Dr Rajib Dasgupta
In the media briefing on July 20, 2021, Professor Balram Bhargava, the Director General, Indian Council of Medical Research (ICMR) backed reopening of schools whenever it is possible to do so, and that “it’ll be wise to open primary schools first before opening secondary schools” as “children can handle viral infections better than adults”. He also gave the example of several Scandinavian countries that did not close their schools. The fourth national sero-survey for COVID-19 conducted by the ICMR across 70 districts in 21 states tested for the presence of antibodies specific to SARS-CoV2 virus; overall, 67.6 per cent were found to have them. Importantly, in this round, children in the age group of 6 to 17 years were also included; the sero-prevalence was 57.2 per cent among 6-9 years and 61.6 per cent among 10-17-years.
The Supreme Court in its order of January 13th2021 had ordered States and Union Territories (UTs) to take a decision by January 31 on the opening of Anganwadi (Integrated Child Development Services) centres. Schools and Anganwadis provide a wide spectrum of critical services including formal education, early child development, midday meals as well as social, physical, behavioural and mental health inputs. Parents are naturally anxious about the reopening and the safety of their children in view of the ongoing pandemic. What is the global evidence?
The WHO advises a district-based strategy
While emphasising that the goal all across countries is to promote safer in-person learning and child care, the WHO advises that decisions on full or partial closure or reopening should be taken at the local administrative level, guided by local levels of transmission of the virus and the extent to which reopening of these institutions may enhance transmission in the community. It emphasises that shutting down educational facilities should only be considered when there are no other alternatives. The WHO advises four categories of district (or, sub-district) based strategy, depending on local levels and patterns of transmission. Districts with no cases or sporadic cases are advised to keep all schools open and implement COVID-19 prevention and control measures. Districts with cluster transmission can keep most schools open and consider closing schools in the areas experiencing an expansion in the number of clusters that includes schools. Districts with community transmission shall most likely require school closure particularly with increasing trends of COVID-19 cases, hospitalisations and deaths.
“The child is not to blame”
Children appear to be infected by the SARS-CoV-2 virus (that causes COVID-19) far less frequently than adults; when infected typically have mild symptoms in the vast majority of cases. The key question: to what extent can children transmit COVID-19? The evidence so far indicates that a child is rarely the suspected index case, with symptom onset preceding illness in adult household contacts. They typically develop symptoms after or concurrent with adult infected contacts; this implies that children are not the source of infection and acquire COVID-19 from adults, rather than transmitting it to them. Studies from Ireland and Australia analysing school contacts found an extremely low level of transmission in schools. Some modelling studies early on during the pandemic forecasted that school closures alone will prevent only 2–4% of deaths. These analyses suggest that SARS-CoV-2 transmission in schools may be less important in contributing to community transmission than was earlier believed. School-based transmission is a known driver of influenza epidemics and mandatory closure of schools is a key public health intervention; this contrast in relation to COVID-19 explains why some countries chose not to shut down the schools and early child care centres while others did so as a precautionary principle.
What about older children and adolescents?
The US experience indicated that the estimated cumulative rates of infection and symptomatic illness in the 0-4 years group are roughly half of those among 5-17 years. More intense contact and mixing among children and adolescents in schools increase susceptibility; the second wave in Israel started shortly after reopening of schools at the beginning of May 2020with major outbreaks in several highschools. This was followed by a lockdown and schools reopened in September; this led to a surge of cases, specifically in the 15-19 years age group. It has been considered prudent to consider this age group as adults in terms of the transmission characteristics. Some analysts suggest that secondary transmission in school settings is significant only when prevention strategies are not implemented or are not followed. While outbreaks can certainly occur in school settings, researchers from Australia, the UK and the USA observed that if prevention strategies are followed, transmission within school settings is lower than or similar to the levels of community transmission.
Instituting layered prevention strategies in schools
The complete set of layered prevention strategies include promoting vaccination, consistent and correct use of masks (the US-CDC recommends this for all children above the age of 2 years and the WHO for those above 5 years), physical distancing, screening testing for early identification of cases, improved ventilation (opening windows to increase dilution of indoor air by outdoor air, with due safety precautions), handwashing and respiratory etiquette, staying home when sick and getting tested, contact tracing and routine cleaning with disinfection under certain conditions. Teachers and other staff shall need to be vaccinated and protected as substantial proportions of them can be expected to have co-morbidities.
The WHO advises a distance of at least 1 metre is for both students (all age-groups) and staff members outside classrooms. A distance of at least 1 metre should also be maintained in districts or sub-districts with community or cluster transmission. In other areas, children under the age of 12 are not required to maintain physical distance at all times. As far as feasible, children aged 12 years and above should keep at least 1 metre apart from each other while teachers and support staff should be 1 metre apart from each other and from students.
Making it all work
Several elements shall shape COVID related safety in schools and Anganwadi centres. In many instances, these require significant strengthening of school-level infrastructure and resources including ventilation, water supply and toilets.‘Stay-at-home when sick’ policy should be promoted and effectively practiced. Inclusive and early collaboration, as well as frequent consultation between the school administration, community leadership, parents’ groups and teachers’ organisations, are critical to roll out and sustain these processes. Frequent communications and messaging are essential to communicate that mitigation measures are being sustained as well as engage with rumours, misleading information and stigma. In order for these institutions to reopen all staff members need to be fully vaccinated on a priority basis. Vaccines from children above 12 years is under trial and shall roll out in due course. Doubtless, all decisions will have implications for children, parents, teachers and other staff and more broadly, their communities and societies; the policymakers and the educators have a tough job to do and need every possible support to be able to sustain these services as reopening continues.
(The author is Chairperson at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi. He is also a member of the National AEFI (Adverse Effects Following Immunisation) Committee. Views expressed are personal and do not reflect the official position or policy of the Financial Express Online.)