We are learning minute by minute with coronavirus and we have only been studying it for nine months.

 

We may always have a gap in our knowledge about kids and COVID-19. Because schools were closed very early in the pandemic, it’s hard to figure out what benefit it had, if any. And because they were closed early, fewer children may have gotten the virus and thus not transmitted it to others. That could also explain why many cases in kids could be traced back to their adult family members. Kids were being kept in isolation early in the pandemic, while adults were going out. That is why data from other countries who reopened schools is so important. We will see how the US fares with schools reopening this fall.

We don’t have great testing data on kids. Children’s infection rates seem to be proportional with how often they’re tested, given the limited data we have. Are they being tested less because they don’t have symptoms? Or because they’re not infected at all? And most parents aren’t going to volunteer their children, especially their young children, for COVID-19 testing. We could be missing lots of information about asymptomatic kids.

 

 

Things to Consider When Sending Your Child Back to School or Day Care

  • Is someone in the household high-risk for complications from COVID-19 (see list here)?
  • Is someone that regularly interacts with the family high-risk?
  • Is your child in good health or does he or she have underlying conditions or obesity?
  • Community spread
    • Is it spreading uncontrolled in your community?
    • Is your community doing a good job with testing, contact tracing, ventilation, masks?
  • What precautions are they taking at your child’s school?
    • Small classes, ventilation/outdoors, hand-washing, masks and face shields, temperatures, distance, etc..
    • Are they taking significant measures to break transmission of the virus among adults in the facility, who are much more likely to get it and spread it?
    • Do they have staggered or alternating schedules?
    • Do they encourage testing?
    • Are they transparent with parents?
    • Does the school have a plan of action in the case of multiple cases or an outbreak? Will they shut down?
    • Can cases be traced and isolated?
  • Is your child <  9 years old?
  • Is your child a teenager?
  • How conscientious is your teenager about washing hands, social distance, fresh air, etc.?
  • Economic issues. Can you afford to stay home doing childcare/teaching your child or can you hire help?
  • Personal fear levels. How frightened and anxious will you be if your household gets infected?
  • What are your needs for normalcy, social connection, or time alone in your home?

 

How Does This Translate into My Personal Decision-Making?

I wish the decision to put my child back in day care was quick and clear-cut. But of course, it wasn’t. I have a high-risk person in the home and I would be very concerned about complications if he got COVID-19. However, the costs to keep her out of day care have been high for us: at-home childcare, the stress and psychological effects of her being away from friends and school, and the disruption of our daily routine, normalcy, and sanity.

 

Based on this research, I no longer worry that going to day care would be a direct line of infection into our home. I will be looking for a day care that is doing an excellent job on precautions, is transparent, and has small class sizes. I will still wonder about her classmates’ parents’ exposures, which could infect their child and potentially arrive at the school. However, it would be a stretch, as younger kids are less likely to get it or spread it. I will be paying attention to how the teachers are preventing transmission between themselves at the facility. There will still be a small risk that her day care could have an outbreak, but it isn’t very likely that it would infect us. What we, as adults in the home, do to limit our exposure to the virus has the greatest benefits for protecting our household. If I can’t find a day care that fits those criteria, I will look into a nanny share with other kids her age, younger than 9 or 10 years old, as a way to reduce costs and help with socialization.

Photo by Timon Studler on Unsplash

 

What does this mean for letting my child play on a public playground? I saw a playground in my neighborhood this weekend packed with kids and only three children were wearing masks. It was a large group of maybe 40+ kids and parents. It was outdoors, so ventilation was good. In general, I would feel more at ease with my child at a playground knowing that kids < 9 are not as likely to pick it up or spread it. However, I would still opt for a more vacant playground with plentiful social distance. I would hand sanitize after she plays on the equipment.

 

Putting Kids Back in Schools Has Many More Benefits Than Costs, Especially for Those Under 10 Years

When there is a threat of danger, we all instinctively gather our children close under our wings to keep them safe. The evidence, however, suggests that our young children (< 9) are not in significant danger. The elderly and sick are. After considering the national and international data to date, schools do not seem to be a breeding ground for the virus. Day cares and elementary schools seem especially safe and that bears out the world over. Middle schools and high schools will see more transmission, but it’s still much lower than among adults. They are ½ as likely to be infected as anyone over age 20. The bigger risk is that adults bring it home to kids, or teachers transmit it at schools. Of course, there are no 100% guarantees.

Overall, schools don’t appear to be a COVID-19 incubator, but they would be much safer if the numbers in the community were tamped down. Basically, even with kids’ and adolescents’ improved resistance to the virus, if it’s spreading in their community and into their home, they can still get it. That’s why even with many precautions in place, it’s extremely important to boost yours and your child’s immunity against coronavirus. Reopening schools will be most successful if testing, tracing, and isolating is ramped up and if other social activities continue to be severely curtailed.  Each family has to juggle their unique collection of risks, worries, and resource limitations. I hope this mini-review of the international and national data helps you make the best decision for your family when it comes to kids, schools, and COVID-19.

References

  1. Colson P, Tissot-Dupont H, Morand A, et al. Children account for a small proportion of diagnoses of SARS-CoV-2 infection and do not exhibit greater viral loads than adults. Eur J Clin Microbiol Infect Dis. 2020.
  2. Davies NG, Klepac P, Liu Y, et al. Age-dependent effects in the transmission and control of COVID-19 epidemics. Nature medicine. 2020;26(8):1205-1211.
  3. Viner RM, Russell SJ, Croker H, et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. 2020;4(5):397-404.
  4. Viner RM, Whittaker E. Kawasaki-like disease: emerging complication during the COVID-19 pandemic. Lancet. 2020;395(10239):1741-1743.
  5. Carsetti R, Quintarelli C, Quinti I, et al. The immune system of children: the key to understanding SARS-CoV-2 susceptibility? Lancet Child Adolesc Health. 2020;4(6):414-416.
  6. Dhochak N, Singhal T, Kabra SK, Lodha R. Pathophysiology of COVID-19: Why Children Fare Better than Adults? Indian journal of pediatrics. 2020;87(7):537-546.
  7. Xu S, Chen M, Weng J. COVID-19 and Kawasaki disease in children. Pharmacol Res. 2020;159:104951.
  8. Li X, Xu W, Dozier M, et al. The role of children in transmission of SARS-CoV-2: A rapid review. J Glob Health. 2020;10(1):011101.
  9. Bi Q, Wu Y, Mei S, et al. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. Lancet Infect Dis. 2020;20(8):911-919.
  10. Panovska-Griffiths J, Kerr CC, Stuart RM, et al. Determining the optimal strategy for reopening schools, the impact of test and trace interventions, and the risk of occurrence of a second COVID-19 epidemic wave in the UK: a modelling study. Lancet Child Adolesc Health. 2020.
  11. Liao CM, Chang CF, Liang HM. A probabilistic transmission dynamic model to assess indoor airborne infection risks. Risk Anal. 2005;25(5):1097-1107.
  12. Cowling BJ, Ho LM, Leung GM. Effectiveness of control measures during the SARS epidemic in Beijing: a comparison of the Rt curve and the epidemic curve. Epidemiol Infect. 2008;136(4):562-566.
  13. Zhang J, Litvinova M, Liang Y, et al. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China. Science (New York, NY. 2020;368(6498):1481-1486.
  14. Zhang J, Litvinova M, Liang Y, et al. The impact of relaxing interventions on human contact patterns and SARS-CoV-2 transmission in China. medRxiv. 2020.