By Marie Rosenthal, MS

As COVID-19 cases, hospitalizations and deaths continue to rise across the country, America is grappling with a difficult question: Should children return to a physical classroom in the fall?

Although they can become infected by SARS-CoV-2, children with COVID-19 often present with mild or no symptoms, giving credence to the idea that they would be safe if they returned to school. But the risk is not zero to children or the adults in the building, which leaves many public health experts, school officials and parents wondering what to do.

This is truly a time to carefully weigh the risks versus the benefits. Here are some considerations laid out by pediatric and infectious disease specialists, as well as school officials.

What Are the Benefits?
Children appear to learn better in a classroom setting, but there are many other benefits to children being physically present in a classroom, according to a joint statement from the American Academy of Pediatrics (AAP), the American Federation of Teachers, the National Education Association and AASA, The School Superintendents Association.

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“Children get much more than academics at school,” the statement said. “They also learn social and emotional skills at school, get healthy meals and exercise, mental health support and other services that cannot be easily replicated online.”

In addition, schools address racial and social inequity, according to the organizations. “This pandemic is especially hard on families who rely on school lunches, have children with disabilities, or lack access to [the] Internet or health care,” they said. Schools provide a respite from homes that are far from ideal—households where some members abuse opioids, alcohol or other drugs, or where the children are neglected or abused—and school officials often are the people who report this abuse to social services and law enforcement. One in seven children experienced abuse and/or neglect before COVID-19, according to the CDC. The pandemic has increased the vulnerability of these children, partly because of the increased stress levels among parents, according to a report from the Substance Abuse and Mental Health Services Administration. 

When schools transferred to online learning in March, the CDC started to see a decrease in routine childhood vaccine uptake. A report that evaluated vaccines ordered through the federal Vaccines for Children Program—through which 50% of the country’s children are immunized—and vaccine administration data from the CDC’s Vaccine Safety Datalink found 2.5 million fewer vaccines were ordered from mid-March to mid-April 2020 compared with previous years (MMWR Morb Mortal Wkly Rep 2020;69[19]:591-593). The report also found that the weekly number of doses of measles-containing vaccines administered fell from an average of nearly 5,000 doses per week from January to mid-March 2020, to approximately 1,300 doses per week between mid-March and mid-April.

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How Many Students Attend School?

In 2019, about 56.6 million students attended elementary, middle and high schools across the United States: 50.8 million students in public schools and 5.8 million students in private schools

Of the 50.8 million public school students:

  • 35.5 million attended prekindergarten to grade 8
  • 15.3 million attended grades 9 to 12
Source: National Center for Education Statistics, 2019.

But it is showing signs of turning around. At the recent meeting of the Advisory Committee on Immunization Practices, Nancy Messonnier, MD, the director of the CDC’s National Center for Immunization and Respiratory Diseases, said the CDC is already starting to see an increase in orders for vaccinations. And because many states require vaccination for school entry, vaccination uptake is likely to further increase as children return to their pediatricians and schools.

What Are the Risks?
Although returning to school is important for the health, development and well-being of children, reopening must be done safely because not every child is without risk; many have the same chronic conditions that lead to severe disease in adults. For instance, based on estimates from various associations and the CDC:

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Still, the COVID-19 numbers are encouraging; children account for about 3% of the total reported hospitalizations, which is lower than the cumulative influenza hospitalization rates among children during recent flu seasons, according to the CDC. And only about 0.5% of the 149,000 COVID-19 deaths (as of July 29) in the United States are among children. 

A small group of U.S. and European pediatric patients have developed COVID-19–associated multisystem inflammatory syndrome in children, which is associated with COVID-19. CDC surveillance data from March 14 to May 20 from 26 states described 186 children with MIS-C: 31% were Hispanic and 25% were Black; 80% required ICU care and 20% required mechanical ventilation. As of May 20, 70% had been discharged; 28% were still hospitalized and 4% died. But these are very small numbers.

“If we look at the latest data on COVID-19 and children, we find that children represent a little over 7% of all the confirmed cases of COVID-19 among states that report COVID-19 cases by age,” said Tina Q. Tan, MD, FIDSA, a  professor of pediatrics and an infectious disease pediatrician at Northwestern University Feinberg School of Medicine, in Chicago. 

However, between June 18 and July 2, 50,000 new cases of COVID-19 were reported among children, which represents a 43% increase compared with earlier in the pandemic, she added. And “this is probably an underrepresentation of the true number of cases because children are less likely to be tested for COVID-19 compared with adults,” said Dr. Tan, who is also an attending pediatrician at the Ann & Robert H. Lurie Children's Hospital of Chicago.

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“Why COVID-19 appears to be less severe in children than adults still remains unclear,” Dr. Tan said during a press briefing sponsored by the Infectious Diseases Society of America. It could be that they don’t develop the intense immune response to the virus that adults do, particularly the cytokine storm that is so devastating to adults. There also tends to be more “viral interference,” Dr. Tan explained, which means that children are exposed to many respiratory viruses that compete with the ability of SARS-CoV-2 to infect them. There is also a difference between children and adults in the expression of the angiotensin-converting enzyme 2 receptor, which SARS-CoV-2 attaches to for entry into the body (Acta Paediatr 2020 Mar 25. doi.org/10.1111/apa.15271). 

