2020•11•20

The Global Health Reflections series brings together opinion pieces, commentaries, and summaries of major issues related to global health. It is informed by the research and activities of UNU-IIGH fellows and our partners.

By Michelle Remme

In the early months of 2020, the novel SARS-COV-2 caused an unknown respiratory disease that was spreading globally at a rapid pace and very efficiently through asymptomatic patients. Health systems in the most affected countries were rapidly hitting their limits, and quick action was needed. In March and April, international borders around the globe closed, and full or partial lockdown measures were introduced in most countries. Unsurprisingly, school closures were part and parcel of these generalised movement restrictions to enforce physical distancing. After all, we knew very little then about the susceptibility and impact of COVID-19 on children, or their role in its transmission. On the other hand, for other respiratory diseases like influenza that tend to affect children more seriously and to be spread by them, school closures have been considered viable short-term policy interventions to reduce transmission.(1)

Photo by Omotayo Kofoworola on Unsplash

UNESCO estimates that more than 1.5 billion students and their families have been affected by the disruptions of education systems globally during the course of this year. (2) As of November 2020, 572 million children are affected by school closures, including 30 country-wide closures. (3) Many of the affected children, especially the most vulnerable and those in LMICs, have not been receiving any alternative forms of schooling during these prolonged periods without in-person education. (2,3)

As we near the end of 2020, we now have a better understanding of the risk of COVID-19 for children, their role in transmitting the disease, as well as the effectiveness of school closures in stemming community transmission compared to other public health measures. We also have the experience of safely reopening schools across a range of settings with basic and effective safety measures. (3,4) Beyond COVID-specific outcomes, it has become increasingly evident that there are serious non-COVID harms associated with school closures that need to be considered in any policy decision. While the science continues to grow and fills the many gaps and unanswered questions, governments can already make better-informed decisions as there is a lot more light in the tunnel.

“As we near the end of 2020, we now have a better understanding of the risk of COVID-19 for children, their role in transmitting the disease, as well as the effectiveness of school closures in stemming community transmission compared to other public health measures.”

On 21 October, WHO released its 39th Coronavirus update on what we know about COVID-19 transmission in schools. (5) Based on what we now know about COVID-19, children, and schools, it states that school closures should only be considered if there is no alternative. This is repeated in WHO’s Interim Guidance on public health and social measures in the context of COVID-19 (dated 4th of November),(6) which stipulates that schools and childcare services should remain open with safety measures, along with other essential services, and reducing in-person education should only be considered in uncontrolled epidemic settings with limited or no additional health system response capacity.

What we know about children and COVID-19 – Disease risk and transmission

Globally, children represent 8.5% of reported COVID-19 cases(7) (and 29% of the population,(8) with variations across regions and countries). (9) They tend to have mild or asymptomatic infections (10) Critically, they are at much lower risk of severe illness, hospitalization, and death from COVID-19 compared to adults. (10-13) When exposed to the virus, children under 10 are significantly less likely to be infected. (14,15,16) In fact, their susceptibility appears to be a fraction of adults’ susceptibility. (17)

The role of children in transmission is still not fully understood yet. However, when infected, the risk of transmitting to others (infectivity) has been found to increase with age. While adolescents appear to transmit as often as adults, children under 10 may be somewhat less contagious. (14,18,19)

Caution is nonetheless required for children with underlying conditions who may be at higher risk of severe illness and, in very rare cases, children have developed severe disease like multisystem inflammatory syndrome. (8,20)

What we know about COVID-19 and schools – Role in community transmission

Based on what we now know, most COVID-19 transmission happens in households (46-66%). (21) The reopening of schools after the first wave of lockdowns did not lead to increased community spread where community transmission was low. (4,22,23,24,25) Transmission in schools reflects transmission in the community but does not drive it. Infections and outbreaks in school settings were uncommon, and most of the detected cases were linked to staff rather than children. (24) Evidence therefore suggests that children-to-children transmission is rare and that children in schools are not the primary transmitters of COVID-19 to adults. (4)

That being said, outbreaks can occur in specific circumstances where there is widespread community transmission and inadequate preventive measures in schools. (26) This happened in a high school in Israel, for example, where a heat wave led to the removal of masks and the use of air-conditioning without natural ventilation in overcrowded classrooms. (27)

Modelling studies have found that unlike for influenza epidemics (1), school closures would have relatively limited returns when it comes to reducing transmission, compared to other physical distancing and public health measures. (1,17)

What we know about the impact of school closures on children’s health and wellbeing

While the relative effectiveness and added value of school closures for the control of COVID-19 are limited, the harms and risks for children’s health and wellbeing are very significant both in the immediate and long term. (28) The WHO update highlights a number of indirect health and social impacts, and several other researchers and organizations have flagged and analysed them.

