Schooling Under the COVID Cloud

In July, MedPage Today published a story that examined the debate around whether and how to reopen schools in the midst of a pandemic. In this follow-up, we explore how that debate evolved as the academic year got underway and more data accrued.

In mid-August, the American Academy of Pediatrics (AAP) updated interim guidance first issued in June, in which the group strongly recommended that kids return to school in-person.

The AAP stated that "the preponderance of evidence" suggests that children "may be less likely to become infected and to spread infection," and less likely to develop symptoms or even severe illness if they do contract the virus.

The document based its rationale on the experiences of "tens of thousands" of children of essential workers who attended emergency daycare in the spring, as well as on the success of several European and Asian countries that reopened schools during that time or, as in the case of Taiwan, never fully closed them.

The original guidance underscored the need to respond quickly to "new information," while also hammering home the message that "all policy considerations for the coming school year should start with a goal of having students physically present in school."

President Trump leveraged the AAP's guidance, urging governors to reopen schools and even threatening to withhold funding from states that did not reopen schools. It became clear that the argument for school reopening was, for some, an economic one: Until children returned to school, many parents couldn't return to work.

The discussion, like so many aspects of the pandemic, snowballed into a political fight, with educators and union leaders firing back at the president that neither students nor teachers would return to school until it was safe, and warning they would strike if pressed to return before it was safe.

A Kaiser Family Foundation study found that about one-quarter of teachers have a condition that puts them at risk of serious illness if they contract coronavirus.

But the debate wasn't solely focused on student and teachers' safety versus jobs. The lack of access to free and reduced-price meals and disparities in access to remote learning also factored into the discussion. Only 66% of children in households earning less than $50,000 a year were using online resources for schooling, and only 77% of children in households earning between $50,000 and $99,000 had access to such resources, according to the U.S. Census Bureau.

Worries also grew about the potential for child abuse. Reports of child maltreatment fell by 40%-60% from March to May -- in part due to teachers' limited access to children -- according to a study from Chapin Hall at the University of Chicago. (Importantly, Chapin Hall researchers also noted that only 11% of referrals from educational personnel are substantiated and that increased surveillance does not ensure increased protection.)

In the ensuing months, the AAP tempered its initial recommendations, acknowledging that the "uncontrolled spread of SARS-CoV-2" called for more options.

"Although the AAP strongly advocates for in-person learning for the coming school year, the current widespread circulation of the virus will not permit in-person learning to be safely accomplished in many jurisdictions," the AAP wrote in the revised guidance.

Still, the latest update (from Jan. 5) repeats what the group has said all along, that "all policy considerations for school COVID-19 plans should start with a goal of having students physically present in school."

Bad News: Children Get COVID

In December, MedPage Today caught up with pediatricians, infectious diseases specialists, and an academic researcher in an effort to synthesize the latest research regarding children's risk of contracting, transmitting, and becoming seriously ill from COVID-19 and to weigh the evidence for and against in-person learning during a pandemic.

"I think the one thing that really has to be emphasized is that anybody can get COVID-19 disease," said Tina Q. Tan, MD, professor of pediatrics and a pediatric infectious diseases physician at Northwestern University's Feinberg School of Medicine and Lurie Children's Hospital of Chicago.

For months, the White House downplayed the risks of coronavirus in children, Tan said. In July, President Trump inaccurately claimed that children are "almost immune" to the virus, and some media outlets echoed that message.

But such statements are simply false, Tan said. While children may be less likely to acquire COVID-19, and more likely to be asymptomatic, they are still susceptible to the virus. They're also capable of spreading the virus, infecting vulnerable teachers and other school personnel. However, research has found that children under 10 are less effective at transmitting the virus, though child-to-adult infection can happen. Transmission can, of course, also run in the opposite direction -- from school staff to students, Tan said.

Over 1.8 million children have been infected with COVID-19 since the start of the pandemic, according to a joint report from the AAP and the Children's Hospital Association, which is based on state-level reports and was published on Dec. 17. The report also found a 25% increase in COVID cases among children -- 1,460,905 to 1,821,746 -- from Dec. 3 to Dec. 17.

Across the 24 states and New York City that track hospitalizations by age, 0.2% to 4.0% of all child COVID-19 cases led to hospitalization. As for mortality, cumulatively there were 172 child deaths as of Dec. 17 in the 42 states and New York City that track that measure; 0.01% of child cases resulted in death. Thirteen states reported zero child deaths, according to the report. No more than 0.09% of all cases of COVID-19 in children were fatal in states that reported such data.

(One important limitation of the report is that states' definition of a "child" ranges anywhere from ages 0-14 to 0-20.)

