Children wash their hands at Hoyonomori Gakuen, a school in Tokyo's Shinagawa ward. Public schools reopened in the city last month.
Children wash their hands at Hoyonomori Gakuen, a school in Tokyo's Shinagawa ward. Public schools reopened in the city last month.Photo: Washington Post Photo By Simon Denyer
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Children wash their hands at Hoyonomori Gakuen, a school in Tokyo's Shinagawa ward. Public schools reopened in the city last month.
With coronavirus science still iffy, U.S. schools hope to reopen for 56.6 million K-12 students
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In just a matter of weeks, tens of millions of children will start a new school year, and what that will look like has become the nation's thorniest political and epidemiological issue. School officials have to figure out how to resume schooling while limiting the risks to children, their teachers, school staffers and their communities.
This pivotal moment in the coronavirus pandemic comes as scientists are still trying to understand precisely how the virus affects children and how children affect the spread of the virus. This dicey decision point has generated tension between President Donald Trump and his own public health experts at the Centers for Disease Control and Prevention, with Trump saying the CDC is "asking schools to do very impractical things" to allow classes to resume.
The reopening of schools is likely to be halting and improvisational. It could be marked by setbacks. There is no proven strategy for the remobilization of 56.6 million K-12 students amid a pandemic like this one.
"It's not going to be easy because we've never done it before," Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said Thursday in an interview with The Washington Post. "This is uncharted waters - always remembering the primary issue is the safety and welfare of the children as well as the teachers who are going to be interacting with the children."
Children are clearly at low risk of serious illness from covid-19, the disease caused by the virus. Research suggests they're also less likely to get infected to begin with. But it's unclear to what extent they can still transmit it to each other and to vulnerable adults - such as their teachers or family members.
Much of the scientific understanding of how the coronavirus affects children is provisional. A study by researchers in the United Kingdom published last month found that children are only about half as likely as adults to become infected with the virus. Another study, from the University of California at Berkeley, did not see any significant effect on the community spread of coronavirus from the closing of schools in March.
But scientific research on children and covid-19 has not been nearly as extensive as research on older people, because there haven't been nearly as many sick children to study, and children are rarely tested as part of disease surveillance programs. Deborah Birx, coordinator of the White House coronavirus task force, said Wednesday the age group with the lowest rate of testing is children younger than 10.
"I think Americans have done a great job in keeping infection rates low in children," she said.
A research effort funded by the National Institutes of Health is enrolling 6,000 people from 2,000 families to try to better understand the dynamics of the disease across age groups, Fauci said.
"The data that is clear is that children do not get serious consequences of infection compared to adults," Fauci said. "That's a fact. Everything else is less secure. It is more anecdotal."
The anecdotal evidence, he said, is that children do not transmit the coronavirus to adults as readily as adults infect one another. But, he acknowledged, "the definitive study has not been done."
The pandemic has shown a clear pattern of discriminating by age. The CDC's provisional death toll from covid-19 stood at 112,000 on Wednesday - a figure officials acknowledge is likely an undercount - and of those deaths, 29 were among children under the age of 15. That compares with 37,247 deaths among people 85 and older. (A Post analysis shows more than 130,000 people in the United States have died from covid-19.)
Though epidemiologists agree that children generally dodge the worst of covid-19, the emergence of a rare but dangerous "multisystem inflammatory syndrome" in children has been linked to the virus. The syndrome, which can manifest in a variety of early symptoms such as fever and rash, shares some characteristics with Kawasaki disease, a rare illness that usually affects children under 5.
If left untreated, children can suffer lasting heart damage because of inflammation in blood vessels and arteries - though treatment has been largely successful. According to a study published in the New England Journal of Medicine, New York hospitals identified 15,515 cases of covid-19 among people under age 21. Of those cases, 95 presented with the multisystem inflammatory condition - fewer than 1 percent.
There is no formula for how to reopen schools safely, though school officials are developing strategies for keeping kids separated as much as possible. Many school districts are adopting "hybrid" plans with students alternating between in-school and at-home learning and attending class in shifts to allow more space between desks and fewer people in buildings.
