It’s hard to believe it’s already August. If you’re a parent like me, that means that pretty soon, if you haven’t already, you’re going to need to decide whether to send your children back to school, do distance learning this fall, or some combination. I’m not going to lie and tell you that it’s a simple decision. It’s complex and depends on many factors: your child’s age, any high-risk conditions they or other people living in your household have, the current level of COVID-19 in your local area, your own ability to do distance learning and/or your child’s needs for on-site services, and how prepared your school is to protect your children from the spread of COVID-19.
In this week’s post, I’m going to review the available evidence, prominent expert statements on whether schools should reopen, and share resources to help you make your decision.
This past March, all 50 states closed schools in response to the first wave of COVID-19 in the United States. This was done for two reasons: because school closures was one of several effective measures used to control the spread of the 1918 flu pandemic, and because physicians and scientists have long known that children spread influenza and other infections of the nose and throat. A 2016 study found that children were 78% more likely than adults to be infected with influenza, and 65% more likely to spread it. Indeed, I suspect any parent whose child has spent more than a few weeks in child care can attest to how quickly a common cold can spread first through an entire classroom and then to all of the kids’ family members.
However, COVID-19 has not behaved like influenza or the common cold. Children have much higher rates of colds than adults do. Influenza is most severe among young children and older adults. In contrast, older adults and people with certain health conditions are at higher risk of severe COVID-19, whereas there have been fewer known severe cases of COVID-19 in children, even considering the Multisystem Inflammatory Syndrome in Children.
You may have heard certain politicians calling for schools to reopen, as well as that the American Academy of Pediatrics (AAP), British Medical Journal (BMJ) and New England Journal of Medicine (NEJM) all recently supported reopening schools. I won’t comment on the politicians, but let’s examine the AAP, BMJ and NEJM statements more closely.
First, the AAP’s statement, which was jointly issued along with the American Federation of Teachers, National Education Association and the School Superintendents Association, was not an unequivocal call for all schools to reopen immediately regardless of circumstances. They stated that “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” and that “schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts. A one-size-fits-all approach is not appropriate for return to school decisions.”
However, they concluded that where schools can be safely reopened, in-person schooling is critical not only for education, but for children’s social and emotional development and well-being, racial and socioeconomic justice, and for special services that may not be able to be offered elsewhere.
Likewise, the BMJ viewpoint reviewed the published literature on COVID-19 in children and concluded that there is very little to no evidence that children are “super spreaders” of COVID-19 as had been initially suspected. Again, the BMJ article emphasizes decision-making based on science and evidence.
Finally, while the NEJM opinion piece states that they believe that “safely reopening schools full-time for all elementary school children should therefore be a top national priority”, they recommend that more efforts be undertaken this summer to lower rates of COVID-19 to less than 10 cases per 100,000 people in order for schools to safely reopen. They again note the multiple benefits of in-person schooling, not only for education but for kids’ physical and mental health, reducing racial and ethnic disparities (many of which have worsened over the last several months), and allowing parents and guardians to re-enter the workforce, including essential health care services. As with the BMJ article, they cite evidence of low rates of COVID-19 among children, as well as data from countries that have already reopened schools.
So, what does the evidence show about school closures, COVID-19, and children?
First, there is some evidence that closing schools this spring may have somewhat helped to control the COVID-19 outbreak in the U.S. An article published online in the Journal of the American Medical Association (JAMA) last week reported that the increase in new U.S. cases and deaths due to COVID-19 both decreased by about 60% after schools closed, and that states that closed schools earlier had larger decreases. Using a predictive model, they estimated that 424 new cases out of 100,000 people and that 12.6 deaths out of 100,000 people were prevented in the first 26 days after schools closed. To put that in context, there are over 328 million people living in the U.S. If these estimates are correct, then nearly 1.4 million cases of COVID-19 and over 40,000 deaths were prevented within 4 weeks of closing U.S. schools.
Those are pretty remarkable findings. However, the study has a big limitation: while it measures changes in COVID-19 cases and deaths after schools closed, it doesn’t account for other COVID-19 control measures put in place at the same time or soon after schools closed. As you likely recall, state and local governments put many other control measures in place around the same time, including travel bans, isolation and quarantine orders, restrictions on large gatherings, closure of non-essential workplaces, stay-at-home orders and (in some locations) mask requirements. When several things all occur at or close to the same time, it’s nearly impossible to determine how much each individual action affected the final outcome. Therefore, it would be a reach to say that all of those cases and deaths were prevented by school closures alone when we know that many other public health actions were happening at the same time.
