Children are less likely to get COVID-19 infection and much less likely to get sick. Recent studies have helped us understand why. Children have fewer cells lining their mouth, nose and upper respiratory tract with receptors that the COVID-19 virus uses to enter the body. Without those target cells, the virus’ “key” cannot open the cell’s “lock,” can’t start infection and then can’t spread within the body.
In fact, children, because of their exposure to other cold viruses, may have enhanced immunity that protects them from infection or causes a more rapid clearance of infection. In a study looking at the blood cells from people collected before fall 2019—the time when COVID-19 first entered into the human population—about half of study participants appeared to have some level of COVID-19 protective immunity due to active memory immune cells from other, previous coronavirus infections.
Contact tracing studies tell us that the risk of infection within schools is low and is lower for children than adults even in the same household. In France, researchers found that a symptomatic child with COVID-19 infection did not spread infection to any of 112 school contacts. In an Australian report on school transmission, looking at the spread of infection across 15 schools from 18 original infections in nine students and nine staffers, secondary spread among students was rare (< 1%) and there were no cases spread from students to staff. The Australian investigators concluded that COVID-19 spread within schools is limited and substantially less than other infections like influenza. Even in households, where the risk of spread from children to adults is thought to be greater, a review of 31 household outbreaks in China found only three of these outbreaks were initiated by a child. While those studies are relatively small, they also support other similar observations showing very low rates of infections in schools in Taiwan, South Korea and Sweden, places that did impose universal school closures.
So with an increased understanding that children are much less likely to be infected, less likely to become severely ill, less likely to spread infection, we should feel less afraid of opening schools and summer programs and more ready to let our children return to their normal lives.
Initially, deciding to close schools in the context of a new respiratory disease pandemic with a potential to devastate our hospital systems was reasonable. But, now, based on evidence, our hesitation in reopening schools and summer camps for children is not.
A first principle of public health is to take the least restrictive means necessary to protect as many people as possible. Another is to do no harm. The closure of schools and summer programs are harmful. Children are not learning. Caregivers must remain at home suffering loss of income. Essential employees within municipal programs or health-care systems cannot work full time. One study suggested because almost one of three health-care workers have childcare obligations, the need to provide childcare due to school closures could result in fewer available health-care workers and subsequent increases in deaths.
In addition to learning, schools serve child development through socialization and physical activity. For many children, U.S. schools provide necessary meals to children they would not otherwise receive and provide after-school enrichment programs including athletic programs. In fact, at the end of April 2020 in the wake of sweeping school closures, more than one in five households with children younger than 18 years old were food-insecure, meaning they did not have enough food to eat. That figure constitutes a dramatic rise compared to 2018.
Educators expect with early closure of the 2019-2020 school year, children will be months behind in educational attainment. Those delays could have lasting effects on graduation rates, future productivity and economic inequality. Education is the most powerful factor in raising family income and breaking the generational cycles of poverty. Gaps in schooling result in increased dropouts and failed educational achievement.
If we can accept the evidence that the risk to children is low and that the risk of children’s contributing to the propagation of the epidemic is also small, we can bring children back to schools safely. The best approach would be to regularly ask all staff and students about symptoms of illness.
Of course, we know that some people without symptoms can spread infection. Scientists estimate the frequency of those silent infections to be one in six. Testing all children to find silent infections would be costly. The more efficient approach is to make sure those with symptoms of illness do not attend. Policies should focus on providing rapid testing to students (or staff) with symptoms and getting them promptly isolated. Making hand-washing and covering mouths and noses when sneezing and coughing normal everyday behaviors will have the largest payoff, reducing many infectious diseases.
School staff should be actively monitored for symptoms of infection—cough, fever, sore throat, headache, loss of smell or taste—and not allowed to work if ill. Policies should be in place to make sure school workers of all kinds would get paid if they cannot show up to school due to illness. Sick staff should be instructed to follow current recommendations and not return to work for at least 3 days after symptoms resolve and 10 days after symptoms first appeared.
Perhaps the most disruptive and least beneficial intervention being considered in school (and summer program) settings is social distancing through modifications in classroom size, structure or scheduling. Given the absence of substantial risk in school settings to children and the larger community such interventions may not be justified. Complex schedules break up the routine that children depend on for stability and may result in stress. While smaller-sized classrooms would certainly benefit learners, if new funding is not provided to support the costs of additional teachers or space, the push to reduce classroom size will only result in fewer classes and less learning.
The COVID-19 pandemic has taught us a lot about the consequences of public health interventions and the costs of uncontrolled infection both in dollars and lives lost. Because of school closures, most people have come to believe that children are a reservoir of COVID-19 infection and spread it to the old and vulnerable. That narrative is wrong and harmful. Nearly all the available evidence we’ve seen so far tells us that children are not an important factor in the spread of COVID-19. Children are at a very low risk both for getting infection and for experiencing severe disease. They account for less than 2 percent of identified cases and few deaths.
In recent weeks, parents have been alarmed by a new syndrome called multisystem inflammatory syndrome in children. That disease is very similar to Kawasaki disease, an inflammatory disease of the heart and blood vessels associated with viral infections. Kawasaki disease affects about 400-500 children a month. While epidemiologists do not know the true frequency of multisystem inflammatory syndrome and how often children with COVID-19 develop that complication, it is felt to be rare and as common or less than Kawasaki disease.
Harkening back to first principles, any disruption in our kids’ lives should be the least intrusive, absolutely necessary and justifiable. Our policies must be evidence-based. Ignoring new evidence and reinforcing fears is a disservice to our society and harming those we care about the most, our children.