Many rural districts, however, are planning full reopenings, knowing they may need to close if cases spike. It's unclear whether any districts will keep everyone at home.
The CDC has recommended that schools try to keep students six feet apart. That may be impossible for most schools if all students are present. Another recommendation is to have students eat lunch at their desk. Extracurricular activities could be eliminated.
One recent poll found that parents across the country are split down the middle on whether they want to send their children back to school. But the return of school - real school, in class - is broadly seen as a critical step toward returning the country, and its economy, to something approaching normalcy.
Since the onset of the pandemic, parents have been forced to balance work with home-schooling. They represent a large portion of the national workforce, which is already struggling with massive job losses and a pandemic-induced recession.
Distance learning has not gone well in much of the country. In Philadelphia, many students did not have computers, so the district directed teachers to use the time for review of material already taught. No new content was introduced, and students did not get grades.
Fairfax County Public Schools in Virginia suffered privacy breaches, online harassment and multiple technical failures. Public schools in Memphis offered no live instruction, and students were not required to turn in work.
In the District of Columbia, it took weeks to get most students the necessary technology to participate in distance learning, and even then teachers at low-income schools reported dismal attendance.
Keeping children at home carries its own risks, the American Academy of Pediatrics has said. Last month, the organization strongly recommended that schools try to reopen.
"Policies to mitigate the spread of covid-19 within schools must be balanced with the known harms to children, adolescents, families, and the community by keeping children at home," the group said.
"We have two not-great options. We're stuck in a very bad place right now in the U.S. with how many infections are going," said Sean O'Leary, a pediatrician who helped write the pediatric academy's guidelines.
He said the risk to schoolchildren from the coronavirus is in line with other respiratory viruses such as influenza. "It's not that kids don't get sick, but it's similar to other things we accept in our daily lives normally," said O'Leary, a pediatric infectious-disease specialist at Children's Hospital Colorado.
He said school districts have to accept there will be some infections and some outbreaks.
"It's not about risk elimination," he said. "It's risk mitigation."
In recent days, the Trump administration has stressed the academic and emotional downsides to keeping children out of school. Schools also provide mental health counseling, socialization and meals.
CDC Director Robert Redfield, speaking at a forum sponsored by the Hill, said Thursday that having schools closed "is the greater public threat to children than having the schools reopen."
Other infectious-disease experts have generally endorsed a reopening of schools in some fashion, but only with safeguards and mitigations. The virus, they note, is following its own path without regard for the pain and suffering it inflicts. Most people in the United States still lack immunity to the virus. Cases continue to surge in Southern and Western states.
"If we open up the schools and haven't really figured out how to control the virus adequately, it's not going to be that different from opening up the bars and restaurants, and the problem we've seen in the Sun Belt right now," said Jeffrey Shaman, an epidemiologist at Columbia University who has studied the spread of the virus throughout the pandemic.
Decisions on school reopenings will largely be made at the local level, and the map of viral spread is complicated, with ongoing spikes in coronavirus cases and hospitalizations in Arizona, Florida and Texas.
In response to a White House education summit this week, Arizona Department of Education superintendent Kathy Hoffman published a letter saying the discussion "did not reflect the magnitude or severity of Arizona's growing public health crisis."
Hoffman said her state must get covid-19 under control and emphasized that while the virus might not pose as much risk to children as it does to older adults, older adults are involved in a return to school, too.
Ohio Gov. Mike DeWine, a Republican, said last week he plans to open schools this fall and announced guidelines including facilitating frequent hand washing and cleaning of surfaces, social distancing and developing a mask-wearing policy.
But he left many big decisions to school districts, which he says can implement the state's recently released guidance as they see fit. If schools want to take students' temperature on the way in, they can - but it isn't required. If they want to have students eat lunch in their classrooms instead of a crowded cafeteria, that works, too.
Florida's Education Commissioner Richard Corcoran took a firmer stance Monday when he ordered schools to open five days a week when classes are scheduled to resume in August.
