Schools and COVID Jennifer Nuzzo, SM, DrPH Joshua Sharfstein, MD - - PowerPoint PPT Presentation

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Schools and COVID Jennifer Nuzzo, SM, DrPH Joshua Sharfstein, MD - - PowerPoint PPT Presentation

Aug 25, 2023 201 likes •586 views

Schools and COVID Jennifer Nuzzo, SM, DrPH Joshua Sharfstein, MD July 21, 2020 Objectives 1. Discuss the transmission dynamics of children, including susceptibility and transmissibility inside and outside of the home 2. Discuss the relevance

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Schools and COVID Jennifer Nuzzo, SM, DrPH Joshua Sharfstein, MD July 21, 2020

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Objectives

  • 1. Discuss the transmission dynamics of children, including

susceptibility and transmissibility inside and outside of the home

  • 2. Discuss the relevance of issues of equity when considering school

reopening

  • 3. Discuss the potential risk to teachers and staff of school reopening
  • 4. Review what other countries have done when reopening schools
  • 5. Review a process by which communities can undertake school

reopening, including the resources schools need

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Reminder: Epidemiology of SARS-CoV-2 Infection In Children

  • 6/23 COVID-19 Grand Rounds
  • Analysis of 149,760 US laboratory-confirmed cases through 4/2
  • 2572 (1.7%) among children aged <18y
  • Children comprise 22% of US population
  • Median age 11 years
  • 813 (32%) reported cases in children 15-17y
  • 282 (27%) in children 10-14y
  • 398 (15%) in children aged <1 year
  • 388 (15%) in children aged 5-9y
  • 291 (11%) in children aged 1-4y

MMWR Morb Mortal Wkly Rep 2020;69:422–426. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e4

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Reminder: Epidemiology of SARS-CoV-2 Infection in Children

  • Hospitalization status (data available on 29%)
  • 5.7% hospitalized (vs 10% adults 18-64y)
  • 0.58% to ICU (vs 1.4%)
  • 20% of those for whom status known (vs. 33% adults)
  • 2% to ICU (vs. 4.5%)
  • Children <1 year accounted for highest proportion of

hospitalized children

  • Three deaths

MMWR Morb Mortal Wkly Rep 2020;69:422–426. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e4

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Susceptibility of Children to COVID-19: Household Studies

Study population Number of participants Household secondary attack rate, adults

China 392 households 105 index patients 17.1% secondary attack rate adults 4% children China 195 unrelated clusters 212 primary cases, 137 nonprimary cases 1938 uninfected close contacts 17.7% secondary attack rate aged > 60 13.7% aged 20-59 5.3% aged 0-19 NY State. Excluding NYC 498 total persons in the households of the initial 229 cases 343 households Prevalence rises with age Between 42-55% aged 18 and older (55% aged >65) 28 % aged 5-17 years 20% aged < 5 years Israel 13 household clusters; 36 adult contacts, 58 child contacts 58.3% of adults infected 32.5% aged 5-17 11.8% aged 0-4 Meta analysis 18 studies; 9 contact tracing Pooled OR of being an infected contact in children compared with adults for all contact tracing studies 0.44 (0.29, 0.69)

Li W, at al. Clin Infect Dis. 2020 Apr 17:ciaa450. doi: 10.1093/cid/ciaa450. Jing QL, et al. medRxiv. 2020 Apr 15:2020.04.11.20056010. doi: 10.1101/2020.04.11.20056010. Preprint. Rosenberg ES< et al. Clin Infect Dis . 2020 May 8;ciaa549. doi: 10.1093/cid/ciaa549. Online ahead of print. Viner ML, et al. medRxiv 2020.05.20.20108126; doi: https://doi.org/10.1101/2020.05.20.20108126 Somekh E, et al. Pediatr Infect Dis J 2020 Aug;39(8):e202-e204. doi: 10.1097/INF.0000000000002783.

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Transmission Dynamics: Children and the Household

  • Geneva, Switzerland
  • Schools closed March 16th
  • March 10 to April 10, 2020
  • All patients <16 years old with COVID-19 identified by Geneva University

Hospital’s surveillance network

  • Chart reviews used to retrieve clinical data
  • Parents called for patients and household contacts follow-up

Posfay-Barbe KM et al. COVID-19 in children and the dynamics of infection in families. Pediatrics 2020 May 26; 146:e20201576.