Children represent about 12% of all cases at large, and about 2,400 of every 100,000 children have contracted COVID-19, which is not "nothing," said Wendy Sue Swanson, MD, MBE, a pediatrician, book author, blogger, chief medical officer for SpoonfulOne, and a MedPage Today editorial board member.

It's especially noteworthy if one believes, as Swanson does, that children have been under-diagnosed, particularly minority children. Swanson cited a JAMA study that found that Black, Hispanic, and Asian children had lower rates of COVID-19 testing but were "significantly more likely" to have positive results.

The "tide changed" for her when she realized that the long-term cardiovascular, neurological, mental, social, and emotional health impacts on children from the virus are still unknown, she said.

However, Swanson remains concerned about children being "deeply isolated" for long periods, particularly in light of rising suicide rates among youth.

Schools provide meals -- at a time when one in four households is food insecure -- shelter and a means for identification of child abuse and neglect, on top of basic socialization, Swanson said. "It's devastating when you start listing out what the benefits of schools are."

At the same time, Tan, who expressed similar concerns about child equity in education, pointed out, "there's a growing number of kids now that require hospitalization for their COVID disease."

Where Tan works, in Chicago, there have been around four times the number of children hospitalized for acute COVID-19 infections or for multisystem inflammatory syndrome versus earlier months of the pandemic, she said.

Despite what experts believed early in the pandemic, children are able to transmit the virus, Tan said. Younger children aren't as effective at spreading the virus compared with older children, but both groups are contagious.

Good News: Schools Aren't Super-Spreaders, Masks Work

But the news isn't all bad: New research on masks and the "bidirectional protection" they offer both the wearer and the people around them provides some rare, positive news, explained Swanson.

It's also becoming more clear that social and physical distancing is effective, she said.

"I think the biggest thing we've learned since September is that there is a way to do [safe in-person learning]," said Preeti Malani, MD, chief health officer at the University of Michigan.

One of the hardest challenges, she said, has been getting buy-in from students, teachers and parents.

Malani compares her own fear as an infectious diseases physician entering the clinic in March to what many parents, teachers, and students may have felt as schools reopened in the fall.

She said she grew comfortable being in a healthcare setting over time. Part of that comfort stemmed from research on the efficacy of masks -- in particular, the study of two hairstylists in Missouri who saw customers while positive for COVID-19. Both stylists wore masks, as did their clients, and none of the 139 clients caught the virus.

"The mask is our vaccine for now," Malani said.

But she accepts that some people feel more vulnerable than others, and some, who have underlying conditions, statistically are more vulnerable than she is.

"You can do everything to make a situation safe, but if people don't feel safe ... that is something that is not easy to fix," she said.

That said, classrooms are not a site of spread, Malani stressed.

"Is there zero spread? It's hard to say, but I have not heard of a a credible case myself of someone [who] was in class and they got infected," Malani said.

Swanson agreed that most schools aren't super-spreaders "when they have the physical plan to socially distance, to wear masks, and to afford good 'presentee' policies."

These are the schools that offer in-person teaching when the risk of infection is low, and that quarantine and contact trace "aggressively" if an incident occurs, while consistently providing the option of remote learning. But "it takes a ton of work and a ton of resources," to achieve that level of safety, Swanson said.

Swanson is part of a four-physician team that meets for an hour each week, poring over data and consulting with the public health department before offering recommendations to her children's independent school in Madison, Wisconsin.

"Most schools do not have that," she said.

The school also uses an app that parents and staff complete information on each day, which includes a symptom check, temperature check, and questions about travel and contacts.

A lot of the changes needed to make schools safe are typically available only to independent schools and wealthy school districts, Swanson said. She's frustrated that lawmakers have focused on keeping bars and restaurants open to the detriment of schools, and she wishes more resources were funnelled into supporting schools.

"We want small businesses to thrive, but we want small people to thrive too," Swanson said.

Emily Oster, PhD, an economist at Brown University in Providence, Rhode Island, has been tracking cases of the virus among students and school faculty at schools that voluntarily submit their data -- in collaboration with Qualtrics, an online survey platform -- on the COVID-19 School Response dashboard since early August.

In October she wrote an editorial, "Schools Aren't Super-Spreaders," for The Atlantic, arguing that fears around school reopenings leading to outbreaks in the community were "overblown."

Oster's data, at that time, showed an infection rate 0.13% among students and 0.24% among staff, or roughly 1.3 infections across a 2-week period among 1,000 kids, and 2.2 infections over the same period in a group of 1,000 staff.

Schools and the Community

The most recent data from Oster's dashboard shows an infection rate of 0.35% among students and 0.82% among staff from Nov. 30 to Dec. 11.