As with so many orders issued by states in response to the pandemic, this one may sew confusion, because local jurisdictions are deciding on their own approach. The Miami-Dade County School Board last week approved a multiphase plan that includes a mix of in-person and online learning. The plan asks parents to indicate whether they prefer their child to attend classes in a school building or online.
Wednesday, New York Mayor Bill de Blasio, a Democrat, announced his plan for reopening classrooms to the city's more than 1 million public school students. That plan includes an all-remote option for those who want it. Families wanting in-person instruction will find that their children will probably spend just a couple of days each week in a school building.
Ask any parent in the Mother Jones office and it’s clear they are eager to get their kids back to school. But as more schools move to reopen this fall—and as President Trump increasingly pressures and even threatens schools to reopen—experts warn there’s still quite a lot we don’t know about kids and COVID-19. What role do children play, for instance, in spreading this virus? Are they just as likely to get infected as adults? Are they just as infectious? And why have a small number of children developed a potentially deadly inflammatory illness after testing positive for COVID-19?
Reopening schools may very well be a risk worth taking—after all, so much of our economic recovery depends on it—but it’s unlikely that we’ll have clear answers to many of these questions in the near future and know with any certainty just how safe schools would be for kids, teachers, and communities. While it feels like we’ve been living with the coronavirus forever, we’re still in the early phase of understanding it; the research on children and COVID-19 is relatively limited, and the studies that do exist have shown conflicting results. At this point, “following the science” to safely reopen schools simply doesn’t mean much—and it’s near impossible to try to rely on data to help you decide whether you should send your kids back to school.
As David Abramson, a professor of social and behavioral sciences at NYU’s School of Global Public Health, explains, getting kids back in classrooms means that students “will serve as potential vectors back into the community.” But at the same time, “it’s almost impossible to imagine not opening schools given all that is at stake. And so it’s like a devil’s bargain.”
It’s probably no surprise then that there’s no clear consensus among health experts about schools reopening. In late June, the American Academy of Pediatrics issued a recommendation that school administrators aim to have children “physically present in school” for the next school year. Meanwhile, the Centers for Disease Control and Prevention maintains that virtual-only classes are the lowest risk option for schooling. And while some countries, including Denmark, Austria, and Germany have had success in reopening schools, other countries, including Israel and Japan, and South Korea, have opened and re-closed schools after seeing a surge in new cases.
So, what gives? Why don’t we have a clearer picture of how kids transmit and are impacted by the coronavirus? Part of the reason is that conducting research on a new virus at lightning speeds is difficult enough in adults—for kids, it is significantly harder. Here’s a breakdown of a few key reasons why studying kids and COVID is so difficult—and why reopening schools now would mean doing so with a lot of uncertainty.Many children with COVID-19 appear to be asymptomatic. That makes it hard to understand the full scope of the problem.
When it comes to kids and the coronavirus, one of the few things that is clear is that children can become infected with SARS-CoV-2, the virus which causes COVID-19, at all ages. “There are a number of papers that show that children can become infected,” explains Dr. Steven Zeichner, a professor in the Department of Pediatrics at the University of Virginia. “Some of them are symptomatic, there’ve been a few deaths”—but, he adds, “a large number are asymptomatic.” And for children who do show symptoms, he says, research shows their “disease course” tends to be milder than in adults.
A study of 2,135 pediatric COVID patients in China, initially published in mid-March in Pediatrics, for instance, found that more than 90 percent had asymptomatic, mild, or moderate cases. And in the US, a recent report from the CDC shows that about 5 percent of lab-confirmed COVID-19 cases between January 22 and May 30 were in people 19 years old or younger, or nearly 70,000 individuals; less than 50 people in that group died from COVID, according to the CDC’s analysis.
But because so many children are likely to show mild symptoms or be asymptomatic, the true number of cases is likely to be much higher than we know. “At this point, primarily, we’re testing people who are symptomatic, except in the case of health workers and others where we need to know if there’s been a lot of exposure,” says Dr. Cynthia Haq, a clinical professor and chair of the Department of Family Medicine at the University of California, Irvine, “and because children are less likely to be symptomatic, you’re less likely to be tested.”