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Transmission Dynamics: Children and the Household

  • 4310 patients with SARS-CoV-2
  • 40 (0.9%) < 16 years
  • One patient with no telephone follow-up excluded
  • The median follow-up of the households was 18 days ([IQR]: 14–28)
  • 29 (74%) patients previously healthy
  • Most frequently reported comorbidities: Asthma (10%), diabetes (8%), obesity (5%), premature

birth (5%), and hypertension (3%)

  • 7 (18%) hospitalized
  • 2 for non-hypoxemic viral pneumonia, 2 for fever without source, 1 for apparent life-

threatening event, 1 for sepsis

  • All with complete resolution of symptoms by day 7 post diagnosis

Posfay-Barbe KM et al. COVID-19 in children and the dynamics of infection in families. Pediatrics 2020 May 26; 146:e20201576.

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Transmission Dynamics: Children and the Household

  • Average 4 household members per family (IQR: 3–4)
  • 111 household contacts
  • mothers (n = 39)
  • fathers (n = 32)
  • pediatric siblings (n = 23)
  • adult siblings (n = 8)
  • grandparents (n = 7)
  • Adult household contacts developed symptoms/confirmed COVID-19

before study child in 79% (31/39)

  • 8% (3/39) the study children developed symptoms before household

contacts

Posfay-Barbe KM et al. COVID-19 in children and the dynamics of infection in families. Pediatrics 2020 May 26; 146:e20201576.

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Transmission Dynamics: Children and School

  • Retrospective study in Ireland
  • All SARS-CoV-2 notifications to public health departments screened

to identify children and adults who had attended school setting

  • Cases identified within the Computerised Infectious Disease Reporting

system (Ireland’s national infectious disease surveillance system).

  • 3 pediatric cases and 3 adult cases of COVID-19 with a history of

school attendance identified

  • Based on epidemiological data, none infected in the school setting

Heavey L, et al. Euro Surveill. 2020 May;25(21):2000903. doi: 10.2807/1560-7917.ES.2020.25.21.2000903.

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Transmission Dynamics: Children and School

Heavey L, et al. Euro Surveill. 2020 May;25(21):2000903. doi: 10.2807/1560-7917.ES.2020.25.21.2000903.

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Data from Contact Tracing in South Korea

  • South Korea’s public health system monitored contacts of 5706 index

cases with COVID-19 symptoms between 1/20/20 and 3/27/20

  • Index case: the first identified laboratory-confirmed case or the first

documented case in an epidemiologic investigation within a cluster

  • 59,073 contacts of index cases were tracked for an average of 9.9

days (range 8.2-12.5) after SARS-CoV-2 infection was detected

  • Schools were closed during this time

Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Data from Contact Tracing in South Korea

  • All household contacts tested
  • Only symptomatic out-of-household contacts tested
  • Non-high-risk asymptomatic contacts were required to self-

quarantine x14d & were placed under twice-daily active surveillance

  • Rigorous contact tracing combining “shoe-leather epidemiology” with

large databases (global positioning system, credit card transactions, closed-circuit television)

Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Infection Rates among Contacts

  • 10,592 household contacts
  • 11.8% tested SARS-CoV-2 positive (95% CI 11.2-12.4%)
  • Rates were higher for contacts of adolescents than adults: In households with

an index patient 10-19y, 18.6% (95% CI 14-24%) of contacts had COVID-19

  • Lowest rates were for contacts of children 0-9y: 5.3% (95% CI 1.3-13.7%)
  • 48,481 non-household contacts
  • 1.9% tested SARS-CoV-2 positive
  • Rates were low for children 0-9y [1.1% (95% CI 0.2-3.6%)] and 10-19y [0.9%

(95% CI 0.1-2.9%)]

Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Data Limitations

  • The first person in a household to become symptomatic may not be

the first to be infected

  • As only symptomatic children were followed, the efficiency of

transmission from asymptomatic children remains uncertain

  • The number of cases may have been underestimated owing to lack of

identification of all asymptomatic patients

Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315

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Summary and Hypotheses

  • Children 0-9y half as likely as adults to spread the virus to others
  • Postulated explanations:
  • These children exhale less air
  • They exhale closer to the ground
  • Provides support for the opening of elementary schools
  • Children 10-19y more likely than adults to infect others
  • Speculation:
  • Lack of attention to non-pharmaceutical interventions
  • More likely than younger children to socialize with peers
  • Engenders concern regarding reopening of middle and high schools

