Covid-19: Are pediatricians and epidemiologists scared of going back to school?

After more than 6 months of in-person inactivity, the nearly 30,000 schools and educational centers that exist in our country have already reopened their doors to host more than 8 million schoolchildren of all ages. Mostly eager to get back to class.

There are many pending duties accumulated in these months to guarantee a back to school safely. And that, added to the more than worrying trends in the transmission of the coronavirus at the national level, it has generated enormous anxiety among parents and education professionals, who are frustrated by the lack of clarity about how this return to the classroom is being carried out. In addition to being legitimately concerned about the risk that it may entail for individual and collective health.

The fact that the responsibilities for proposing specific recommendations and regulations for the reopening of educational centers are decentralized in the autonomous communities does not help much. Especially since it has ended up generating 17 different plans and, sometimes, without much coherence. Added to that is a general sense of lack of leadership that does not invite optimism.

But amid all this gibberish, what really worries pediatricians and epidemiologists?

The Pediatrician’s Vision: Individual Risk

Pediatricians have spent the last few months in a discreet background, aware of the low vulnerability of children in this pandemic, and without an excessive workload and specific concern about the impact of Covid-19 on the individual health of the little ones. There seems to be consensus to this day that children suffer from very mild the consequences of infection by SARS-CoV-2, being a not inconsiderable proportion of asymptomatic infections.

LDeaths, serious complications, and hospitalizations by Covid-19 in the pediatric age they are rare. Moreover, it seems that the disease respects even children with concomitant chronic pathology, unlike what happens with adults.

Perhaps the only exception to this rule are the cases of multisystem inflammatory syndrome in children (MIS-C, for its acronym in English), a late complication associated with virus infections, and that shares some symptoms with Kawasaki syndrome and toxic shock. This rare but potentially serious complication has been confirmed in several dozen cases in our country. And although with the high frequency it may require intensive care, it is important to note that early treatment with specific anti-inflammatory therapies usually respond positively.

Therefore, we can affirm that the risk at the individual level of children who become infected appears to be low, and therefore acceptable. Her physical health does not seem to suffer too much at the moment. A very different thing is mental health and the indirect effects that months of confinement and general uncertainty may be having on the children. Those will need to be proactively and carefully monitored.

The Epidemiologist’s Vision: Collective Risk

Epidemiologists are concerned about the effect that a certain pathogen may have on population health, and on its transmissibility, that is, on how it can spread between individuals. In this sense, and taking into account our previous knowledge about other viral respiratory infections such as influenza –a priori considered similar to Covid-19–, it was initially considered that children could act as «supercontagators». Children were also claimed to be much less susceptible to infection. And that, therefore, they played a very minor role in community transmission.

The evidence accumulated in recent months, far from confirming these hypotheses, seems to suggest the opposite. On the one hand, children can become infected in a similar way to adults, and they can have high viral loads even in the absence of symptoms. Of course, it is important to note that detectable viral load is not necessarily synonymous with potentially infectious virus.

On the other hand, although we now know that children are capable of infecting other children, or even adults, everything indicates that they have a ability to infect markedly less efficient. Nevertheless, we must be cautious because our ability to identify children as “initiators” of outbreaks or chains of transmission is strongly biased by the high prevalence of asymptomatic infections in pediatric age.

Given all this, it is important to note that, with our current knowledge, we cannot rule out that children make a significant contribution to community transmission. Consequently, it is our obligation to recommend the widespread and strict implementation of good transmission prevention measures in schools. Centers that are places of obvious risk due to the high concentration of people who meet there.

Mathematical models based on initial data from the pandemic in China and Korea, and other similar epidemics, suggested that early school closings seemed to play little role in containing and progressing the pandemic. However, more recent data from Israel show just the opposite, after identifying multiple community outbreaks originating from schools with low implementation of prevention strategies.

Caution and good prevention and surveillance strategy epidemiological should be a priority in newly opened classrooms.

Prevent better than cure

In just 9 months, Covid-19 has turned our world upside down, causing nearly a million deaths and tens of millions of cases. Compared to adults, children have shown low vulnerability to the effects of the virus. However, its precise role in the community transmission chain has yet to be determined.

In order to prevent schools from becoming amplifiers of community transmission, it is essential that we take extreme precautions and ensure proper implementation of prevention measures. Education is a fundamental right in childhood, and children deserve to be able to resume their education in a safe and optimistic way, without thereby putting the rest of our society at risk.

Quique Bassat. Pediatrician and epidemiologist, ICREA researcher, Barcelona Institute of Global Health (ISGlobal).

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