All this begs the question that’s crucial for schools in particular: If children show milder symptoms, does that mean they aren’t spreading the virus as much? That’s not totally understood, Zeichner says. “The likelihood of transmission depends on the amount of virus that somebody is producing, and the interaction of the person with the virus with the person who isn’t infected,” he says. “It is likely that children and adults with fewer symptoms may be producing less virus, which probably makes them less likely to transmit the infection.” But researchers are still investigating whether that’s the case.To study children, researchers have to jump through lots of hoops.
“When we conduct research on children, there are special levels of protection because children are more vulnerable,” Haq says. “We don’t want them to be exploited for research purposes.” As a protected group, children can’t formally consent to testing. In general, she adds, “we don’t like to conduct studies on children unless there’s clearly no evidence of harm from the study or definite evidence of benefit.”
On top of that, “you have to be really mindful of what you’re saying to a child,” says Abramson, who also directs a health disaster research center. “You can’t be saying things that are going to upset them. You can’t ask them questions in ways that will be potentially harmful to them. If you’re going to talk directly to children, that’s going to be a very difficult and challenging event.”
For these reasons, random testing of children on a large scale is not always feasible. And if you’re going to rely on parents to report on their children’s health or behavior, research shows that’s not always reliable. For example, in a 2017 study, Abramson and colleagues asked a group of children and their mothers about the child’s mental health following the BP oil spill; they had a difference of opinion about a third of the time.A lot of studies coming out right now aren’t always the “gold standard” of research.
If you wanted to answer the question of how much children spread the coronavirus, there are a number of scientific avenues you could take—hypothetically speaking. Randomized controlled trials are considered the most rigorous way to conduct research, but in this case, that might not be possible: an experiment in which you expose a group of children to the coronavirus and see how many become infected is, for obvious reasons, unethical.
Aside from that, you could:
But each of the above methods of research can be biased. As Dr. Sheila Nolan, chief of pediatric infectious diseases at Boston Children’s Health Physicians, puts it, in general, “there’s lots of things being published and lots of stuff coming out, but most of it is either retrospective or somewhat anecdotal. And it’s not that gold standard of how to really do a research study, which is exceedingly difficult to do while you’re in the middle of a crisis.”
Take, for example, a recent survey in New York. Researchers went around the city testing thousands of people at grocery stores and other shopping locations for coronavirus antibodies. From the results, they estimated in April that nearly 14 percent of New Yorkers have likely had COVID-19. But if you only look at grocery store shoppers, Abramson says, you aren’t getting a representative sample of the population. You’d miss, for example, people in prison or nursing homes. In effect, the design biases the study.
The fact that so many childhood cases are asymptomatic can further complicate study design and introduce bias in research, says Justin Lessler, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health and a co-author of an early contact tracing study in China. To measure how this virus spread within households, for instance, researchers in early contact tracing investigations typically identified homes with at least one infected individual, tested everyone else in the household, and observed who picked up the virus. The problem is, “primary cases” tended to be adults with symptoms, so “if children are asymptomatic more frequently,” Lessler says, “it’d be harder to find them as a primary case because usually, the first person you find is sick.” As a result, you might only see how adults spread the coronavirus to kids—missing how kids spread it to adults—and could fail altogether to capture homes with infected children. (There are other times, Lessler explains, where you may see the opposite effect, like when school is in session during a seasonal flu epidemic.)
One researcher I spoke with, Dr. Yvonne Maldonado, a professor of pediatric infectious diseases and of health research and policy at the Stanford School of Medicine, told me her “ideal study” would be to follow children in school settings and their households. She’d track their infection rates and antibody development over time to see how COVID-19 spread among children. She and her colleagues had actually planned to do a study along these lines—until schools shut down. Now, she’s limited to only doing that study in households. “Because children aren’t actually interacting with other kids, etcetera, the whole interaction is gone now, it’s not there,” Maldonado says. “So we might have limited data here, but it’s still worthwhile to consider.”
