Sharon Kirkey, The ChronicleHerald
It’s hardly a comfort to parents that a prominent voice in medical ethics believes reopening schools come fall will amount to one of the biggest human experiments in living memory.
“An oft-made argument holds that COVID-19 infections in children are ‘benign’ and that students don’t infect teachers (or vice versa),” Arthur Caplan, founding director of the division of ethics at New York University Langone Medical Center and physician-epidemiologist David Lilienfeld write in Newsday.
“But we don’t really know that because the available data are simply too sparse to be informative.”
In fact, both child-to-child and child-to-adult transmission has occurred. Just this week, South Korean researchers who traced an astonishing 59,000 contacts of 5,706 “index” cases — the first identified case in a cluster — reported that household transmission of the SARS-CoV-2 virus was high if the “index” person was aged 10 to 19. Kids under age 10 were least likely to spread the virus, though the researchers caution young children may show higher attack rates when schools reopen.
“There will be transmission,” University of Minnesota infectious diseases expert Dr. Michael Osterholm told the New York Times . “What we have to do is accept that now and include that in our plans.”
Others point to data suggesting school-aged children aren’t significant drivers of the pandemic, and relatively few children get severely ill from COVID-19. School re-openings in countries with low community transmission hasn’t resulted in significant or sudden surges in the growth rate of COVID-19 cases and school-based transmission could be an entirely “manageable problem,” according to a commentary published this week in the journal Pediatrics . Schools should remain open, the authors suggested, “even during periods of COVID-19 spread.”
Canada’s child specialists are also urging a safe return to classrooms and daycares, by September, arguing the months of isolation are affecting the mental, emotional and developmental health of children, particularly the ones most vulnerable even before the pandemic hit.
Among epidemiologists, however, the mood is decidedly uneasy. “Proposal: ‘I am a paediatrician and my friends are paediatricians and we are fine with kids going to school’ is the same level of evidence as: ‘Nine out of 10 doctors surveyed smoke Chesterfields. Discuss,” tweeted University of Toronto professor of epidemiology David Fisman.
Fisman says the per-test positivity in children — the number of cases found per those tested — is no different in Ontario, per capita, than in the 20-to-40 age group. “So the idea that there is something magic about kids that makes them uninfectable, we don’t seem to see that in Ontario at all,” he says.
As the experts debate how to open schools safely, parents are struggling with their own agonizing dilemma: Do I send my child back? How do you make an informed decision when the evidence keeps shifting beneath your feet?
From the very first days of the pandemic, from the early dispatches from China, children appeared relatively resistant to the virus that causes COVID-19. Seven months out, researchers are still trying to unpack why transmissibility by kids might be different, why younger children seem to acquire COVID-19 less frequently than adults — a biological advantage or under-testing? — and why kids get less sick than adults even though they have similar viral loads.
In Canada as of July 21, children ages 19 and under accounted for 7.6 per cent of confirmed COVID-19 infections. But it’s still not clear that children, particularly young ones, truly acquire COVID-19 less often than adults. With schools, playgrounds and water parks padlocked, there hasn’t been many opportunities for children to become infected.
And while it seems they are less vulnerable to the virus, kids can get seriously sick. In Canada, 124 children under 19 have been hospitalized, 23 needed intensive care and there has been one reported death, an Ontario child under age 10.
It’s not clear why children, to some extent, seem better able to resist serious infections. Dr. Alain Fischer is a French professor of pediatric immunology. Writing in the journal, Mucosal Immunology, Fischer describes one French study that found children are 25 times less likely than adults to be hospitalized with COVID-19, and 500 times less likely to die.
What is their secret? There are only hints and hypotheses. No child died of SARS-1, a related coronavirus, Fischer notes. There are other infectious diseases that are milder in children, like chicken pox. With COVID-19, children seem to mount a much more appropriate and less hyperactive immune response to the virus than adults. Relatively fewer kids have ongoing health problems like obesity, cardiovascular disease and diabetes — some of the worst risk factors for severe COVID-19.
There might be something biologically different in children about the receptor the virus uses to latch on to and invade healthy human cells. “I wonder if it’s a combination of those things or there are factors we don’t yet know,” says Dr. Laura Sauvé, chair of the Canadian Paediatric Society’s infectious diseases committee and a pediatric infectious diseases specialist.
When it does attack kids, most have mild or “atypical” symptoms like a headache and runny nose, according to a study from Switzerland of the first 40 children under 16 who tested positive for COVID-19 at a Geneva hospital. Some (21 per cent) had loss of smell and abdominal symptoms. In only three cases was the child the suspected “index” or first case in the house, suggesting parents contaminate their kids, not the other way around.
When children are sick enough to be hospitalized, eight per cent require intensive care and four per cent mechanical ventilation, according to a Europe-wide study of 582 COVID-infected children as young as three days old. Four children in the study, all over the age of 10, died, a case fatality rate the researchers called “reassuringly low” and that is likely to be lower still, given many kids with mild disease are never brought for medical attention.
Pediatricians across Canada are watching carefully for a rare, mysterious syndrome linked with COVID-19 that causes hyper-inflammation, toxic shock or acute, appendicitis-like abdominal pain. Without treatment the symptoms can rapidly progress to multi-organ dysfunction. There have been cases reported in some of the worst-hit places for COVID-19 — New York City, the U.K., Spain and Italy — but so far the majority of suspected cases in Canada turned out to be due to other causes.
It’s also not clear why younger children don’t seem to be efficient spreaders. One hypothesis is that because kids tend not to get very sick , they’re less likely to be coughing and spewing out infectious droplets.
Deciding whether to send children back to school is about balancing the good with potential harms, Sauvé says. “Every parent has to think about not just the risk of COVID, but also the mental health and social and emotional learning risks of not being in school.” Schools need to open, but precautions must be taken, she says — more cleaning of high-touch surfaces, frequent hand washing, nobody sick attending school. “If we do those things, the risk exists, but probably the benefits of getting kids back to school outweigh that for most children.”
Still, the distribution of cases by age is dropping in Ontario and other provinces. And infections in children are clearly being missed, epidemiologists say. For one thing, it’s tricky to do nasal swabs on a preschooler. A saliva-based field test, Fisman said this week during a virtual meeting of the Global Research Collaboration for Infectious Disease Prevention, would be a “godsend.”
September keeps Fisman awake at night. He believes there’s a pretty strong seasonal component to COVID-19. “Come September, schools will be open,” he said in an interview. “We’re already getting pretty tired of distancing. There’s a strong thread in the popular dialogue that we locked down and nothing happened, rather than we locked down so nothing would happen.” There’s going to be pressure to return to normal life by the fall, Fisman says, when he believes the virus will likely be ramping up again, just as the flu and other viral bugs are bound to circulate. In the Europe-wide study, children with viral co-infections — infected with SARS-CoV-2, plus one or more other viruses — were more likely to need ICU care.
We’ve been hit, Fisman says. In Canada, as of July 21, 8,860 people have died. But relative to what this virus can do, we haven’t been hit hard yet.
“My concern is that a combination of complacency, seasonality and indoor living will get us back to exponential growth in Ontario in the fall and we may not react as promptly as we did last time, and that will cause many people to die.
“That’s my biggest worry.”