In an effort to protect children and reduce the health risks of COVID-19, school closures are having negative consequences on their health in other ways. The disruption of school-based services has reduced children’s access to immunisation, school meals, mental and psychosocial support. (3,29,30) At the same time, their disrupted routines, reduced physical activity, lack of interaction with peers and prolonged social isolation are likely contributing to an increased risk of depression and anxiety among children and adolescents. (31,32) While keeping them out of school for their safety, too many children are facing domestic violence and maltreatment in their homes, and child protection systems are less able to identify and respond to their needs. (3,33)

“While keeping them out of school for their safety, too many children are facing domestic violence and maltreatment in their homes, and child protection systems are less able to identify and respond to their needs.”

School closures are further exacerbating a massive learning crisis, constraining children’s ability to learn, with a high risk of school dropouts in the post-COVID period. The World Bank has estimated significant reductions in the average years of schooling, and learning outcomes for the current cohort of learners around the world, with implications for future productivity and earnings – conservatively estimated at USD 10 trillion (in lifecycle earnings). (34)

As with most aspects of this pandemic, these impacts will not be spread equally – they will exacerbate inequities and disproportionately affect the most vulnerable children, especially in LMIC settings. Harms will be greater for girls, who are more likely to drop out of school, be affected by teenage pregnancies, sexual exploitation, violence and child marriage (35); as well as children with disabilities, ethnic minorities, indigenous populations, migrants, refugees, and children living in conflict settings, among others. (36,37)

Beyond these direct impacts of school closures on children, they have also impacted parents’ ability to work (especially mothers) (38) with knock-on impacts on household income, and increased parenting stress, which further affect children’s health and wellbeing in the immediate and long-term. (34,39,40)

Photo by Feliphe Schiarolli on Unsplash

Implications for public health policy in schools

School closures should only be considered as policy interventions to control the COVID-19 epidemic as a last resort. Given that their effectiveness to reduce community transmission is limited, this policy measure could be substituted with other public health measures with fewer indirect negative consequences.

This in no way implies that there are no risks in schools, but the WHO underscores the need for decision-makers to take a risk-based approach to minimize those risks to students and staff, while considering the full range of health, education, and socioeconomic consequences. Public health measures in the community are essential to protect schools and should be the focus of government policies.

WHO’s guidance on public health measures to keep schools safe is clear and mirrors the required community measures: hygiene and handwashing, physical distancing, age-specific use of face masks, adequate and appropriate ventilation, and symptom screening. (5,41)

Translating this evidence to national COVID-19 response policies

Even though we know that children are at low risk and do not have a higher likelihood of spreading COVID-19, many government policies around schools are not following the evidence. According to UNICEF, 137 million children (97% of students) in Latin America and the Caribbean, and about 65 million in East and Southern Africa are currently out of school, for example. (42,43) While schoolchildren in high-income countries have lost on average six weeks of schooling since the start of the pandemic, schoolchildren in LMICs have already lost nearly four months. (4,42) In addition, at least 40 million children have missed out on early childhood education, due to closures of childcare facilities. (43,45)

This disconnect between the most recent evidence and government policies begs the simple question: Why are schools still closed? And why are so many countries not prioritizing their safe reopening?

This is an area of investigation that would benefit from more research and policy analysis to determine what factors are playing a role and driving decisions.

• Is the latest evidence reaching and convincing decision-makers and the public?

The story of this pandemic has been intertwined with a parallel infodemic that has fuelled the spread of misinformation, conspiracy theories and fear, rather than facts. In certain settings, policies around schools have been particularly influenced by poor risk communication and resulting parental and societal anxiety around COVID-19 risks for children. (46)

• Are health, social and economic risks being valued and weighted differently in different cultural and socioeconomic contexts?