In contrast, consider the article published in the BMJ in July 2020, which I previously discussed in my post about social distancing. That article examined 149 countries or regions that used a variety of different combinations of COVID-19 control measures. Among other findings, they found that countries that closed schools without closing workplaces prevented fewer cases of COVID-19 than countries that closed both.
In addition, a letter to the editor published in Nature Medicine in June 2020 described a statistical model that estimated the spread of COVID-19 in countries with varying population ages and density. After making various tweaks to the model, their final version closely matched COVID-19 outbreaks in several countries. They then simulated the effects of 3 months of school closures on the spread of influenza and COVID-19 in three cities. They found that school closures reduced simulated flu outbreaks by one-sixth to one-third, but did not have a substantial effect on COVID-19 outbreaks.
If children really are “super spreaders” of COVID-19, then it might make sense to shut down schools even if children don’t get very severe infection. However, the available data does not support the “children-as-super-spreader” theory.
A case series published this month in Pediatrics described the first 40 cases of COVID-19 in children in Geneva, Switzerland, including cases of COVID-19 in their households. Nearly 4 in 5 of the children had an adult in their household with symptoms of COVID-19 before the child developed it, whereas less than 1 in 10 children in this case series were the first members of their household to develop COVID-19. This suggests – but doesn’t prove – that children may be far more likely to catch COVID-19 from an adult in their household than to spread it to their household members. If this bears true, then it could mean not only that children are not the “super spreaders” they are often suspected of being, but that closing schools (where they primarily come into contact with fellow children) might put them more at risk by putting them into closer contact for longer periods of time with adult family members.
A non-peer reviewed preprint article released online in March analyzed studies published between December 2019 and March 2020 describing “clusters” of COVID-19 spread within households in China, Singapore, South Korea, Japan, and Iran. Out of 31 household clusters that they reviewed, only 3 (1 in 10) were spread by children. However, take this finding with a grain of salt since the article was not peer-reviewed (or at least the version I read was not; I was unable to find a published version). Peer review is a very important process in which experts in a field review journal articles before they are published in order to identify potential errors, evaluate whether the researchers used appropriate methods and whether their conclusions correctly reflect their findings, and recommend whether the article should be published. There have been a lot of attention-grabbing headlines about non-peer reviewed preprint articles over the last 5 months and, unfortunately, some of those articles turned out to be fraudulent or poorly done. I don’t recommend basing any major decisions on a single non-peer reviewed article, but it can be suggestive of something that bears further research.
Finally, a small case series published in June in Clinical Infectious Diseases described case investigations and contact tracing from 2 cases of COVID-19 in siblings attending preschool and secondary school, and 1 case of COVID-19 in an adult preschool staff member. All students from the same class as the two siblings were put under quarantine and monitored for 14 days, and all other students and parents from the school were notified of the exposure and asked to monitor for symptoms of COVID-19 and were tested for COVID-19 if they developed any symptoms. Although many children at the preschool or school developed cough or runny nose within 14 days after the initial cases occurred, none tested positive for COVID-19. In the preschool with the case in an adult staff member, 16 coworkers caught COVID-19 as did 11 household contacts of cases. All students at the preschool were tested for COVID-19, regardless of symptoms, but once again no children exposed in the preschool tested positive for COVID-19.
In summary, there are many benefits to in-person schooling, the evidence does not support that children are super-spreaders, and evidence is mixed (at best) regarding the extent to which school exclusions help control COVID-19. However, keep in mind that they did not necessarily find that school exclusions don’t help control COVID-19 at all, but that they might be less effective than other social distancing measures. Additionally, even if the risk of children catching and spreading COVID-19 is lower than for adults, that risk will be much higher in communities with high rates of COVID-19. Returning to in-person schooling is not risk-free, but there are steps that schools, parents, and community members can take to lower that risk.
First of all, we all need to continue to social distance, wear masks, wash our hands and follow the basic steps to control the spread of COVID-19, even if you’re lucky enough to live in an area where there isn’t much COVID-19 spreading, and even if your local government doesn’t require it. If your child does return to school, then check their temperature every day and monitor them for signs of COVID-19. If they have a fever or any new signs or symptoms of COVID-19, or has any other sickness, then please keep them home and call their healthcare provider, even if you wouldn’t ordinarily do so under different circumstances.
