Photo: Sergey Kolomiyets via Unsplash

Understanding COVID-19 in school settings

By Dr David Nabarro and Katherine DeLand.

Educational continuity is essential to long term social cohesion and economic success. That is why in the context of COVID-19, we must better understand what it might mean to reopen schools so students can continue their education, whilst staying ahead of the virus.

Schools are a unique setting in society: they educate and protect children and create the foundation for a generation’s successes. This is particularly true when girls are educated. Schools provide children with not only education, but are also important sources of mental well-being, security, social well-being and – particularly in poorer communities – food. For many primary and secondary students, schools are also a key location for vaccine campaigns.

Communities around the world are conducting risk assessments to determine whether and how to reopen schools. Drs Mike Ryan and Maria Van Kerkhove from the World Health Organization (WHO) have said: A safe return to school can be managed only at the local level and only if local disease transmission is low.

This means that overcrowded schools with the fewest resources and most socio-economically disadvantaged students will be at a disproportionately high risk for outbreaks.

Going back to school depends on the local epidemiology, the local transmission, the local profile of schools, the size of schools, the density of schools, the resources that schools have.

Dr Mike Ryan, Executive Director, WHO Health Emergencies Programme

The age of the children in a given school will help tailor the risk calculus: younger children will have a harder time complying with precautionary measures (e.g. masking in under 10s), while older children will likely have more inclination to socialize without physical distancing.

The WHO/UNICEF/International Pediatrics Association guidance recommends that:

  • children aged up to 5 years should not wear masks for source control;
  • for children between 6 and 11 years of age, a risk-based approach should be applied to the decision to use of a mask; and,
  • children and adolescents 12 years or older should follow the WHO guidance for mask use in adults.

There is no ”one size fits all” for individual family decisions on returning children to schools – all families will have their own risk profiles, including elderly or vulnerable family members living in the house, that must be considered.

The greatest risk for schools re-opening is for employees who are exposed to people each day they work on campus. These school employees, regardless of the level of educational institution, are at an increased risk of contracting and transmitting COVID because of their contact with a high number of people every day. This includes teachers, administrators, professors, aides, janitorial, grounds, maintenance and security staff.

Many schools are implementing creative, innovative re-opening strategies such as staggering start times, reducing student movement around the school, requiring masks and hybrid approaches (i.e. part in-person learning, part virtual learning environments). However, the decision to or not to reopen schools is complex, depending tremendously on local context and virus transmission rates, and is an obvious source of worry for parents, teachers, and students. Importantly, schools don’t operate in isolation; if there is transmission in communities, there can be transmission in the schools that operate in those communities.

Importantly, testing is no guarantee of a safe return to school because of the high rate of false-negative results with currently available tests. The challenge with false-positives isn’t that the test is inaccurate, but instead in interpreting what the test results might mean: it could mean that one did not have COVID-19 at the time of testing, but developed it later, or that the sample was not collected properly or collected too early in the infection. A negative test doesn’t prevent subsequent infection, so testing provides only a point in time understanding of COVID in a population.

Younger children will have greater challenge complying with prevention measures like masking, hand washing, etc., without substantial oversight.

However, case investigation indicates that child to child transmission in schools is uncommon, particularly in preschools and primary schools. Nonetheless, it is useful to note that surveillance strategies that only test symptomatic children will not identify children who are asymptomatic or have mild symptoms and recent data indicates that up to one-fifth of children are asymptomatic.  As leaders and parents move forward in taking decisions about children and schools, it is particularly important that they remain mindful of the rates of transmission in the local community and tailor their approaches accordingly.

large new study from South Korea offers an answer: Children younger than 10 transmit to others much less often than adults do, but the risk is not zero. And those between the ages of 10 and 19 can spread the virus at least as well as adults do.

The findings suggest that as schools reopen, communities will see clusters of infection take root that include children of all ages, several experts cautioned.

Older children are better able to comply with prevention measures like masking, hand washing, etc., but may find oversight difficult.

As social habits change and peers become more important, physical distancing becomes particularly challenging.

Secondary schools tend to be larger than primary/elementary schools. As in any circumstance, increased population density increases the risk of spreading COVID.

NB: Secondary boarding schools will have concerns similar to those at universities because of the dormitory living quarters.

Universities are particularly challenging because students often live in dormitories, where mitigation and prevention measures can be difficult to maintain.

Snippet about the University of North Carolina, United States of America:
On Monday, Aug 10: The University of North Carolina at Chapel Hill started classes.
On Friday, Aug 14: Two clusters of COVID cases (defined as 5 or more cases in close proximity) were identified, one in a residence hall and one in a student apartment building near campus.
On Saturday, Aug 15: A cluster was discovered in a college fraternity.
On Sunday, Aug 16: Another cluster was found in a residence hall. Within a week of the start of classes, 130 students had tested positive, 13.6% of those tested. Visit the live dashboard: UNC-Chapel Hill COVID-19 Dashboard
On Monday, Aug 17: A week after the start of classes, with 177 students in isolation and 349 in quarantine, UNC announced it will shift to all remote undergraduate instruction on Aug 19 and attempt to greatly reduce dormitory occupancy.
Source: UNC University News

The recommendations for children are being considered by school and, if masking is appropriate in schools for 12-18 year olds and they are to be considered as adults for this purpose, then it is reasonable that masks also be considered for adult students of all ages. 

WHO, UNICEF and the International Paediatric Association have recently recommended that children over 12 follow the same masking guidance as adults. Adults are advised to wear masks as part of a comprehensive package for prevention that also includes hand washing, physical distancing and avoiding crowded spaces. 

In settings where people are speaking with raised voices, it may also be appropriate for visors to be warn by the speaker for the protection of others. Virtual options for teaching continue to be an important option.

The question on whether or not to go back to school must not be made in isolation. Schools should be considered part of their community, with transmission risk prevention decisions taken in the context of local virus transmission rates.

Being ready to reassess decisions when the number of cases in the community changes, is the best way to stay on top of the virus and provide students and their families with opportunities to continue education with low risk.

WHO, UNICEF and the International Paediatric Association jointly reviewed the available evidence to develop guidance on the use of masks for children. In the absence of strong scientific evidence, consensus among these groups forms the main basis for this guidance.

The European Centre for Disease Prevention and Control published an overview of the epidemiology and disease characteristics of COVID-19 in children (0-18 years) in EU/EEA countries and the United Kingdom (UK), and an assessment of the role of childcare (preschools; ages 0-<5 years) and educational (primary and secondary schools; ages 5-18 years) settings in COVID-19 transmission.

Snapshot from WHO COVID-19 Weekly Epidemiological Update, as of 10:00 CET 23 August 2020

Over 1.7 million new COVID-19 cases and 39 000 new deaths were reported to WHO for the week ending 23 August, a 5% decrease in the number of cases and 12% decrease in the number of deaths compared to the previous week (10 to 16 August)

As of 4:33pm CEST, 28 August 2020, there have been 24,299,923 confirmed cases of COVID-19 reported to the WHO including 827,730 deaths.

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