This article has been endorsed by the GGPC (Gauteng General Practitioners Collaboration).
21 May 2020
This week, we all waited in anticipation to hear what Basic Education Minister, Angie Motshekga, would say about schools opening. Her announcement that schools will be opening from 1st June has been met with mixed feelings from parents, teachers, students and the media. There has been a lot of commentary from various sources, and I am going to concentrate on the medical facts that impact on the safety of children and teachers returning to school. I have engaged with many anxious parents worrying about their children leaving the safety of the cocoon they have been in at home for the past eight weeks, and some of these issues need to be addressed. Schools in 190 countries around the world have been closed over the last two m months, so we are not alone in South Africa as we try to negotiate a balance between safe reopening of schools and increasing infection rates.
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 3 main points :
• Risk to children of disease and death
• Transmission of virus from children to adults
• Social and economic costs of keeping children at home
Let’s look at these three issues:
1. COVID 19 IN CHILDREN:
Fatality rates from COVID 19 by age (ourworldindata 21 May) show that for COVID 19, unlike many other diseases like Influenza and Malaria, the risk of dying if infected is negligible. Data from today from South Korea, Spain, China and Italy, show a 0% case fatality rate in children 0 to 9 years, and from South Korea, Spain and Italy, a 0% case fatality rate in the 10 to 19 year age group, with a 0.2% case fatality rate in the 10 to 19 year age group in China. The USA CDC reported on 1 May that there were 9 deaths among children age 0 to 14 years (0.02% of their total deaths). Sadly, South Africa reported the death of a 2 day old neonate from COVID yesterday (the mom was also positive), making this the only fatality (0.3% of total SA deaths) in the 0 to 9 year age group in South Africa, and no deaths in the 10 to 19 year age group. Paediatric pulmonologist, Prof Robin Green tonight in a lecture stated categorically that this death was a result of severe prematurity and NOT COVID-19.
Large studies from Italy, Japan, the Netherlands, Switzerland, South Korea, Iceland and Germany all show very low infection rates in children under 10 years, with one study from Vo in Italy, who screened 86% of their population, detecting NO infections in children tested under age 10 years. A summary by Munro of the five studies (done in China and Japan) looking at whether children catch the disease at the same rate as adults, concluded that children are significantly less likely to acquire COVID infection when exposed to it, than adults.
The South African age stats figures from 19 April showed that COVID 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). No more recent SA data is available with age breakdown. Prof Green stated that to date in SA, there has not been one child in South Africa admitted to ICU with COVID 19 infection, and stressed that COVID has both a lower incidence and severity in children.
In a nutshell, children are far less likely to contract COVID 19 and to suffer severe disease if they do get it.
2. TRANSMISSION OF VIRUS FROM CHILDREN TO ADULTS
Evidence from around the world is consistently showing that, although children were initially thought to be super spreaders (based on the Influenza model), this assumption was incorrect, and in fact children are rarely the primary sources of infection in a household or population.
The concern was that, as for Influenza and the 2003 SARS epidemic, children might have asymptomatic infection and unknowingly drive household and community transmission. 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. SOCIAL AND ECONOMIC COSTS OF KEEPING CHILDREN AT HOME
I am keeping this update medical, so am not delving into the benefits that children of all ages derive from going to school (socially, psychologically, educationally, nutritionally) or the pros and cons of staying at home for online learning. Suffice to say that the social isolation of extended lockdown 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.
Questions I’ve been asked most frequently around going back to school :
1. Is it safe to go back?
Government regulations stipulate that schools must be sanitized and specific protocols put in place to ensure the safety of learners and teachers. Most private schools have spent the last few months exploring these measures and will be ready to open on 1st June. The crucial points for safe return to school include the basic principles of physical distancing, hand hygiene and wearing of masks. There are multiple details that need to be taken into account, which are beyond the scope of this update - there are comprehensive protocols and guidelines available, which I urge you to check that your schools are implementing. Screening before entering campus, limited numbers of children in classrooms, spacing between desks, rigorous sanitisation, wearing of masks, and playground supervision are just some of the considerations that should be taken into account. Schools also need policies around what to do when a teacher or child gets infected, and around sick children staying at home. If all the recommendations are followed, I do believe that it is safe for children to go back. In public schools, where there is often poor sanitation and overcrowding, these measures are going to be much more difficult to implement.
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- these need to be avoided.
2. My child is immunocompromised or has asthma; should I rather keep them at home?
The advice from Prof Green and other paediatric pulmonologists in South Africa is that each case should be assessed and 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. 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 all need to be individually assessed for risk versus benefit. There is no blanket decision that is correct for all of these children. Even some in these categories might be able to attend school with proper cautions 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 tonight said that Asthma is not a contra-indication to going back to school, particularly if well controlled. He felt that the only children who should probably be kept at home for now are those on continuous immunosuppressive therapy, but reiterated that children with comorbidities should be assessed on an individual basis.
3. My child is healthy, but at home someone (grandparent/ parent) is immunocompromised. Should we keep our child at home so that they can’t infect the rest of the family?
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. The elderly/ sick person does need to remain as isolated as possible. Each family needs to weigh up the risk : benefit ratio for themselves and make a decision based on what is correct for them. 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. This should be discussed both with the school and with your doctor.
4. I am a teacher at a school, but I am over 60 / have a comorbidity. Am I at risk? What must I do about going back to school?
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, with appropriate provision of personal protective equipment, and adequate facilities for social distancing, hygiene and sanitation. All teachers at risk should be individually assessed and a decision made as to whether they are able to continue working through the pandemic, or should rather stay home.
5. I’ve heard that children are at risk of Kawasaki disease from COVID, which can be fatal - is this true?
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. Without going into too much detail, this is something that doctors are watching out for, but is EXTREMELY RARE (despite the media over-reporting of it). Most (of the few) children who have been treated for Kawasaki from COVID, have recovered from it.
6. My child is too anxious to go back to school. He/she is worried he will get sick.
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 need lots of patience and encouragement while they adapt to the new normal. Children need to be taught the practicalities of viral control at home, and coming home to take off shoes, wash hands, and change clothes needs to become a way of life.
7. Is it safe for my child to wear a mask?
Cloth masks are compulsory in public in South African law and will be mandatory at school in order to prevent infections. (Children under age 3 should NOT wear masks). Children need to be taught how to safely put on and remove masks with clean hands, and should be reminded not to touch eyes, nose and mouth. In younger children, face shields might be feasible options that are easier to wear. Masks are worn to reduce droplets being sprayed from infected people, and have been documented to reduce the spread of infections such as COVID, Influenza and RSV from asymptomatic carriers. They are NOT dangerous to wear, except as a choking hazard in toddlers.
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. Some people do find masks difficult to wear; they also come with the complication of contamination when not worn properly and touched often; however on balance where students may have asymptomatic infection, it will reduce droplet spread and are essential in any public setting.
For Nursery school children, other alternatives could be looked at, as has been done in China, like face shields or hats with shields.
8. Should my child have a flu vaccine before going back to school?
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.
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.
Dr Sheri Fanaroff
MBBCh(Wits) FCFP(SA) MFamMed(Wits)