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

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 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

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

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

Susceptibility of Children to COVID-19: Household Studies Study population Number of participants Household secondary attack rate, adults China 392 households 17.1% secondary attack rate adults 105 index patients 4% children China 195 unrelated clusters 17.7% secondary attack rate aged > 60 212 primary cases, 137 nonprimary cases 13.7% aged 20-59 1938 uninfected close contacts 5.3% aged 0-19 NY State. 498 total persons in the households of the initial Prevalence rises with age Excluding NYC 229 cases Between 42-55% aged 18 and older (55% aged >65) 343 households 28 % aged 5-17 years 20% aged < 5 years Israel 13 household clusters; 36 adult contacts, 58 child 58.3% of adults infected contacts 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.

Transmission Dynamics: Children and the Household • Geneva, Switzerland • Schools closed March 16 th • 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.

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.

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.

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.

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.

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

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

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

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

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

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

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

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

The Dilemma • Children benefit immensely from in-person schooling • Education • Nutrition • Safety • COVID poses a risk to children, families, teachers, and staff 19

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?