Finally, researchers are trying to understand the virus in kids through modeling, which is “essentially generating data,” Abramson says. Models are built on a series of assumptions, so one model on its own might be an outlier. Therefore, Abramson says, it makes little sense to rely on just one model; when models are done well, he says, “they really give you a great understanding of how dynamics can shift an outcome.” But because models are not observations of real events, he says, “no model will accurately reflect reality.”The research on kids and COVID that has been done hasn’t shown coherent results.
If anything, the coronavirus has reminded us that science is messy, it’s slow, and it doesn’t always make sense. For example, consider Lessler’s contact tracing study, which included 391 people in China with coronavirus infections and 1,286 of their close contacts. One of the key findings was that children under 10 years old were just as likely to be infected with COVID-19 as adults, but less likely to show symptoms. When it first published as a preprint in early March—that is, as a preliminary finding and before undergoing peer-review—it “really scared everybody,” Alasdair Munro, a pediatric infectious diseases researcher at University Hospital Southampton in the UK, told Nature in May.
But in the months since, other studies have shown that kids are less likely to get infected with the coronavirus. It’s still unclear if these differences in results were due to bias in the study designs, real differences in the population, or something else. “It’s possible that our study is an outlier,” Lessler told me early last month. “The numbers are small, so it’s perfectly possible that our result is not going to be borne out over time. And that’s the nature of science.”
Modeling studies have also produced head-scratching results. One study, which initially published in Science in late April, estimated that school closures could delay the pandemic and essentially flatten the curve by 40 to 60 percent. “My simulation shows that yes, if you reopen the schools, you’ll see a big increase in the reproduction number, which is exactly what you don’t want,” Marco Ajelli, a mathematical epidemiologist then at the Bruno Kessler Foundation in Trento, Italy, told the New York Times in May. But other modeling studies have since suggested that school closures don’t have much effect at all on slowing viral transmission.
Though frustrating, it’s not particularly surprising that we’re seeing conflicting results in research on a virus that nobody’s ever seen before, that’s being conducted at rapid speeds, and in the middle of a pandemic. And, of course, no single finding is definitive. As time goes on, we’ll almost certainly gain a better understanding of the transmission dynamics among children. Until then, administrators will be left to “safely reopen schools” without knowing what that really means. As Haq puts it, “We need to get children back to school to support their psychosocial development, but this will inevitably increase the risk of transmission. There are no easy answers. We’re in the land of tradeoffs.”
Donald Trump has been pressuring public schools around the country to fully reopen. So, of course, nearly every piece and cable news segment I saw on the issue yesterday either contended or insinuated that the president was “ignoring science” — the Washington Post’s cool-headed conservative columnist Jennifer Rubin simply accused Trump of wanting to “kill your kids.”
Unmentioned by most is the fact that the American Academy of Pediatrics, a group that represents 67,000 pediatricians, “strongly advocates” that every policy about next year “start with a goal of having students physically present in school.”
The group goes on:
The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.
The left likes to unsheathe “science” whenever it wants to shut down debates over policy tradeoffs, but in this case, not even “science” is opposed to reopening schools. Some European countries have successfully kept schools open throughout the pandemic, and others have had them open since April. Denmark, Austria, and Germany have all begun reopening classrooms, and none have seen a significant increase in cases.
I don’t know if the American Pediatric Association will ultimately be right, but the fact that the CDC — which, let’s not forget, advised Americans not to wear facemasks as the pandemic exploded and then later sent out tests tainted with COVID — has done everything it can to dissuade schools from holding in-person classes this fall does not imbue me with great confidence. Yet, not even the CDC has recommended school closures.
In the end, the decision over school reopenings will hinge on numerous societal considerations and not merely “science” — which itself is open to interpretation and debate. This is one of those times the public could use lots more information, but instead, as is often the case during the Trump era, they are subjected to journalistic malpractice.David Harsanyi is a senior writer for National Review and the author of First Freedom: A Ride through America’s Enduring History with the Gun. @davidharsanyi