Policies on schools and COVID-19 have been a striking reminder that policy decisions have trade-offs and are greatly influenced by societal values and emotions. (47) In the new wave of lockdowns that have just been introduced across Europe, for example, countries are maintaining in-person education as an essential service, with limited resistance, whereas school closures have been hotly debated in other countries, like Australia and the United States (clearly with very different levels of community transmission and epidemic control). (46,48) In Bangladesh and the Philippines, on the other hand, the heads of state announced earlier this year that schools would remain closed until a vaccine becomes available and the pandemic is no longer a risk (26).

“Policies on schools and COVID-19 have been a striking reminder that policy decisions have trade-offs and are greatly influenced by societal values and emotions.”

With this pandemic, it is clear that there are no risk-free solutions, and all options have varying degrees of uncertainty – yet tolerance for health and non-health risks vary across and within countries. (49,50,51) Future risks and benefits tend to get discounted in times of crises, and in some settings immediate economic benefits are being prioritised over short to long term social and health benefits, including for school children. However, this may be a false dichotomy for school closures, given their limited additional effectiveness for epidemic control.

• Are there insurmountable infrastructure and resource constraints that make it more difficult to reopen schools safely for children and school staff, or has there been a lack of prioritization of investments in making schools safe to operate?

As with all essential services, public health measures remain critical to ensure the safe functioning of schools for staff, children and the community. However, the capacity to keep schools safe is more limited in resource-limited settings and requires prioritized investment. For example, joint monitoring by WHO and UNICEF revealed that 51% and 56% of schools across South Asia and sub-Saharan Africa respectively, did not have access to basic handwashing with soap and water in 2019. (52,53) Even in high-income settings, physical distancing requirements mean that many schools lack the physical space to operate normal schedules and may need to implement rotational schedules. (41)

Good policy decision-making requires transparent and explicit considerations and weighting of policy alternatives, including all their benefits and risks, as well as effective communication to the public. We have not seen enough of this around school closures.

On balance, the latest evidence shows that the harms of keeping schools closed outweigh the benefits for epidemic control. Schools should therefore be prioritized and among the first institutions to re-open safely and the last to be closed. Governments around the world have the moral obligation to protect children’s health and well-being through functional school systems. They should be prioritizing and investing in schools’ preparedness to open safely by installing water, sanitation and hygiene facilities, and procuring protective equipment and masks for teachers and students, among others. The question should not be whether to re-open schools; it should be how to do so safely and expediently.

Acknowledgments: This piece was prepared with the assistance of Dr Harvy Joy Liwanag, and with helpful comments from Dr Johanna Riha and Dr Claudia Abreu Lopes.

