By Dr Sheri Fanaroff  MBBCh FCFP MFamMed, a Family Physician, practicing in Melrose, Johannesburg.

Please Note: This article was written on 21st May as part of a series of regular updates on the COVID-19 pandemic for the benefit of her patients. It was written in an attempt to answer the many questions that patients have asked about how safe going back to school is. The article was written with reference to the best available evidence on this date, noting that the knowledge and guidelines around COVID change rapidly as more information becomes available. It has been endorsed by the GGPC (Gauteng General Practitioners Collaboration).

Parents everywhere are raising their eyebrows as to how safe it is for both their kids and teachers to go back to school. Schools in 190 countries around the world have been closed over the last two months. We are thus not alone in South Africa as we try to negotiate a balance between safe re-opening of schools and increasing infection rates. So, how safe is going back to school really?

The safe return to school depends on 3 issues

Stellenbosch University recently published an in-depth policy brief which states that the question of when and how children should return to school depends on :

1.  Risk to children of disease and death
2. Transmission of the virus from children to adults
3. Social and economic costs of keeping children at home

Let’s clarify these and then visit some frequently asked questions:

1. Risk of Covid-19 in children, deaths and infections 

Deaths

Fatality rates from COVID-19 by age (ourworldindata 21 May) show that for children the risk of dying if infected is negligible. Case fatalities to date:

Worldwide

      • 0-9 years: South Korea, Spain, China and Italy, 0%
      • 10- 19 years: Case fatality in South Korea Spain and Italy was 0% and in China was 0.2%
      • 0-14 years: The USA CDC reported on 1 May that there were 9 deaths (0.02%)

In SA

      • 0-9 years: Sadly, South Africa reported the death of a 2 day old neonate from COVID  (the mom was also positive), making this the only fatality (0.3% of total SA deaths). However, paediatric pulmonologist Prof Green said it was much more likely that this death was a result of severe prematurity and NOT COVID 19.
      • 10-19 years: 0%  

Infections

Children are far less likely to contract COVID 19 and to suffer severe disease if they do get it.

Worldwide
Children are significantly less likely to acquire COVID infection when exposed to it, than adults. (the Munro summary of the 5 studies done in China and Japan). Further studies reveal the following for children under 10 years:

      • Italy, Japan, the Netherlands, Switzerland, South Korea, Iceland and Germany all show very low infection rates
      • A study from Vo in Italy, who screened 86% of their population, detected NO infections in children under age 10 years.

In SA:
The South African age stats figures from 19 April showed that:

      • COVID-19  had been detected in 97 (2.6% total) children aged 0 to 10 and
      • 136 (4.3% total) children aged 11 to 20 (from a total of 3144 infections).

2. Transmission of the virus from children to adults

Evidence from around the world is consistently showing that the assumption that children are “super-spreaders”, was incorrect. In fact, children are rarely the primary sources of infection in a household or population. Data from studies done in China, the French Alps, New South Wales and the Netherlands, all suggest that SARS-CoV-2 is mainly spread between adults and from adult family members to children. Tracing studies from US, Australia, Germany, the Netherlands, China, South Korea and Singapore all support the hypothesis that children are NOT the primary spreaders of the virus.

3. The social and economic costs of keeping children at home

Keeping kids home for extended periods can 

  • create anxiety,
  • depression,
  • inactivity and other problems in children,
  • and that the longer children stay out of school, the more difficult it is to get them back.

 

  • safe is going back to school

    Credit Reuters News Agency – Ivory Coast children head back to school after virus shutdown

Frequently Asked Questions

Question: How safe is going back to school?

Answer: If all the recommendations are followed, I do believe that it is safe for children to go back. In a nutshell, children are far less likely to contract COVID 19 and to suffer severe disease if they do get it.

Government regulations stipulate that schools must be sanitized and specific protocols put in place to ensure the safety of learners and teachers. The crucial points for safe return to school include the basics of physical distancing, hand hygiene and wearing of masks.

You are urged to check the comprehensive protocols and guidelines available, and if your school is implementing them. Some of the considerations include: 

  • Screening before entering campus,
  • limited numbers of children in classrooms,
  • spacing between desks,
  • rigorous sanitisation,
  • wearing of masks, and playground supervision
  • Schools also need policies around what to do when a teacher or child gets infected,
  • and around sick children staying at home.

Most private schools have been putting measures into place to start on June 1st. In public schools, where there is often poor sanitation and overcrowding, these measures are going to be much more difficult to implement.

Avoid social gatherings and car-park chatter! It has been suggested in a few sources that infections are more likely to be transmitted between parents congregating at schools and through social gatherings outside of schools.

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Question: My child is immunocompromised or has asthma, should I rather keep them at home?