There are good data to suggest that children are infected at lower rates than adults—at least younger children—although there has been some confusion over whether this is due to less testing or changed habits and decreased contacts because of school closures, according to Wendy Armstrong, MD, FIDSA, a professor of medicine and the vice chair of education and integration in the Department of Medicine at Emory University School of Medicine, in Atlanta. 

A surveillance series in Iceland showed an infection rate of 6.7% in children younger than 10, but the rate doubled to 14% for children older than 10 years of age. The positive rate continued to increase as the children’s ages increased. By 20 years, the rate was similar to adults. South Korea saw a similar trend. COVID-19 transmission was lower among households with younger than older children (Emerg Infect Dis 2020;269(10). doi.org/10.3201/eid2610.201315). 

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“There seems to be a difference between children under 10 and children over 10,” Dr. Armstrong said. 

Studies also have shown that children may not transmit the virus as effectively as adults, Dr. Armstrong added. Children were the index case in only 10% of families with multiple members infected by SARS-CoV-2. Another study from South Korea found a similar pattern—at least among younger children. However, children aged 10 to 19 years had similar transmission rates as adults.

What Should Parents Do?
“So, what does all this tell us about reopening schools at this point? This is all theoretical data. How does it apply in real life?” Dr. Armstrong asked. One way to help with the decision is to consider experiences in other countries. For instance, Denmark and Norway were very successful in reopening schools (Euro Surveill 2020;25[22]:2000921. doi: 10.2807/1560-7917.ES.2020.25.22.2000921).

However, the community transmission of SARS-CoV-2 was very low at the time, and there were very careful plans in place. Schools opened to younger children first. Class sizes were limited, with physical distancing, appropriate cleaning and masking protocols, she said.

In contrast, Israel had a less successful experience. Although schools reopened when community transmission was low and class sizes were kept small, after two weeks, the restrictions on class sizes were lifted and there was a simultaneous surge of cases in the community, according to Dr. Armstrong. One month after reopening, two weeks after allowing larger classes, there were significant outbreaks in the schools. One high school reported 153 students and 25 staff were infected, and the infections were not all epidemiologically linked (Euro Surveill 2020;25[29]. doi: 10.2807/1560-7917.ES.2020.25.29.2001352).

These experiences show that “to open safely, community spread must be controlled,” Dr. Armstrong said, and plans must be tailored toward the children’s ages. 

“If they can tolerate masks, they should be worn. There should be plans for physical distancing and other safety measures: cleaning, ventilation and so on,” she said.

Noelle Ellerson Ng, MA, the associate executive director of policy and advocacy at AASA, called opening schools a priority, but said superintendents will only do so if it is safe for the students and staff. “We agree with President Trump that we should start with a position of opening [schools], but we add the very clear caveat like we did in a joint statement with the American Academy of Pediatrics—that we start with the position so long as it is safe and practical,” Ms. Ng said. Because COVID-19 is a different disease in different areas of the country, there are many hybrid approaches. In some cases, the first quarter will be fully online, whereas others are opening for certain days or partial days. Some are opening fully. 

“If you are able to bring students in and you do so on a rotating basis, you are going to need to do a deep clean of the buildings,” Ms. Ng said. 

In addition, just as public health learned the hard way that the infrastructure could not handle a pandemic, Ms. Ng said the school infrastructure also needs an overhaul. “If you don’t have an air filtration system that can move the air and clean and purify it to a standard, that is a moot point for opening schools,” she said.

Drs. Tan and Armstrong, who are both parents weighing the decision about sending their kids to school, said the plans for school reentry must be carefully considered and communicated to parents and the community. In addition to social distancing, masking, and deep cleaning and filtration, schools need a plan about how to handle a positive case. “The public health response to this really needs to be written on paper for us to really feel more comfortable with sending the children back to school, in addition to all the other mitigation steps that can be used to basically try and decrease the transmission and spread of COVID,” Dr. Tan said.

Getting children into the classroom is essential to the nation’s recovery, explained Erin Sauber-Schatz, PhD, MPH, the lead of the CDC’s Community Interventions and Critical Populations Task Force on the response. “The default needs to be that schools are fully open and operational in the fall, so that students can resume full-time learning,” she said, although she conceded that hot spots for COVID-19 might have to resume remote and distance learning until COVID-19 is controlled in those areas.

For schools to reopen, CDC Director Robert R. Redfield, MD, said communities have to get the virus under control by practicing the mitigation strategies: social distancing and masking. “We owe it to our nation’s children to take personal responsibility to do everything we can to lower the levels of COVID-19 so that they can go back to school safely,” he said. 

Although parents and school staff are feeling trepidation about sending their kids to school, there are steps that can be taken to make the schools safer, he insisted. Decisions about when and how schools reopen will have to be local, according to Dr. Redfield, and strategies need to meet the different needs of each community.

The CDC offers guidance here, as does the AAP.