References

1. Viner, R. M. et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health 4, 397–404 (2020).
2. What have we learnt? Findings from a survey of ministries of education on national responses to COVID-19. UNICEF DATA https://data.unicef.org/resources/national-education-responses-to-covid19/ (2020).
3. UNICEF. Averting a Lost COVID Generation: A Six Point Plan to Respond, Recover and Reimagine a Post-Pandemic World for Every Child. https://weshare.unicef.org/CS.aspx?VP3=SearchResult&ALID=2AMZIFJ1LM9W&VBID=2AMZVNBQ64GD&POPUPPN=1&POPUPIID=2AMZIFB714DX (2020).
4. Ismail, S. A., Saliba, V., Bernal, J. A. L., Ramsay, M. E. & Ladhani, S. N. SARS-CoV-2 infection and transmission in educational settings: cross-sectional analysis of clusters and outbreaks in England. medRxiv 2020.08.21.20178574 (2020) doi:10.1101/2020.08.21.20178574.
5. WHO, EPI Win & infodemic management. What we know about COVID-19 transmission in schools. 32 https://www.who.int/docs/default-source/coronaviruse/risk-comms-updates/update39-covid-and-schools.pdf?sfvrsn=320db233_2 (2020).
6. WHO. Considerations for implementing and adjusting public health and social measures in the context of COVID-19. https://www.who.int/publications-detail-redirect/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance (2020).
7. WHO. Coronavirus disease (COVID-19): Schools. https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-schools (2020).
8. UNICEF Office of Research-Innocenti. The Evolving Epidemiologic and Clinical Picture of SARS-CoV-2 and COVID-19 Disease in Children and Young People. https://www.unicef-irc.org/publications/1107-the-evolving-epidemiologic-and-clinical-picture-of-sars-cov-2-and-covid-19-disease.html (2020).
9. United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects 2019. https://population.un.org/wpp/ (2019).
10. Swann, O. V. et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ 370, (2020).
11. Götzinger, F. et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. The Lancet Child & Adolescent Health 4, 653–661 (2020).
12. Viner, R. M. et al. Susceptibility to SARS-CoV-2 Infection Among Children and Adolescents Compared With Adults: A Systematic Review and Meta-analysis. JAMA Pediatr (2020) doi:10.1001/jamapediatrics.2020.4573.
13. Castagnoli, R. et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatr 174, 882–889 (2020).
14. Goldstein, E., Lipsitch, M. & Cevik, M. On the effect of age on the transmission of SARS-CoV-2 in households, schools and the community. medRxiv 2020.07.19.20157362 (2020) doi:10.1101/2020.07.19.20157362.
15. Viner, R. M. et al. Susceptibility to and transmission of COVID-19 amongst children and adolescents compared with adults: a systematic review and meta-analysis. medRxiv 2020.05.20.20108126 (2020) doi:10.1101/2020.05.20.20108126.
16. Madewell, Z. J., Yang, Y., Longini, I. M., Halloran, M. E. & Dean, N. E. Household transmission of SARS-CoV-2: a systematic review and meta-analysis of secondary attack rate. medRxiv 2020.07.29.20164590 (2020) doi:10.1101/2020.07.29.20164590.
17. ISEE Global Education Channel. GABRIEL LEUNG – School Closure for COVID-19 Control. (2020).
18. Jones, T. C. et al. An analysis of SARS-CoV-2 viral load by patient age. medRxiv 2020.06.08.20125484 (2020) doi:10.1101/2020.06.08.20125484.
19. Park, Y. J. et al. Contact Tracing during Coronavirus Disease Outbreak, South Korea. Emerging Infectious Diseases journal – CDC 26, (2020).
20. Jiang, L. et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet Infectious Diseases 20, e276–e288 (2020).
21. Lee, E. C., Wada, N. I., Grabowski, M. K., Gurley, E. S. & Lessler, J. The engines of SARS-CoV-2 spread. Science 370, 406–407 (2020).
22. Faust, S. N. & Munro, A. P. S. It’s Time to Put Children and Young People First During the Global COVID-19 Pandemic. JAMA Pediatr (2020) doi:10.1001/jamapediatrics.2020.4582.
23. Public Health Agency of Sweden. Covid-19 in schoolchildren – A comparison between Finland and Sweden — Folkhälsomyndigheten. http://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/c/covid-19-in-schoolchildren/.
24. European Center for Disease Prevention and Control. COVID-19 in children and the role of school settings in COVID-19 transmission. (2020).
25. Macartney, K. et al. Transmission of SARS-CoV-2 in Australian educational settings: a prospective cohort study. The Lancet Child & Adolescent Health 4, 807–816 (2020).
26. Couzin-Frankel, J. et al. School openings across globe suggest ways to keep coronavirus at bay, despite outbreaks. Science | AAAS https://www.sciencemag.org/news/2020/07/school-openings-across-globe-suggest-ways-keep-coronavirus-bay-despite-outbreaks (2020).
27. Stein-Zamir, C. et al. A large COVID-19 outbreak in a high school 10 days after schools’ reopening, Israel, May 2020. Euro Surveill 25, (2020).
28. Levinson, M., Cevik, M. & Lipsitch, M. Reopening Primary Schools during the Pandemic. New England Journal of Medicine 383, 981–985 (2020).