Answer:  Several South African paediatric pulmonologists have stated that mild to moderate, well-controlled asthma is NOT a contra-indication to going back to school. Each case needs to be discussed with the individual’s doctor or paediatrician. There is still not enough hard evidence in children as to which comorbidities might be more dangerous in children affected with COVID 19. The risk vs benefit should be individually assessed for children with:

  • underlying cardiac disease, severe lung disease,
  • immunosuppression eg HIV or Cancer,
  • those on chemotherapeutic or immunosuppressive medications,
  • those with severe uncontrolled asthma, diabetes, cystic fibrosis, and
  • post bone marrow transplants

Some in these categories might be able to attend school with proper precautions in place. Remember that children who fall into these categories would always be at risk for infectious diseases, including Influenza and RSV, which are always around in winter. Prof Green said that he felt that the only children who should probably be kept at home for now are those on continuous immunosuppressive therapy, but re-iterated that children with comorbidities should be assessed on an individual basis.

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Question: My child is healthy, but at home someone (grandparent/ parent) is immuno-compromised. Should we keep our child at home so that they can’t infect the rest of the family?

Answer: The elderly/ sick person does need to remain as isolated as possible.

As stated above, the evidence shows that there is only a small risk of children spreading illness from school to home. However, it is important that the elderly/ ill person at home is protected. This means that if the child is going to school, in the home there needs to be physical distancing, strict hand hygiene and possibly mask wearing if in close contact. 

Each family needs to weigh up the risk:benefit ratio for themselves and make a decision based on what is correct for them. Moreover, many schools will offer a blended learning environment or continued distance learning for vulnerable students. There are some families who need to take advantage of this. Discuss this both with the school and with your doctor.

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Question: I am a teacher at a school, but I am over 60/ have a comorbidity.
Am I at risk?  How do I know how safe it is to go back to school?

Answer: All teachers at risk should be individually assessed. Thereafter, a decision can be made as to whether they are able to continue working through the pandemic, or should rather stay home.

The Department of Health has published documents outlining risk assessments for the workplace, including questionnaires for vulnerable employees (including teachers). The onus is on the employer/ school to provide a workplace that is safe. Furthermore the school should provide appropriate personal protective equipment, as well as adequate facilities for social distancing, hygiene and sanitation. 

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Question: I’ve heard that children are at risk of Kawasaki disease from COVID, which can be fatal – is this true?

Answer:  This is something that doctors are watching out for, but is EXTREMELY RARE (despite the media over-reporting of it).

Kawasaki disease is a rare autoimmune disease pre-empted by a virus, and there have been recent reports of Kawasaki linked to COVID-19 in children.  Most (of the few) children who have been treated for Kawasaki from COVID, have recovered from it.

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Question: My child is too anxious to go back to school. He/she is worried he will get sick.

Answer:  This is natural, as they mirror parents behaviour. Children will need constant reassurance and lots of patience. 

Remember that children take cues from their parents’ behaviour and reactions. If you are constantly watching COVID news and expressing your concerns, of course your children will absorb this and be nervous. Children may need constant reassurance, both from their teachers and from their parents, and will also need lots of patience and encouragement while they adapt to the new normal. They need to be taught the practicalities of viral control at home. Taking off shoes, washing hands, and changing clothes needs to become a way of life.

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Question: Is it safe for my child to wear a mask?

Answer: Yes, masks are NOT dangerous to wear. However, children under age 3 should NOT wear masks due to choking hazards.

Cloth masks are safe and compulsory in public in South African law and will be mandatory at school in order to prevent infections. They are difficult to wear, but children need to be taught how to safely put on and remove masks. Remember: clean hands and do not touch eyes, nose and mouth. In younger children, face shields or hats with shields might be feasible options. They are easier to wear.

Masks are worn to reduce droplets being sprayed from infected people. They do reduce the spread of infections such as COVID, Influenza and RSV from asymptomatic carriers. Despite public perception, and various social media campaigns, there is NO evidence that cloth masks cause hypercapnia (a build up of CO2). Medical masks such as N95 may do this if worn for prolonged periods of time, but oxygen and CO2 filter perfectly through cloth masks. 

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Question: Should my child have a flu vaccine before going back to school?

Answer: It is highly recommended that all school aged children have a flu vaccine this year in particular.

Influenza symptoms are very similar to COVID symptoms and also cause high morbidity and mortality. Flu vaccine is an inactivated vaccine, so should not cause side effects other than a mildly bruised arm. Flu season usually comes in April and lasts until October. (Our epidemic is late this year, probably due to lockdown). Flu together with coronavirus can cause serious illness. If you’ve had the flu vaccine and get sick during winter, your doctors will know that flu is very unlikely and corona is very likely.

In Conclusion

We are now entering a period where we expect thousands of new cases each day. This is not surprising and, in fact, was predicted. This was the reason that the lockdown was instituted in the first place, giving the health system time to design the protocols necessary to cope with the inevitable increase in cases. It remains the responsibility of all of us to do our best to stay safe and healthy. Reasoned and responsible actions, as opposed to panic and anxiety, will help ensure that you and your families are looked after in the best possible way over the months ahead.

When faced with difficult medical choices, patients have often asked me “What would you do if it were your child?” I can confidently reply that I will be sending both my children back to school as soon as we are able to do so, having faith in the processes that our school has put in place, and trusting in the best available evidence that suggests that this is the right course of action at this time.
Please discuss any concerns both with your school and with your doctor.

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