Children appear to be less likely to become infected with the coronavirus and when they do, they’re not often seriously ill, but it’s not clear how easily they spread the virus to others — a key question facing public health and education leaders.
Nonetheless, school administrators under intense time pressure to return students to classrooms in the fall will need to figure out how to do it safely — or safer, since there may be no way to avoid infections entirely — even as the virus almost certainly continues to spread widely.
“This pandemic is so relatively new, and we’re gathering information at a lightning speed. But there’s still so much we don’t know, particularly in children,” said Dr. Tara Greenhow, regional lead of pediatric infectious disease at Kaiser Permanente Northern California.
In the Bay Area, children and teens have made up about 10% of all coronavirus cases, or about 2,000 in all. Statewide about 13,300 people 18 and younger have tested positive for the virus, about 8% of the total cases. No children have died of COVID-19 in California.
It’s hard to say how well those numbers capture the actual infection rates among children, infectious disease experts say. Children may be less likely to be tested, for several reasons — they are less often hospitalized, and more often experience symptoms that could be mistaken for some other respiratory virus, for example.
What the numbers do show is that children are not immune to the virus.
Children still need to return to classrooms, even if the pandemic is hardly contained, many education and health experts say.
Schools should be prioritized for reopening, even if some parts of the economy remain closed, said Dr. Theodore Ruel, chief of the division of pediatric infectious disease at UCSF. Education is a critical public health issue, he said.
Children need to learn, and they need the development that comes from in-person teaching and interaction with their peers.
That view is somewhat contentious, and some school administrators say they may stick to virtual education in the fall if the coronavirus outbreak is still raging in their communities. But many public health and education leaders agree that in-person education should resume, though it may look very different from the classrooms kids left four months ago when schools closed.
Federal and state officials, along with experts in pediatric infectious diseases, have put together some general guidelines for how schools should reopen. Children should be taught in contained “cohorts” — groups of students who stick together throughout the day and don’t interact with others outside their clusters. Administrators should avoid large gatherings at lunch and recess and not hold school-wide assemblies.
Children should be kept home when ill, and it may be wise to institute daily checks for temperatures or other symptoms of COVID-19. Students, teachers and school staff should wear face coverings if they can.
But figuring out the details of applying those guidelines — and the costs associated with them — may largely fall on counties and districts, or even individual schools. There’s not yet consensus on how big the cohorts should be, for example, or how to schedule classes so that schools aren’t too crowded. It’s not clear if young children should be required to wear masks, or what the age cutoff should be.
Administrators will need to decide what works best for their communities — and what they’ve decided is safest based on the available data about local outbreaks, infectious disease experts say. That may mean that education looks very different in one district than in its neighbor.
“The message to families should be that they can trust that these are thoughtful plans being made, even though we’re doing this (based) on limited data,” said Ruel, who has consulted with several Bay Area districts about reopening plans, and who’s eager to send his own children back to school in the fall. “They are thoughtful plans that have been catered to the situations in each county.”
Infectious disease experts say that the data collected so far, though incomplete, support that the coronavirus is not as big a threat to children and teenagers as it is others, and older adults in particular.
Some children with COVID-19 have developed a secondary inflammatory response that causes serious complications, but that condition is rare and appears to be treatable. There is also some research that suggests people who don’t have symptoms may still suffer lung damage; whether that’s true in children is not known.
Early studies out of China, where the virus first took hold, found that children were infected at much lower rates than others. A study published last week, looking at infection and transmission rates in six countries, found that children and adults younger than 20 were half as likely to be infected as adults.
When they are infected, children are less likely to have noticeable symptoms, according to last week’s study. Less than a third of children under age 20 had symptoms, compared with half of people in their 50s and more than two-thirds of people age 70 and older.
Even if the data increasingly suggest that children are less directly impacted by the coronavirus, they may still be able to infect others. With most respiratory viruses, children are considered large reservoirs of disease — they are very often carriers who spread the illness among themselves and their families and into the community.
It’s not clear if that’s the case with the new coronavirus.
“We probably would have known more about kids, except in March kids got sent home from school,” said Dr. Yvonne Maldonado, a pediatric infectious disease expert at Stanford. “School ended before we could really see what kinds of transmission could happen.”
It’s uncomfortable to say it, infectious disease experts acknowledge, but reopening schools is going to be a grand experiment. Educators and public health authorities may not know what strategy works best until they get kids back into class and see what happens.
Schools have reopened for in-person instruction in other countries, including South Korea and Israel, and in a few cases have closed again when students tested positive. But infectious disease experts said it’s hard to say whether those experiences overseas will be repeated in the United States, where the pandemic has played out on different — and often more damaging — trajectories.
“These are some of the challenges of this kind of decision making,” said Dr. Matt Willis, the Marin County health officer. “In COVID time, trying to forecast into August is really challenging.”
Last week, Marin County became one of the first counties in the state to release specific guidance for districts to resume in-person education. Teachers and community advocates already have questioned some parts of the guidance that they say will not let students maintain social distance and could risk spreading the virus.
Willis said he watched the constant flow of new research on the coronavirus and how it affects children as he considered guidelines, and he acknowledges they could shift in the coming months. Research, new data from the pandemic and changes in rates of transmission in his community have made it hard to set policy for more than a couple of weeks out, he said.
“I do think that evidence is important as we rebalance the risk and benefits (of reopening schools), the more we learn,” Willis said.
Regardless of school plans to reopen, none is going to be flawless and districts should expect new cases among students, infectious disease experts said. A key part of their reopening guidelines needs to be how to identify and contain those cases.
Ideally children would be tested for illness regularly, said UCSF’s Ruel, but that’s unlikely to happen because of costs and the time it takes to conduct tests and get results. Checking kids for fevers and other symptoms will help, but it obviously won’t catch all new infections if some large percentage of children never gets fevers or coughs.
“The public needs to understand that as with all of this, whether it’s adults or children, as you expand contact with people, there are going to be more cases,” Greenhow said. “There’s no way to prevent all cases. So then it’s, how do we mitigate that in the best way possible?”