The biggest question on a lot of parents minds right now is whether or not to send their children back to school.

Dr. Dan Grove, who is an expert pulmonologist and recovered COVID-19 patient, weighed in and shared the following on his blog:

In our home we have transitioned from home school to home camp. This has not been a dramatic shift. The main difference for the kids has been a combination of less time on Zoom and a major relaxation of hygienic standards. The famous psychologist Abraham Maslow created a pyramid categorizing a hierarchy of human needs from the basic physiological needs to the lofty need for self actualization. With this as my inspiration, I have created a COVID-19 parenting hierarchy of needs moving from most basic and necessary to what have become lofty aspirations.

  1. Food and water. This is the lowest level neglected by only the most deplorable of parents. This, as of now, has not been impacted by the pandemic in quantity although quality has certainly suffered.
  2. Injury Prevention. This includes preventing the children from injuring themselves or their siblings. It also includes maintaining parental sanity so the parents don’t injure the children. The pandemic has, only on rare occasion, challenged this rung of the hierarchy. After several dozen interjections, at some point even the most patient of parents will be resigned to let the kids fight it out to resolve the dispute. This can occasionally lead to injuries but casualties are unavoidable in wartime.
  3. Clothing. Under normal conditions, putting clothing on the children is typically mandatory. This was abandoned early on in the pandemic. The 4 year old is free to wander naked so long as he only pees on the tile flooring.
  4. Bathing. We have now achieved a level where as long as there are no visible maggots or obvious foul odors this has become completely optional.
  5. Education. This has been handed over entirely to the internet.

It is clear then why most parents are awaiting their school districts’ plans for the fall with great anticipation.

All joking aside, schools are much more than a means of preventing our homes from turning into an extemporaneous production of The Lord of the Flies. The role of schools cannot be underestimated. Our children are already falling behind and it is a legitimate fear that if school doesn’t start in the fall the loss may be irreversible.

Aside from the education, for many children, the schools are a source of their only substantive meals along with vital social services. Further, how can the parents go back to work if their kids are not in school? These are not trivial concerns.

With that said, children are walking petri dishes. With most other infectious diseases children are the main spreaders of disease. The thought of mixing their snotty noses together by the millions in tight indoor school corridors with poor circulation causes many a public health official to lose sleep.

The question of whether to start school is then a balance between the risk to society of children spreading and being infected with COVID-19 and the cost of them staying home.

From the beginning of the pandemic it has been clear that children have a lower rate and severity of disease, even among kids with comorbidities. This is good news. As bad as this nightmare has been, if kids were dying it would have been unbearable. They are more likely to be asymptomatic which does make things a bit tricky, Further, there was still the question early on if, as for influenza, children are the primary drivers of household transmission. If they are, spread from children who have no symptoms could be a serious driver of spread of the disease. This is what prompted school closures in the spring.

Since the spring, a number of observational studies have suggested that, despite similar viral levels as adults children <12 are less likely to infect the adults in their household with COVID than the other way around. The observational studies have suggested that kids rarely caused outbreaks. All of these studies are not entirely conclusive and have many flaws but are consistent and highly suggestive.

Recently there was a report of a large study of contact tracing data from South Korea. This was the largest and best designed study yet including almost 60,000 contacts of nearly 6,000 cases. They used meticulous epidemiologic techniques to identify index cases and tested everyone. They found that 5 out of every 100 people who lived with a kid under 10 with COVID-19 and 19 of every 100 of school kids 10-19 got infected. This clearly shows that kids can transmit the disease but that it was a low risk with a risk that declines with younger age.

The caveat is that this study was conducted when schools were closed and people were already staying home, social distancing, and wearing masks. The spread could have been much higher if school was in session. A study from China showed that school closure and social distancing significantly reduced the rate of COVID-19 among contacts of school-aged children but other models have predicted that with asymptomatic surveillance, contact tracing, and quarantine measures going to school will result in fewer infections than if kids stay at home and don’t have those measures taken.

On the school level, early data showed that schools do not appear to have played a major role in COVID-19 transmission. Transmission from students to staff and from students to other students (especially younger students) appears to be rare, and will likely would have been more rare with appropriate risk mitigation strategies.

Saying children are less likely to be the primary source of spread is very different from saying they do not spread the disease. These studies do not provide answers with certainty but tilt the scales of the evidence towards there being a low risk that kids will be a major source of community spread.

In fact, the National Academies of Sciences, Engineering, and Medicine recommended that school districts should prioritize reopening schools full time. They felt that opening schools will benefit families beyond providing education, including supplying child care, school services, meals, and other family supports. Without in-person instruction, schools risk children falling behind academically and exacerbating educational inequities. Based on the evidence above, they felt the priority should be higher for K-5 education and for kids with special needs.

The American Academy of Pediatrics has also strongly advocated that all policy considerations for the coming school year should start with a goal of having students physically present in school

Both reputable societies are advocating opening schools with the following necessary mitigation strategies (some will certainly sound familiar):

  • All students and staff should wear face masks. Younger children may have difficulty using face masks, but schools should encourage compliance as much as possible. Schools should be prepared to give masks to students.
  • Provide hand washing stations or hand sanitizer for all people who enter school buildings, minimize contact with shared surfaces, and increase regular surface cleaning.
  • Limit large gatherings of students, such as during assemblies, in the cafeteria, and overcrowding at school entrances, possibly by staggering arrival times.
  • Reorganize classrooms to enable physical distancing, such as by limiting class sizes or moving instruction to larger spaces. The AAP said that if 6 feet cannot be maintained it is acceptable to space 3 feet apart if everyone is wearing masks.
  • Cohort classes to minimize crossover among children and adults within the school; the exact size of the cohort may vary.
  • Utilize outdoor spaces when possible.
  • Limit unnecessary visitors into the building.
  • Eliminate the use of lockers.
  • Have teachers rotate instead of students when feasible and stay 6 feet from students when possible.
  • Temperature checks are not helpful but kids can be questioned about symptoms. Sick children must stay home.
  • There need to be plans in place for quarantine of close contacts in the event of a COVID-19 child.

Most of the recommendations are designed for school administrators but I felt it was useful for parents to be aware of the recommended mitigation strategies so they can make sure their schools are minimizing the risk as much as possible. It also can provide parents with reassurance that sending their children to school is not crazy or irresponsible.

Confused yet? Hopefully you are used to this from this virus. The conflicting and unclear data and expert recommendations, while frustrating, are unavoidable. Decisions have to be made with imperfect data. As more evidence comes in the recommendations must change. School is too important to close except in the most dire of circumstances. With the appropriate reasonable precautions schools can remain open in a relatively safe way. No plan will be perfect but the costs of closing schools are tremendous.

Hopefully we can climb back up the hierarchy back to self-actualization. At the very least we can get these kids to start bathing again. I feel like I’m living in a National Geographic special.