Additionally, a Dec. 15 CDC Morbidity and Mortality Weekly Report case-control study looked at infection rates in 236 students under age 18 in Mississippi. It found that "close contact with persons with COVID-19 and gatherings with persons outside the household and lack of consistent mask use in school were associated with SARS-CoV-2 infection, whereas attending school or child care was not associated with receiving positive SARS-CoV-2 test results."

Tan agreed with the basic premise of Oster's argument.

"The schools themselves are not the super-spreaders, but the contributing factor is the amount of transmission that's occurring in the community," Tan said. "What we've seen is there's not been a lot a lot of spread among students but there's been a lot of spread among teachers."

Staff may congregate in a break room or other area, she said, "and there's a higher chance for these individuals to spread COVID among themselves and even to some of the students." Asymptomatic students might also transmit the virus to teachers who then "spread it among themselves," she added.

Indeed, COVID's broad prevalence in the community combined with asymptomatic transmission makes infection control extraordinarily difficult, in schools as everywhere else, Tan said.

In October, scholars at Duke and Johns Hopkins Universities issued a report outlining core strategies for K-12 schools to open for in-person classes and included a series of questions to help schools assess their risks.

The report also emphasized the importance of leveraging testing and screening protocols, which Christina Silcox, PhD, of Duke Robert J. Margolis Center for Health Policy in Durham, North Carolina, described as one element of "a Swiss cheese method of risk reduction."

In an email to MedPage Today, Silcox explained that individual schools and school districts need to engage in individual risk assessments that factor in local infection rates, and school infection control measures -- including distancing ventilation, and transportation -- and weigh those against the "tolerance for risk" in a particular community. Any risk-benefit analysis must also factor in how well students can learn at home and the safety of teachers, she added.

"No strategy will be 100% perfect, but by layering mitigation strategies such as masking, distancing, hygiene, ventilation, and when appropriate, screening tests, we can work to make schools as safe as possible," Silcox said.

Tan noted that CDC guidance suggests that in areas of test positivity rates below 5%, there is little transmission.

The agency also tracks the number of new cases per 100,000 individuals over a 14-day period, and has recommended that anything less than 20 per 100,000 cases is considered "low risk for transmission" in schools, Tan said.

But where communities exceed that 5%-8% threshold, she said,"[schools that open] really do run the risk of increasing significantly the amount of COVID that possibly could be transmitted in the school setting."

The Politics of School

On Dec. 28, President Trump issued an executive order allowing low-income families to use federal dollars to enroll students lacking access to in-person classes at their schools to attend private or parochial schools.

The order noted that decreased school attendance is linked to greater risks of depression and "various types of abuse" among children.

The order cited the AAP's concerns around food security and children's physical activity and a link between "chronic absenteeism" and alcohol and drug use, teenage pregnancy, juvenile delinquency, and suicide attempts.

The order would allow under-resourced families to leverage these "emergency learning scholarships," as they're called, to pay homeschool or "microschool" expenses, to join a learning-pod for special education classes and therapy, tutoring, or "remedial education."

Meanwhile, President-elect Joe Biden has promised to open most schools in his first 100 days in office and is currently considering a multi-billion dollar plan to do so, according to Politico.

The proposal would require weekly testing, at a minimum, for all students, teachers, and staff, which would entail a significant increase in the production of rapid tests and lab capacity over the next few months.

The costs of such a plan could range between $8 billion and $10 billion over a 3-month period, according to a person close to the discussion -- which would, of course, also likely require new funding from Congress.

Swanson, however, was uncertain that the plan could work while COVID continues to surge. Reopening will be "a very delicate process," she said.

All of this is happening against a backdrop of parents, students, and even school staff growing increasingly restless and frustrated by schools' mitigation measures.

Asked whether schools had overreached, Swanson's immediate response was "No way."

"Nobody's known what to do. We haven't had weeks, months, or years of experience to stand on," she said, noting that a conservative approach has made sense. "Every non-conservative inch that you go, you will have additional cases."

Though pediatric safety data on the COVID vaccines currently authorized are lacking, Swanson is hopeful that vaccine allocation for children will happen this summer.

"We should be aggressive about making sure that we get them all immunized before the [next] academic year ... so that most can go back and it can be a much safer experience for everybody including all the teachers and staff," she said.

For more on schooling during the pandemic, see our Facebook Live series: "Schools In," from Aug. 13, and "What We Now Know About School Reopenings" from Oct. 27, both with Tina Q. Tan, MD, and Wendy Sue Swanson, MD, MBE.

Cheryl Clark contributed to this story.

Comment