- Viner RM ,
- Russell SJ ,
- Croker H , et al
. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health) The media highlight of a possible rare new Kawasaki-like vasculitis that may or may not be due to SARS-CoV2 does not change the fact that severe COVID-19 is as rare as many other serious infection syndromes in children that do not cause schools to be closed. Individualised risk assessment and decision-making by clinicians should occur for those considered at exceptional risk (such as in immediately after bone marrow transplant) or where there are other older family members at significant risk.
- Viner RM ,
- Russell SJ ,
- Croker H , et al
. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health)
Reopening schools after the COVID-19 lockdown
Prof Aziz Sheikh
Usher Institute
The University of Edinburgh
Doorway 3, Old Medical School
Teviot Place
Edinburgh, EH8 9AG
Scotland, UK
ku.ca.de@hkiehs.ziza
With nationwide school closures currently operating in 191 countries, the United Nations Educational, Scientific and Cultural Organization (UNESCO) has estimated that 1.6 billion (90.2%) students are currently out of primary, secondary and tertiary education (henceforth schools) as a result of the global COVID-19 lockdown [1]. These restrictions have been introduced to help maintain physical distancing and have contributed to the stabilising incidence of SARS-CoV-2 infections and resulting COVID-19 hospitalizations and deaths now being witnessed in many parts of the world. These measures have the potential however – particularly if prolonged – to result in major detrimental effects on the health and well-being of children and adolescents. In the absence of a robust evidence base on lockdown exit strategies, we consider the range of options being taken globally to reopen schools with a view to informing the formulation of national plans.
It is now well recognized that children and young people can be asymptomatic carriers of SARS-CoV-2 or develop COVID-19 [2]. Although COVID-19 tends to be less severe in children and adolescents, and thankfully relatively few students have died of the condition, a key policy concern has been that young people may be important community reservoirs for the transmission of the virus to household members. Emerging evidence however suggests that children are not super-spreaders of the virus and in fact may not be significantly contributing to spreading the virus [3–5]. A recent (unpublished) systematic review concluded that children and young people under 20 are 56% less likely to contract SARS-COV2 from infected individuals than adults this suggesting they may play a smaller part in transmission than originally thought [6]. It appears therefore that SARS-CoV-2 behaves differently in this respect from many other viral respiratory infections that are responsible for upper respiratory tract infection (URTI) and influenza. A recent systematic review on school closures, which drew primarily on the evidence base from severe acute respiratory syndrome (SARS), concluded that around 2–4% of COVID-19 deaths could be prevented as a result of school closures [7].
Although an important public health intervention in the context of epidemics/pandemics, school closures can have adverse effects on children and adolescents in multiple ways [8]. Not only are they missing out on their education – with potential lifelong implications – children from deprived backgrounds are at increased risk of hunger from missing free school meals, domestic violence, and the poverty that ensues from parents being unable to work because of daytime caring responsibilities. These consequences are felt most by the most vulnerable members of society. The longer lockdowns continue, the greater the risks to the well-being of young people.
What then are the options for reopening schools? The key consideration is how to enable the safe return of as many learners and staff as possible whilst maintaining physical distancing. Table 1 summarises the approaches that are being employed internationally. We briefly consider these four broad approaches in turn.
Table 1
Strategies being adopted internationally to reopen schools after the COVID-19 lockdown
| Strategy | Countries |
|---|---|
| Maintain closures indefinitely until a vaccine or treatment available
|
Current default position for most countries eg, Canada, Israel, Italy, Malta, Spain, UAE, many US states
|
| Open completely
|
Some regions of Japan; Taiwan
|
| Partial reopening:
|
|
| By school-level (eg, primary schools)
|
Denmark, France, Germany, Iceland, Israel, Mexico, Netherlands, New Zealand, Norway, South Africa, Sweden, Vietnam; regions of China
|
| Shifts
|
Vietnam
|
| Outdoor schooling
|
Denmark
|
| Hybrid physical and virtual school | New Zealand, Vietnam; regions of Russia |
The first is to maintain school closures until a vaccine can be administered at sufficient levels to achieve herd immunity or a treatment is found. Optimistic estimates suggest that it will be at least 12-18 months before a vaccine is developed and deployed [9]. Given the substantial negative effects of school closures, it seems most unlikely that this will be a tenable strategy for most countries in the medium- to longer-term.
A second approach is to reopen schools completely once the effective reproduction number (Rt) is well below 1. Whilst this has the benefits of resuming normal schooling, it runs the risk of triggering further peaks in infection. The magnitude of this risk will become clearer as the epidemiology of SARS-CoV-2 transmission in young people becomes better understood. The approach being employed in Denmark whereby children are being taught outdoors and maintaining 2m physical distancing through for example the rearrangement of desks, in an attempt to reduce droplet and contact transmission, could potentially be replicated in a number of other countries [10].
