Children are getting Covid sitting at home, reopening schools can help them & the community

Keeping 250-plus million children away from school is impacting learning severely, and their mingling in school can hasten population or herd immunity.

Representational image | Manisha Mondal | ThePrint

Zugzwang, a chess term of German origin, was recently used in a commentary by renowned epidemiologist Raj S. Bhopal to describe public health strategy options that governments have to play the Covid-19 endgame. It explains a situation where the compulsion to make a move puts the player at a disadvantage.

Prof. Bhopal argued that the population (herd) immunity threshold for Covid-19 is around 50 per cent, and the acquisition of the novel coronavirus by young and healthy people is the safest way towards that goal.

The discussion in India about children and Covid has revolved around keeping them safe at home until a vaccine arrives, or postponing NEET/JEE because of the risk involved. Worldwide evidence, however, suggests the opposite.

Children half as susceptible as adults

Data from 25 European countries shows low mortality (four deaths in 582 hospitalised cases) among children, as does data from the US, where by mid-August, about 0.44 million of the 5.2 million cases diagnosed with Covid-19 were children, with up to 0.7 per cent mortality. A multi-system inflammatory disorder (MIC-S) in children has caused some concern in the West. In the US, 186 Covid-positive children were reported with this condition up to mid-May, with 8 per cent developing coronary artery dilatation, and a 2 per cent mortality.

Studies show that children are half as susceptible as older adults to catching Covid-19, and one-third as likely to be symptomatic. A Korean study reported that within households, older children (over 10 years), once infected, passed the disease to others at a higher rate than adults, while younger children (under 10 years) were the least likely to spread the disease.

A prominent US hospital has documented high nasal viral loads in children. However, studies from Australia and Ireland suggest very low transmission in early childhood care/school settings at the beginning of the pandemic.

The vaccine question

We live in times where venerated medical journals like The Lancet stand accused of hastily publishing studies with iffy data sources, and Donald Trump’s public announcements contradict his scientific advisors’. There is politics everywhere, including in science, and the virus seems to be headed for a November showdown with its vaccine nemeses.

What do vaccine candidates, on which many parents and the public have their hopes pinned, have in store for children? Current trials are on healthy adult volunteers (18-55 years) with no co-morbidities. Safety data from the Oxford trial suggests a majority of participants had mild to moderate pain, if not given painkillers beforehand.

While most vaccines seem to be producing neutralising antibodies in vitro, we still await the efficacy data on the protection from the disease they might provide to adults. How children will react to or be protected by a potential Covid vaccine will not be known for some time.

So where does that leave us in the zugzwang position with respect to children? Will opening schools lead to a huge increase in cases, with many children being infected? Opening of schools in Israel and France was associated with spurt in cases, but not in Germany or Denmark.

The government seems to be inclined to let older children attend schools first, although the evidence points out that the younger kids are less likely to be affected or infective. It is plausible that children will carry the virus home from school and give it to the elderly, given our crowded multi-generational homes.

India is very young. One-third of our population is of school-going age (3-18 years). In 2016, 1.6 lakh Indian children aged between 5-14 years died, nearly half of them due to communicable diseases. About 10,000 children died due to road accidents, of the 47,000 who died due to injuries. Diarrhoea is estimated to kill 19,000 children of school-going age every year. Covid-19 in comparison, has claimed about 400 children of school-going age (less than 1 per cent of all deaths).

Even if we assume a four-fold rise in Covid deaths (currently around 60,000) to 2.5 lakh, it can be estimated that Covid may claim the lives of about 1,500 Indian children of school-going age by the time we gain control over the pandemic.

Is reopening schools more risky than metro or theatres?

We need to reframe the debate on opening of schools in the right perspective. Will the virus run amok in the community if schools open, as compared to metro trains restarting or theatres screening blockbusters?

Let us consider the possibility of population (herd) immunity at this point. The recent round of the Delhi sero-prevalence study showed a prevalence of 29.1 per cent, not significantly higher than the 23.4 per cent that was recorded in July. Is the virus slowing down in Delhi? Does this support the hypothesis that population-level protection may be achieved at around 40-50 per cent rather than 60-70 per cent?

Interestingly, the study, which also sampled school-age children (5-17 years), found that 34.7 per cent of them had Covid-19 antibodies, which was higher than adults! But aren’t kids at home, cooped up in front of tabs/mobiles/TVs, with nowhere to go? Most of these children had no symptoms and didn’t need to be hospitalised.

Unfortunately, sero-prevalence studies in other geographies haven’t included children in their samples, so we won’t know for sure.

If children are getting infected being at home, as seen in Delhi, then how much further risk does sending them to school pose? Will the mingling of 33 per cent of our population in schools hasten population immunity? Or will it put the lives of the elderly at risk?

Will a strategy of shielding the elderly and those with chronic diseases for a few months after school reopening help? Will children then act as the defence mechanism to prevent further morbidity and mortality amongst the most vulnerable, by enhancing population immunity? Should schools open first for younger children, who are at lower risk than older children, or for older children, who can understand social distancing norms better, according to conventional thought?

Instead of a unitary school reopening policy for the entire country, given the difference in timings of peaks and rates of spread in various geographies, we should be empowering states, municipalities and panchayats to take local decisions based on their respective peaks, positivity rates, cases, death rates and sero-prevalence.

It is clear that children are at lowest risk of Covid-19, compared to all other age groups. Whether them going to school will accelerate the spread of the disease to the elderly and other vulnerable, depends on the prevalence of the infection in the community in question (among children in particular) and on hygiene norms followed in school and at home.

Keeping 250-plus million children away from school is impacting learning severely, and will have a long-term socio-economic impact ($10 trillion, according to a global estimate). Is doing so, to prevent possibly increased morbidity and mortality in the elderly, robbing the future to pay for the past? Can phased opening of schools help in hastening the achievement of population immunity? Can this be done at the lowest cost possible to the elderly, through their cocooning, social distancing and hygiene practices?

Are India’s children, its demographic advantage, a strategic asset in the fight against Covid-19? Or are they its voiceless future, who can be sacrificed at the altar of the politics of precaution?

The answers are obvious.

Dr Anand Lakshman is a public health specialist, and founder & CEO of AddressHealth. Views are personal.