The CDC has issued guidance for schools on reopening, as have many state and local health and education departments. The list of recommendations is lengthy, but in general class sizes should be smaller, children should be spaced at least 6 feet apart and/or wear masks in school and/or have sneeze guards or other barriers between desks, schedules should be staggered where possible, large gatherings should be cancelled, postponed or changed to virtual events, teachers and staff should be screened for symptoms of COVID-19 and parents should screen their children, children should be taught and encouraged to wash their hands frequently, and schools should be cleaned frequently and well-ventilated.
If it sounds like I haven’t given a definitive answer about whether to send your children back to school, it’s because there is no one-size-fits-all answer. But here are a few things to consider.
- How much and how quickly is COVID-19 spreading in your area? Hopefully your state or local health department is sharing this information, but if they aren’t then I like both the StatNews Covid-19 Tracker and the information at covidexitstrategy.org. Right now, most (but not all) of the Northeastern U.S. states are decreasing or holding steady, but that could change in the future. Nearly the entire rest of the U.S. is currently experiencing severe COVID-19 outbreaks. I personally would not send my children to school in-person this fall if I lived in California, Texas, Florida, Louisiana, Arizona or Georgia (please note that this is not an exclusive list of states experiencing outbreaks, only some of the biggest current outbreaks).
- Does your child have any high-risk conditions? While children overall appear to have less severe COVID-19, children with cancer, weak immune systems, chronic kidney disease or sickle cell disease appear to be at higher risk. Additionally, two studies of the Multisystem Inflammatory Syndrome in Children suggested that obese children and those with chronic lung disease might be at higher risk of this complication. If your child has any of these conditions or any other conditions that you are concerned about, talk with their primary care provider before you decide whether to return them to school.
- Does anyone in your household have high-risk conditions? If so, could your child potentially expose them to COVID-19 or do you have a plan or way to keep them separate? Again, I recommend that any high-risk household members speak with their healthcare providers about potential risks of your child returning to school.
- What are your school’s plans to protect children and staff from COVID-19? Have they shared their plans with parents yet? How open and communicative are they? Are their plans consistent with CDC and state or local recommendations or requirements? If your school has not shared their plans, is downplaying risks from COVID-19 or plans to return to “all systems normal”, then this is a very red flag. Additionally, I realize that some states have requirements that are much stricter than the CDC recommendations, whereas others have much looser or no requirements. I recommend following the strictest applicable recommendation or requirement. Remember, this is to protect your children and your community.
- Does your children need any special education or services? Can they be given remotely or do they need to be given on-site? If they must be given on-site, then what steps will your school offer to protect your child?
- Do you have the capability for distance learning? In my opinion, this consideration is consistently downplayed or treated as “selfish”, but it is very important. First of all, if your school requires certain technologies that you do not have for distance learning, then it may not be an option for your child. Secondly, do you need to work on-site or can you telecommute? If you need to work on-site then do you have someone to watch your children while you are at work? Many working parents gave up their child care plans when their youngest child returned to school, and child care is at a premium now. If you can telecommute, think realistically about whether you can do so while your kids are at home. If you telecommuted this spring, then think about how things went then and whether you could manage it that way all year. Women have been disproportionately affected by job losses due to COVID-19. It is not selfish to decide to send your children to school because you cannot afford not to or would lose your job if you didn’t.
- How old are your children? I wasn’t able to find studies to cite here, so I apologize, but in general the consensus I’ve seen among public health and education experts as well as fellow parents is that (1) teens have COVID-19 risks more similar to adults than to younger children and (2) teens handled distance learning better, from both educational and social/emotional perspectives, than early elementary school-aged children. You might feel perfectly comfortable having your high schooler fully distance learning or on a hybrid schedule with only a few days in school per week, while wanting your elementary school-aged child in school daily as long as the school can safely protect them.
Finally, a couple of resources to help you with your planning: the CDC recently released an excellent 3-page Back to School Decision Making Tool for parents. I highly encourage you to review it. They also released checklists to help parents and guardians prepare for either returning to school or distance learning, as well as resources to handle stress and uncertainty.
Whether to have your kids return to school or distance learn is a big decision, and I’m sorry I can’t give one single answer, but I don’t believe in oversimplifying complex issues. My best advice to you is to read as much as you can about COVID-19 in your local area and your school’s plans, ask questions, talk to your child’s healthcare provider, and review the CDC decision making tool and checklists. Best of luck with whatever decision you make, stay healthy, and keep wearing your masks and social distancing!
😷 Dr. B