Schools are essential. Don’t rule them out.

Keith J. Loud, MD, MSc (@LoudKJ) is Chair of the Department of Pediatrics at Children’s Hospital at Dartmouth-Hitchcock and the Geisel School of Medicine at Dartmouth

It remains to be seen just how much President Trump’s extension of social distancing guidelines in the United States until April 30 defers the debate over when to safely restart the economy, allowing policymakers to focus on how to ramp up the testing and PPE availability to do so. When the time comes, they also need to contemplate the question asked by Aaron Carroll in the March 17th New York Times, “Is closing the schools a good idea?”

The question was not rhetorical. It cited the food insecurity addressed by school lunch and breakfast programs as well as the physical safety provided, particularly for homeless children. While New York City schools are providing 3 meals/day for children who need, child protective services in many regions are already seeing 50% declines in reporting of child abuse and neglect. With families stressed economically and confined to home without supervision, that is not good news since neglected or abused children are often only identified at school. In this week’s New Yorker Peter Hessler writes anecdotally about 2 suicides in youth attributed to the lockdown in China, matching that country’s total number of pediatric deaths thus far due to SARS-CoV-2 in the literature.

When we think of flattening the curve to protect the most vulnerable in society, our minds jump to the very old and the very young. Evidence from previous influenza pandemics supports our instincts. But SARS-CoV-2 appears different. Not only has critical illness in children in China and Italy been extremely rare, in both countries children make up only 1% all cases.

Even in New York state, where younger age groups seem to have been hit harder than in Italy, children still only represent 2% of cases. Finally, in a country like Iceland, which has tested a large proportion of its population, including many without any symptoms at all, children under 10 years old make up only 2% of the cases. It is these numbers that beg examination of one of Dr. Fauci’s hypotheses in the New England Journal of Medicine – that “children are less likely to become infected.”

The first SARS-CoV pandemic in 2002-2003 documented 135 pediatric cases, or only 1.7% of the 8098 reported worldwide to the World Health Organization (WHO) by the time it was declared contained, with no deaths and only 1 reported case of transmission of the virus from a pediatric patient. The WHO January 2020 Situation Update for the Middle East respiratory syndrome (MERS), another coronavirus, shows children and adolescents to be similarly disproportionally unaffected. A Japanese study of transmission in close contacts of known positive coronavirus 2019 (COVID-19) patients demonstrated a much lower attack rate amongst children than adults.

And according to the Report of the WHO-China Joint Mission on COVID-19, no one performing case tracing on the ground in China could “recall episodes in which transmission occurred from a child to an adult.”

Singapore has been lauded for its ability to mitigate the COVID-19 outbreak. Its rigorous implementation of control measures has included opening (and re-closing, next on April 8th) schools concurrently with other activities. Perhaps, as speculated by Dr. Dale Fisher, an infectious diseases specialist from Singapore who served as a member of the WHO-China Joint Mission, “children… don’t amplify the transmission. They are kind of bystanders while it goes on.”

If true, schools should be among the first US institutions re-opened, not the last. They are at least as essential as liquor stores and gun shops.

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