[By Biswarup Ganguly, CC BY 3.0, via Wikimedia Commons]
Good morning,
This Monday, Mumbai re-opened its schools for standards 8th to 12th. It isn’t alone. Schools have already opened across several states such as Delhi, Karnataka, Telangana, Tamil Nadu and Andhra Pradesh.
In Mumbai, as it stands, students will not be forced to attend school and a parent’s nod will be mandatory for them to attend classes.
This means parents need to take a critical decision—whether to send their children to school or to continue the status quo with online classes.
The decision is not easy. On one hand, if you decide to not send your children to school, you risk learning loss, increased screen time, weight gain, reduced social interactions and even psychological impact. Is it worth it given children are known to have a significantly lower risk of a severe Covid?
But sending your child isn’t as straightforward either. Parents have tons of questions weighing on their minds. What if they get infected or worse yet, bring the virus home to an elderly or co-morbid family member? Will schools be able to ensure social distancing and masking? Isn’t it better to wait for vaccines?
To help parents think through their decision, in this edition of FF Recommends, we speak to Dr. Lancelot Pinto, a pulmonologist and epidemiologist, who has emerged as one of the most trustworthy voices during the pandemic.
We talk about three things
- What are the risks and how should you manage them?
- How to ensure children are safe at school?
- How should you think about vaccines for children?
While Dr. Pinto and we can’t answer whether you should send your child to school—each family has to make their own calls that’s best tailored to their context and risk appetite—we hope this FAQ plays the role of a decision making guide as you figure out your own answers.
FAQ: A guide to help you decide if you should send your child back to school
(With Dr Lancelot Mark Pinto, who is a consulting respirologist at PD Hinduja Hospital. He specializes in the treatment of chronic pulmonary disease, tuberculosis, sleep apnea, and insomnia)
Understanding and managing the risks
1. You have been front and centre in the fight with Covid-19. You have treated many patients and seen many succumb to death too. You are also an advocate for opening schools. Why is that?
Covid-19 has fortunately not affected children to even a tiny fraction compared to the severity with which it can affect adults. Most children who acquire the infection tend to have a mild course, which is more often than not comparable to the common cold. This is reflected in the fact that despite a significant proportion of children having had the infection, the rates of hospitalisation and poor outcomes have been rare. Studies in India which have looked at the prevalence of antibodies among children (which could only have come from prior infection, since children have not yet been vaccinated) have found that up to 55-60% of children have antibodies, and the prevalence is not very different from that among adults. This suggests that in the midst of the two large surges that the country has experienced, children possibly got infected in the same proportions that adults did, but experienced much milder forms of the disease.
2. Even though children are largely unaffected by Covid, for parents who are worried, can you elaborate so that it helps them understand what are the health risks a child faces if they attend school physically?
About 26% of the Indian population is under the age of 15—that’s roughly 350 million children. Over a half of these have already been infected. So to begin with, there is a 50-50 chance that your child who is being sent back to school already has antibodies, and this is likely to be a higher probability if someone in close contact with the child tested positive in the past. Most studies that actually traced contacts of a child with Covid found that a majority of those in contact who tested positive were asymptomatic. So if your child does get infected at school, chances are high that they will not have any symptoms. If they do develop symptomatic Covid, chances are very high that the course will be no different from the common cold. Therefore, an extremely tiny fraction of children may have disease severe enough to warrant hospitalisation—and poor outcomes among those hospitalized have been found in less than 2.5% of children, and these tend to be children with comorbidities.
3. What are the health risks a child faces if they stay at home?
I think the health risks are physical, emotional and developmental. All over the world, as lifestyles become more affluent, adolescent obesity tends to be a major concern. This is clearly compounded by a lack of physical activity, increased screen time, and excessive snacking, all of which have been facilitated by lockdowns in which children have been homebound. Children also learn interpersonal skills, the art of negotiation, and emotional bonds at school. The lack of social interaction with peers has the potential of leading to a mental health epidemic.
Conversations around the safety of children need to be accompanied by taking into account the costs of keeping them safe. We already do this multiple times a day. For example, we don’t worry whether a child will injure themselves while playing as the risk is small and what they will lose out will be far more if they live in fear.
Even before Covid, schools were hotbeds of infection with children constantly falling ill. However, that never stopped us because we saw the immense value that schools offer.
Similarly, it’s important parents now weigh the risks from Covid (which seems really small) and weigh it appropriately with the loss of social interactions, physical fitness and soft skills that play a role in moulding the kids.
Doing one without the other, means we are letting our kids down.
