Aug 11, 2020 12:00 PM

Author: Kylene Metzger


Infectious Disease doctors at University of Utah Health held a Q&A panel about COVID-19 and the potential impact it could have on students, teachers, and families when they return to school. The process of returning to school has caused concerns for parents and teachers. The decision to open classrooms and the guidelines put in place by school districts can influence the safety and well-being of those in the education system.

The panel of health care professionals includes:

Sankar Swaminathan, MD
Chief of the division of infectious diseases at U of U Health 

Andy Pavia, MD
Chief of the division of pediatric infectious diseases at U of U Health

 Adam Hersh, MD
Professor in the division of pediatric infectious diseases at U of U Health

Q: The American Academy of Pediatrics came out in favor of schools reopening. What was the reason behind the recommendation?

A: Swaminathan: The American Academy of Pediatrics (AAP) emphasized the need for schools to open for many reasons. The consequences of not going to school with other children are profound. It leads to social development delays, and for many children, school is an important source of nutrition and moderating their health and well-being. Pediatricians are concerned this is going to have a detrimental impact on children. This will also impact families of disadvantaged backgrounds who have various types of things they get at school that they don’t get at home.

A key clarification that the AAP made about school reopening is “Returning to school is important for the healthy development and well-being of children, but we must pursue re-opening in a way that is safe for all students, teachers, and staff. Science should drive decision-making on safely reopening schools. Public health agencies must make recommendations based on evidence, not politics.”

Q: What is the latest information about COVID-19 transmission among children?

A: Pavia: The data is a little complicated. For teenagers, it’s pretty clear they are somewhat less likely to get infected and somewhat less likely to become seriously ill. But we do see teenagers who become seriously ill and are hospitalized. It’s not as many as it is in older age groups. Teenagers are not immune completely from the disease or complications.

Younger children (age 1-8) very rarely get sick enough to be hospitalized if they are healthy and don’t have underlying health conditions. The other part of that equation is not how often kids get infected, but how easy it is to transmit. We have good data that young kids (age 1-8) are less likely to become infected. Where we have a mixed picture is how readily they can transmit to adults. We know they can transmit, but is it less compared to other adults? Modeling suggests that young children are rarely the cause of family outbreaks and are substantially less likely to transmit. But recently we’ve seen data that suggests this may not always be true, and younger children can be responsible for super spreader events.

Q: Are face masks safe for children?

A: Hersh: Wearing a mask all day is one of the important strategies we have available to protect a child’s health. The science is very clear that wearing face coverings reduces transmission dramatically. We acknowledge it’s uncomfortable to wear a face covering, but it’s one of the most important tools to protect a child’s health, particularly in the school environment.

Q: What kinds of questions should parents be asking to make sure their schools are handling reopening in the safest way possible?

A: Pavia: There are a number of things that are important to reduce transmission.

Mask wearing:

  • Will teachers wear masks?
  • What’s going to be done to teach children how to wear a mask and how to do it successfully?

Ventilation:

  • Will windows and doors be open?
  • What does the HVAC system look like?

Cohorts:

  • What about group sizes?
  • Is there a cohorting approach?

Physical Distancing:

  • What can be done about physical distancing?
  • Is there enough room to keep desks six feet apart? If not six, what about five feet?

Some other difficult questions include what’s the plan for when a child or teacher becomes ill or when the investigation will be done? Are there criteria for who stays home and when you need to close the school?

A: Hersh: Last week, the state provided pretty clear, concrete guidance as benchmarks for when a classroom and a school will need to be required to close for in-person learning. These are important policy parameters for parents and school leadership to be aware of. The state has stated that if three or more children in a 13-day period in a single classroom test positive, that cohort will close. If 15 or more children, teachers, or members of the community test positive in a 14-day period, or if 10% of the school tests positive (whichever is lower), than the school will close for an indefinite period of time. Those are guidelines. A school may choose to enact closure (whether for a cohort or entire school) with lower case numbers.

Q: What do we know about the effectiveness of face shields compared to masks?

A: Pavia: Our experience with getting kids to wear masks is actually very good. Like any other skill, you have to teach kids to do it and get them used to it. We know a lot about masks and their efficacy at protecting the person wearing them, which is modest at preventing from spreading. We know a lot less about face shields. We don’t have data for children wearing a face shield all day. It’s probably better than nothing, but in terms of our understanding of how close it comes to a mask for efficacy, we just don’t know. There are very few if any reasons not to push to use what works, and that’s wearing a mask.

Q: Is it possible to open schools safely and successfully?

A: Swaminathan: There’s no one recipe, and it depends on a lot of different factors such as how well are standards including ventilation, cohorts, mask wearing, and hand sanitation being met. In terms of successful reopening—some of the evidence that suggests kids are not the major drivers of outbreaks is true. Both those studies were done under conditions where the schools were already locked down. They were done shortly after South Korea and Switzerland took fairly dramatic measures when they saw what was happening. So kids weren’t the driving epidemic because they weren’t going to school. But we don’t know how much a problem outbreaks in schools are going to be yet.

The CDC has various criteria down to the county level on COVID-19 community transmission. This is a key variable. It may be possible for one county to open with relatively little risk because there is relatively little community transmission. Despite the best intentions, if there is a raging amount of community transmission like there is in several states and fairly high transmission in at least a couple of counties in Utah, there is going to be a risk of opening schools. The risk to the child may not be very high, but the risk of them exacerbating community transmission and bringing it home exists.

If there’s not enough testing and the positive percentage rate is going up, that tells us that there’s a greater amount of community transmission that we aren’t picking up. Warning signs such as an increase in test percentage positivity and declining test ratios mean restrictions should not be relaxed rapidly. It should be metric driven.

Q: Is it safe to go back if desks cannot be distanced?

A: Hersh: Under normal circumstances, the customary distance between desks is three to four feet in a classroom. The greater the distance, the better. In terms of whether it’s going to be safe depends on the actual classroom itself and the community transmission. The lower the transmission rate in the community, the more able we can tolerate slightly closer together desks than further apart.

Perhaps the most important thing we can all do in the community to open schools and allow them to stay open is to do what we know helps reduce transmission outside the school environment. This includes keeping the appropriate distance between us, not going to mass gatherings, and wearing a face covering at all times in public spaces.

A: Pavia: Is there is one take home, it’s what Dr. Hersh just said—reducing spread in the community is the single factor that will help us have success in school reopening. If you look at case studies of the countries that have had good success, they all started from very low levels of community transmission. These counties include Japan, South Korea, and Norway. The example that it didn’t go well is Israel, where community transmission was modest. It was not very low but not as high as we (in Utah) are experiencing now. They also had very crowded classrooms and moved very quickly to go back to normal operations. It led to a major second wave throughout the country. Things can go very well and can go very badly. We’re going to have to be very alert and flexible. We should not be committed to one course of action but to respond to what we see happening.

Q: Will the length of time students are together impact how effective masks are?

A: Pavia: All of our protective measures are like layers. Each one is not perfect. A layer of protection adds more protection. Masks are one of the most effective layers we have. Ventilation, distance, and time of exposure to sick people is another. If you have an hour-long class, you need to layer all the protections. If you can shorten the interactions, that adds another layer of protection. Not one tool can give you 100% protection or fail.


Kylene Metzger

Public Affairs

coronavirus covid-19 kids health infectious diseases pediatric infectious diseases school

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