The third strategy is to partially reopen schools such that there are fewer students at school at any one point in time thereby enabling physical distancing. This has been the most popular school lockdown exit strategy employed thus far with students typically attending for part of the week or in shifts.
Finally, a hybrid approach whereby in-person classes are live-streamed to those who for example need to be shielded because of underlying chronic disease or have the capacity to study from home. This is however clearly dependent both on having high speed Internet access and appropriate devices (personal computer, laptop or tablet) at home.
The final three options all need to be accompanied by developing surveillance capability and the ability to rapidly test, trace and isolate suspected COVID-19 cases and their contacts. These also requires capacity for regular deep cleaning of schools to minimise the risk of contact transmission.
It is clear that there are no easy answers. Whichever approach countries choose to take, it is crucial that there are carefully planned evaluations of the approaches employed to help develop a robust evidence base to guide decision making for this and future pandemics.
Footnotes
Funding: None.
Authorship contributions: AzS conceived this paper and commented critically on drafts of the manuscript. AsS, ZS & SD sourced the examples and jointly drafted the manuscript. All authors approved the final version of the manuscript.
Competing interest: AzS is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group. This work in no way represents the views of the Scottish Government. The authors have completed the ICMJE Uniform Conflict of Interest form (available upon request from the corresponding author), and declare no further conflicts.
REFERENCES
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COVID-19 and the re-opening of schools: a policy maker’s dilemma
Associated Data
Abstract
The epidemic of coronavirus disease 2019 (COVID-19) broke out in Wuhan, China, in December 2019 and rapidly spread across the world. In order to counter this epidemic, several countries put in place different restrictive measures, such as the school’s closure and a total lockdown. However, as the knowledge on the disease progresses, clinical evidence showed that children mainly have asymptomatic or mild disease and it has been suggested that they are also less likely to spread the virus. Moreover, the lockdown and the school closure could have negative consequences on children, affecting their social life, their education and their mental health. As many countries have already entered or are planning a phase of gradual lifting of the containment measures of social distancing, it seems plausible that the re-opening of nursery schools and primary schools could be considered a policy to be implemented at an early stage of recovery efforts, putting in place measures to do it safely, such as the maintenance of social distance, the reorganisation of classes into smaller groups, the provision of adequate sanitization of spaces, furniture and toys, the prompt identification of cases in the school environment and their tracing. Therefore, policy makers have the task of balancing pros and cons of the school re-opening strategy, taking into account psychological, educational and social consequences for children and their families. Another issue to be considered is represented by socio-economic disparities and inequalities which could be amplified by school’s closure.
Main text
Italy was the first European country to implement a national lockdown to contain the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mitigate the impact of an inevitable surge of COVID-19 cases. After over 8 weeks of social distancing measures, the country is now shifting its strategy from mitigation to recovery, and other countries are watching how Italy will re-open and contain new clusters, with the hope of learning from its experience.
In children, the diagnosis of COVID-19 is complex due to lack of specificity of its symptoms (fever, fatigue, and dry cough), causing difficulties in the differential diagnosis with pediatric infectious diseases occurring in winter and spring seasons. Moreover, children are often unable to describe minor symptoms related to this new disease, for instance myalgia, headache, anosmia and ageusia, and cases can be easily missed. In fact, as observed in a series of 731 pediatric COVID-19 cases the cumulative incidence of patients with asymptomatic, mild or moderate disease was 97%, suggesting a milder presentation in children [1]. This finding is consistent with the results of a systematic review, which found that children at any age were mostly reported to have mild symptoms or were asymptomatic and that pediatric patients with COVID-19 had generally a good prognosis and recovered within 1 or 2 weeks after disease onset [2].
As the pandemic progresses, more data are becoming available on how different age segments of the population are susceptible to the infection. Considering recent data [3], we calculated the cumulative incidence in the three Italian regions most affected by the epidemic, Lombardy, Emilia-Romagna and Veneto, that are 0.29, 0.34 and 0.34 per 1000 children 0–9 years old, respectively, lower compared to the rest of the population. These data are also consistent with reports from the Republic of Korea [4] where only 1% of the first 7755 laboratory-confirmed cases occurred in the 0–9 age group. Additionally, a testing of at risk individuals in Iceland through oro- and nasopharyngeal swabs showed that children under 10 years of age were less likely to test positive (6.7%) compared to other age groups, and that in the general population screening no child under 10 years of age resulted positive [5]. In the municipality of Vo’ (Veneto region, Italy), where the first Italian related COVID-19 death was registered, the entire population was tested twice for the presence of SARS-CoV-2 with nasopharyngeal swabs and no infections were detected in the 234 children aged 0–10, despite at least 13 of them were living with infected family members [6]. A recent investigation suggests that the spread of COVID-19 within New South Wales (Australia) schools has been very limited. In particular, on a total of initial six cases in five primary schools (one student and five staff), only one of 168 close contacts was identified as a secondary case. Moreover, the Australian report shows a small probability of infection among children and no evidence of children infecting teachers [7]. Otherwise, severe cases of SARS-CoV-2 infection in children under 2 years old have been reported in literature [1, 2] and recently, several cases of a multisystem inflammatory syndrome in children with a possible temporal association with SARS-CoV-2 infection have been reported even if further investigations are needed to confirm the association with SARS-CoV-2 [8].