4. There was a prevalent belief that if there is a third wave it will disproportionately affect children. However, you believe data reveals that’s not the case. Can you elaborate?
To the best of my knowledge, there is no scientific rationale supporting this speculation. The hypothesis that children will be protected because they were homebound isn’t plausible, because children don’t live at home by themselves. So, unless they are uniquely resistant to the virus, there is no reason to believe that the adults in the home will get Covid and the children will be spared. This is borne out by the seroprevalence studies. A recent seroprevalence study from AIIMS covering five states (reported in June) found antibodies in 55.7% of those who are under 18. ICMR’s fourth serosurvey covering 21 states in June-July found 57.2% children aged 6-9 years and 61.6% children aged 10-17, have been infected. In Mumbai, 51% kids had antibodies, in a study conducted across 24 wards.
5. What is the risk to other household members, especially the elderly, if a child goes to school? And what’s the best way to manage the risks?
This will depend on their immune status. Vaccinated individuals with no immunosuppressive conditions are likely to be low-risk, and this risk will vary based on these two factors. There is no way to manage this risk, except isolating a child as soon as they are symptomatic, and doing the same for an asymptomatic child who is found to have been in contact with an index case. The alternative is to isolate the high-risk individual till the child is likely to be infectious.
6. Given these factors, are there certain contexts (say if there’s an immunocompromised family member or a child with respiratory illness), where parents should not send a child to school?
Of course, there’s no one-size-fits-all. Policy and guidelines are formulated keeping in mind the greater common good. But, one needs to additionally look at their individual risk-benefit ratios. For example, flying is generally considered to be safe, except for someone who is oxygen-dependent or has several lung diseases.
In such cases, one needs to have this discussion with the child’s pediatrician to understand the risk of severe disease and weigh that against the loss of learning and social interaction.
Ensuring safety at schools
7. What are some reasonable protocols parents should demand that schools follow?
Some things are now well understood: like distancing, hand sanitizing, temperature checks, full vaccination of every adult on campus, sending ill kids back home, and mandating the testing of such kids. Additionally, parents can check and insist that the school takes steps to ensure adequate ventilation. In fact, I do believe it is time to rethink ventilation—and not just because of the risks of Covid.
8. While schools are promising social distancing and masking, it’s being observed that it isn’t followed in practice. Many children remove their masks. It’s difficult to convince them to wear it. Teachers also can’t enforce rules all the time. How should a parent factor this risk into their decision making?
Parents should assume that there is a possibility that the child will get infected, but be assured in the knowledge that such an infection is likely to be no different from the many respiratory infections that the child has picked up from school in the past, and that the benefits of being educated in school far outweigh the risks. This does not mean that one doesn’t take the necessary precautions, but one accepts that kids, being kids, will not adhere to every precaution as rigidly as one expects them to. Expecting a zero-probability-of-infection scenario is likely to make the child as anxious as the parents, and that will not be in anyone’s best interests.
9. Schools have already opened in other countries and states. What is emerging from these places? What have we learnt so far?
Outbreaks will happen, but they are more likely to affect the adults in contact with the children than the children themselves. As evidenced by the two waves that we have experienced when schools were closed, schools being open are definitely not the only determinant in spread of the disease, but they can contribute. Yet, most developed nations have prioritized in-person schooling because the benefits outweigh the risks.
Thinking through vaccinations
10. How should parents think about vaccinating their children, if and when a vaccine becomes available?
First, anytime we vaccinate someone, we need to assess the risk of severe disease if they are infected versus the risk of vaccination. For most adults this calculation is a no-brainer. However, it starts changing as we move to a younger population. That’s why AstraZeneca’s vaccine was suspended in young adults because there was a question whether the incidence of clots, which was an extremely rare event, outweighed the potential benefits in a young person.
Children have been almost unaffected by Covid. A vaccine that is offered to children will hence need to have almost zero serious adverse effects to be able to justify its use in a population that’s vulnerable (they do not give consent themselves) and has an extremely low-risk of getting a serious Covid incidence. The strongest reason to vaccinate children is to protect the elderly from transmission. Parents need to consider if it’s justified as it means exposing healthy kids to even the rarest serious adverse effects.
11. Is it worth waiting for the vaccine before sending your child to school?
It will take nearly a year from the day we start. We have around 450 million kids under the age of 18. It has taken 8 months to vaccinate the 230 million adults so far. So, with the same infrastructure which the kids will have to compete with, it will possibly take us a year more. We need to assess if we are ready to wait that long.