Park YJ et al. Emerg Infect Dis. 2020 Oct [accessed 20 July 2020]. https://doi.org/10.3201/eid2610.201315. nytimes.com/2020/07/18/health/coronavirus- children-schools.html

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Summary

  • 1. Children generally have a mild course of disease when infected with

SARS-CoV-2

  • 2. Children are likely less susceptible to acquiring SARS-CoV-2, but

more data are needed

  • 3. Children less than 10 appear less likely to transmit SARS-CoV-2

than children older than 10 and adults, but more data are needed

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The Dilemma

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  • Children benefit immensely

from in-person schooling

  • Education
  • Nutrition
  • Safety
  • COVID poses a risk to

children, families, teachers, and staff

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Questions

  • 1. How do we incorporate into decision-making the reality that the

communities most severely affected by the pandemic are also the ones most likely to have schools that are understaffed, in need of repair, and limited in their ability to accommodate remote learning?

  • 2. What about the reality that families and students in these

communities may have limited broadband access?

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The Context: Profound Inequity

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Many public school systems are grossly underfunded, with deteriorating infrastructure.

There are enormous divides in access to digital technology.

The COVID pandemic continues to strike hardest in communities

  • f color
  • African-Americans and Latinx are

infected at rates 5X and 4X greater than white Americans, respectively.

  • Deaths among younger adults far

higher in communities of color.

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Risk of Serious Illness

State of the Data

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Much lower for children, particularly at younger ages (but not zero)

Risk of Illness

Appears similar or somewhat lower for children than adults, with 90% getting mild infections.

Risk of Transmission

Appears lower than for adults, but data are still limited

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Questions about Risks to Educators

  • 1. What is the risk to teachers and staff if schools reopen? Does it

differ between elementary, middle, and high schools?

  • 2. School doesn’t look like it did 20 years ago. Students often work

together in small groups with the accompanying proximity between teachers and students; students with special needs often need extra proximity to teachers. How should approaches be modified?

  • 3. Many school buildings are old, with equally old ventilation systems.

It’s really hot in schools in September, with winter soon to follow. How should schools confront these realities?

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Risks to Teachers and Staff

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1/5 of teachers and 1/3 of principals are age 55 and older Teachers and staff may have underlying illnesses Understandable fear Political demands for reopening complicating situation

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Question

What has happened in other countries when schools have reopened?

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Lessons from Abroad

  • Open when ready
  • Take precautions
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Questions

  • 1. What steps would need to be taken for schools to reopen?
  • 2. What variables factor into an assessment of the level of

community transmission at which opening schools might become unsafe?

  • 3. Is it possible to have a single national response?
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First

A Path Forward

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Control the pandemic; Infection rates declining substantially or low

Third

Reduce infection risk at school through cohorts, masks where possible, handwashing, and cleaning

Second

Focus on those students who need in-person schooling most: younger ages, special services, at highest social risk

Fourth

Offer online options to at-risk teachers and students. Prepare response for cases and switch to remote learning

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Questions about Resources

  • 1. What resources would schools need to reopen safely?
  • 2. What kind of PPE do teachers need if schools reopen, and who will

be responsible for providing it?

  • 3. What would a testing, tracking, and isolation system look like in
  • rder to provide as much reassurance as possible to teachers, staff,

students, and families?

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Schools Need Resources to Succeed

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More space More personnel More transportation options More access to testing More communication and engagement

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Question

How do we effectively incorporate teacher perspectives into decisions around reopening?

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Question

If some schools are going to reopen in the fall, what processes should be put into place to study their experiences in order to inform future reopening decisions?

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Question

What are your thoughts on hybrid models, such as having children in cohorts that attend school every other day, or every other week, etc?

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Question

If some private schools open in areas where public schools do not, what ability to private school teachers have to defer returning?

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Objectives

  • 1. Discuss the transmission dynamics of children, including

susceptibility and transmissibility inside and outside of the home

  • 2. Discuss the importance of equity/inequity when considering school

reopening

  • 3. Discuss the potential risk to teachers and staff of school reopening
  • 4. Review what other countries have done when reopening schools
  • 5. Review a process by which communities can undertake school

reopening, including the resources schools need

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SLIDES & RECORDINGS ARCHIVED ONLINE

https://bit.ly/2Y2DIDj