In light of such data, a thoughtful consideration of the implications of school closure policies on children’s health is necessary. Children aged from 2 to 10 years old have an active social life at school which helps learning from peers and positively impacts the development of personality traits and sense of identity. Not only, disruptions of close peer relationships have been associated with depression, guilt, and anger in children. In addition, children experiencing isolation and quarantine have shown an increased risk of developing post-traumatic stress disorder, anxiety, grief, and adjustment disorder [9]. Parents are often the only care providers for children, which limits their work productivity, even when they are fortunate to have a job that allows them to work from home. In some cases, forced cohabitation in a home environment, with parents suffering from economic and mental health issues exposes children to the risk of uncovering violent behaviors. Regarding the educational aspects, during the lockdown, e-learning is not always a feasible alternative to face-to-face instruction for these aged children, particularly when acquiring hand-eye coordination for writing. E-learning could also amplify inequalities (digital divide). Therefore, the potential benefits of dismissing students aged 2 to 10 years old from schools to contain the spread of infection may be outweighed by the negative consequences of keeping them home.
The questions being asked are what could the conditions necessary for a safe opening of schools for children aged from 2 to 10 years be and secondly can school re-opening be considered as one of the policies to be implemented at an early stage in recovery efforts? [10]. As shown before, children aged from 2 to 10 years have a low rate of severe infection, a probably marginal role in spreading the disease, but at the same time they have a big toll to pay for school closure. It seems plausible that the re-opening of nursery and primary schools can be considered a policy to be implemented at an early stage of recovery efforts, but it is important to be able to guarantee safe conditions and an appropriate surveillance system. Safe measures for the re-opening of the schools may include the creation of fixed small groups of children, in order to balance the need to go to school and the need to maintain social distance, taking into account the available spaces and potentially considering the implementation of differentiated shifts to attend schools. Avoidance the sharing of materials, reallocation of common rooms and areas, together with ensuring frequent access to hand washing could also represent successful strategies that can be modulated according to the organisational capacity of the single institution. Measures such as ventilation of rooms and sanitization of environments are fundamental. Moreover, children could greatly benefit from time spent outdoors. In order to check the feasibility of this approach, in the first phase, partial class re-opening, coupled with e-learning could be provided. Teaching and school staff should be additionally trained to identify early signs of mental health issues related to quarantine and isolation. Concerning surveillance system, this should consist in proper information/education of teachers and parents, prompt identification of cases in the school environment, testing capacities, case tracing, isolation, and quarantine.
In Denmark, where the public health system showed the capacity to promptly identify and trace COVID-19 cases, the Government took the decision to send back to school children up to 11 years old on April 15, 2020. School activities have been properly designed in order to limit as much as possible any spread of the virus. After a month, the adopted measures (the creation of small groups of children for lessons and for playtime, frequent hand washing, student’s desks spaced 6 feet apart, and, whenever possible, classes held outside) seem to be effective. In Japan, schools have reopened following the proposal of the Government to give priority for some grades, including first- and sixth- grader at elementary schools. In particular, the decision on when and whether or not to reopen schools has been left to local municipalities based on the number of COVID-19 cases in the area. Guidelines for schools re-opening have been released by the Ministry of Health. The included measures range from checking temperature daily, to maintaining physical distance and wearing face masks. We do not have by now information about safety and effectiveness of school re-opening in Japan.
To sum up, the strategies of schools’ re-opening, if implemented, taking into account the balance of pros and cons for children of the mentioned age, should be led by a flexible approach in order to adapt to the local context in terms of epidemiological data and system capabilities.
Abbreviations
| COVID-19 | Coronavirus disease 2019 |
| SARS-CoV-2 | Severe acute respiratory syndrome coronavirus 2 |
Authors’ contributions
MPF and ML conceived the present letter to the Editor. All authors performed a literature research. CR and GBB carried out data collection. All authors contributed to the interpretation of the data and to the writing and reviewing of the manuscript. All authors read and approved the final manuscript.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
•2–4% of COVID-19 deaths could be prevented as a result of school closures [7].
•Although an important public health intervention in the context of epidemics/pandemics, school closures can have adverse effects on children and adolescents in multiple ways [8]. Not only are they missing out on their education – with potential lifelong implications – children from deprived backgrounds are at increased risk of hunger from missing free school meals, domestic violence, and the poverty that ensues from parents being unable to work because of daytime caring responsibilities. These consequences are felt most by the most vulnerable members of society. The longer lockdowns continue, the greater the risks to the well-being of young people.
•it will be at least 12-18 months before a vaccine is developed and deployed [9]