29. United Nations. Policy Brief: The Impact of COVID-19 on Children. (2020).
30. Roberton, T. et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Global Health 8, e901–e908 (2020).
31. Loades, M. E. et al. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. J Am Acad Child Adolesc Psychiatry 59, 1218–1239.e3 (2020).
32. Zhang, L. et al. Assessment of Mental Health of Chinese Primary School Students Before and After School Closing and Opening During the COVID-19 Pandemic. JAMA Netw Open 3, e2021482 (2020).
33. Baron, E. J., Goldstein, E. G. & Wallace, C. T. Suffering in silence: How COVID-19 school closures inhibit the reporting of child maltreatment. J Public Econ 190, 104258 (2020).
34. World Bank. Simulating the Potential Impacts of the COVID-19 School Closures on Schooling and Learning Outcomes: A set of Global Estimates. World Bank https://www.worldbank.org/en/topic/education/publication/simulating-potential-impacts-of-covid-19-school-closures-learning-outcomes-a-set-of-global-estimates (2020).
35. Burzynska, K. & Contreras, G. Gendered effects of school closures during the COVID-19 pandemic. Lancet 395, 1968 (2020).
36. Burzynska, K. & Contreras, G. Gendered effects of school closures during the COVID-19 pandemic. Lancet 395, 1968 (2020).
37. UNESCO Education Sector. COVID-19 Education Response Webinar: Addressing the gender dimensions of COVID-related school closures. (2020).
38. Taub, A. Pandemic Will ‘Take Our Women 10 Years Back’ in the Workplace. The New York Times (2020).
39. Garbe, A., Ogurlu, U., Logan, N. & Cook, P. Parents’ Experiences with Remote Education during COVID-19 School Closures. AM J QUALITATIVE RES 4, 45–65 (2020).
40. Hiraoka, D. & Tomoda, A. Relationship between parenting stress and school closures due to the COVID-19 pandemic. Psychiatry and Clinical Neurosciences 74, 497–498 (2020).
41. WHO. Considerations for school-related public health measures in the context of COVID-19. https://www.who.int/publications-detail-redirect/considerations-for-school-related-public-health-measures-in-the-context-of-covid-19 (2020).
42. UNICEF. COVID-19: over 97 per cent of students still out of the classrooms in Latin America and the Caribbean. https://www.unicef.org/press-releases/covid-19-over-97-cent-students-still-out-classrooms-latin-america-and-caribbean (2020).
43. UNICEF. Time to re-open schools in Eastern & Southern Africa, as the cost for children escalates in learning, protection and nutrition. https://www.unicef.org/press-releases/time-re-open-schools-eastern-southern-africa-cost-children-escalates-learning (2020).
44. Children in the poorest countries have lost nearly four months of schooling since start of pandemic – UNESCO, UNICEF and World Bank report finds. https://www.unicef.org/eap/press-releases/children-poorest-countries-have-lost-nearly-four-months-schooling-start-pandemic (2020).
45. UNICEF. Nearly 22 million children in South Asia miss out on early education in critical pre-school year due to COVID-19 — UNICEF. https://www.unicef.org/rosa/press-releases/nearly-22-million-children-south-asia-miss-out-early-education-critical-pre-school (2020).
46. Leask, J. & Hooker, C. How risk communication could have reduced controversy about school closures in Australia during the COVID-19 pandemic. Public Health Research & Practice 30, (2020).
47. Weible, C. M. et al. COVID-19 and the policy sciences: initial reactions and perspectives. Policy sciences 1–17 (2020).
48. Why Is Europe Keeping Its Schools Open, Despite New Lockdowns? – The New York Times. https://www.nytimes.com/2020/10/29/world/europe/schools-coronavirus-europe-lockdowns.html.
49. Hoover, A. G., Heiger-Bernays, W., Ojha, S. & Pennell, K. G. Balancing incomplete COVID-19 evidence and local priorities: risk communication and stakeholder engagement strategies for school re-opening. Rev Environ Health (2020) doi:10.1515/reveh-2020-0092.
50. Golinkoff, K. H.-P., Michael Yogman, and Roberta Michnick. Should schools reopen? Balancing COVID-19 and learning loss for young children. Brookings https://www.brookings.edu/blog/education-plus-development/2020/07/21/should-schools-reopen-balancing-covid-19-and-learning-loss-for-young-children/ (2020).
51. Rasmussen, S. A. & Jamieson, D. J. Public Health Decision Making during Covid-19 — Fulfilling the CDC Pledge to the American People. New England Journal of Medicine 383, 901–903 (2020).
52. UNICEF. More than half of schools in South Asia lacked basic handwashing facilities prior to COVID-19 pandemic — UNICEF, WHO. https://www.unicef.org/rosa/press-releases/more-half-schools-south-asia-lacked-basic-handwashing-facilities-prior-covid-19 (2020).
53. WHO Regional Office for Africa. L’OMS et l’UNICEF préconisent la réouverture des écoles en Afrique. https://www.afro.who.int/fr/news/loms-et-lunicef-preconisent-la-reouverture-des-ecoles-en-afrique (2020).