While it may seem that children are more resistant to the new coronavirus, it’s hard to know for sure since their symptoms are often less severe than adults’ and may mimic other diseases. So, if a student shows up to class coughing and feverish, there’s no way to tell whether she has COVID-19, the respiratory illness caused by the highly infectious new coronavirus, or has fallen victim to the second back-to-back year of uncharacteristically severe and widespread seasonal influenza.
In one way it doesn’t matter for schools, says Sean O’Leary, a pediatric epidemiologist at Children’s Hospital, Colorado, and a member of the American Academy of Pediatrics committee on infectious diseases: “They should handle respiratory illness the way they normally would: If a child comes to school with a fever, they’re supposed to be sent home. That’s the standard.”
From flu to respiratory syncytial virus (RSV) to the common cold, schools are no stranger to waves of highly contagious respiratory diseases—several already known to cause severe complications for some students. But while these competing illnesses may complicate national efforts to track and contain the new coronavirus, they also give administrators a clearer path for what to do after the first few kids start coughing.
How can you tell if a sick student has COVID-19?
Children are so far less likely than adults to show symptoms of coronavirus; fewer than 1 percent of confirmed COVID-19 cases in China were of children under 9. However, it’s not yet known whether these children never contracted coronavirus, or simply never had symptoms severe enough to be tested for it. At this point, the vast majority of children who have developed illness related to COVID-19 have had a fever and a cough, according to the Centers for Disease Control and Prevention, and congestion, as well as a runny nose and in one case, vomiting and diarrhea, which was less seen among adults.
“From limited published reports, signs and symptoms among children with COVID-19 may be more mild than adults,” the CDC said, with less risk of difficulty breathing.
COVID-19 symptoms sound pretty much like the start of the seasonal flu or even a really bad cold. The only way to tell for certain that a student has contracted the coronavirus is to run a medical test to identify genetic markers for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the specific coronavirus that causes COVID-19. For now, those tests are being prioritized for health-care workers, those with known connections to people who have contracted the disease, and those who are very ill with no other immediately known cause.
What are the risks for students?
Epidemiologists measure how contagious a disease is by its “basic reproduction number,” or R0 (pronounced “are-not”), meaning the number of people each infected person would be expected to infect in turn. So far, experts believe the coronavirus to have an R0 of about 2-2.5, meaning each infected person would be expected to pass it on to another two or so people. That is nearly twice as contagious as the flu, which has an R0 of 1.3, but much less contagious than another childhood illness, measles, which one infected person could spread to as many as 30 people in a bad outbreak. Based on this base level, children should be more likely to contract coronavirus than the flu.
But we don’t know how readily children contract or spread the coronavirus, because so far, they haven’t been hit as hard by the disease. Worldwide, no one under 9 has died from COVID-19, and 0.2 percent of those ages 10 to 19 have died, based on the Centers for Disease Control and Prevention’s guidance to doctors. Compare that to an overall mortality rate for COVID-19 that is estimated to be more than 10 times that high. Other coronaviruses, like those responsible for earlier outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), similarly seemed to affect children less, though it’s not clear whether children actually were less affected or simply less exposed than adults.
The seasonal flu has killed 136 U.S. children so far during this 2019-20 season, and 11 children during the last week of February alone. But keep in mind, a mortality rate of 0.2 percent would still be higher than the flu mortality rate of 0.1 percent. O’Leary warned it’s too early to tell how severely the coronavirus may affect students, particularly if they already have underlying health conditions like asthma, which affects 1 in 12 school-age children.
“Kids with significant chronic medical conditions, and particularly asthma, do have a harder time with most respiratory viruses,” O’Leary said. “So erring on the side of caution with kids with chronic medical conditions would certainly be a safe approach. ... So districts may decide to use more of a social distancing approach where they ask some students to stay home.”
How do I decide what to do if students start getting sick?
Schools can be hotbeds for disease outbreaks because children are in close quarters, but also because adults have built up more exposure to various illnesses over time. But COVID-19 is new to everybody.
That’s why O’Leary recommended school administrators look to the broader coronavirus spread when responding to a sudden outbreak of sick students.
“This is a rapidly evolving situation,” O’Leary said, “and what schools should do is very dependent on where they are and how much [coronavirus] is currently circulating in the community. There’s no specific number for it to be considered ‘widespread,’ but certain things ... like a death or a hospitalization from someone who didn’t have a known travel exposure could be considered sort of ‘sentinel’ events because those suggest it’s circulating in a community.”
Prior studies reported in the journal Science found no benefit to closing a single class or grade, but closing an entire school could reduce the cumulative rate of infections of a moderately contagious virus (in that case, the flu) by 25 percent, and delay the peak of new infections by two weeks, easing the burden on local health care.
If local public health officials say there is widespread coronavirus in the community, school leaders may ask medically vulnerable students to self-quarantine or close the school as a preventative measure. Studies of previous pandemics such as the 1918 influenza found that closing schools before the first direct case on campus was one of the most effective ways to limit outbreaks within communities. Similarly, school officials should discuss with local public health officials how to support students in vulnerable groups, such as those who are homeless or those who live with elderly or immune-compromised relatives. Health officials recommend schools begin to reach out to families about their medical risks and needs as early as possible.
How much can hygiene help?
Standard cleaning and hygiene practices will help schools prepare for both flu and coronavirus outbreaks, but school leaders should be sure to read the small print:
- Frequent hand-washing tops the lists of the CDC, World Health Organization, AAP, and others for reducing the spread of viruses. Students and staff alike should wash with soap and water for at least 20 seconds—about the length of the “Alphabet Song”—before and after eating or after coughing or sneezing.
- Many schools that don’t have time to truck whole classrooms of students to the bathroom before every class are relying on alcohol-based hand-sanitizers. However, it is important to follow directions for these products; for example, some sanitizers require students to continue using them for up to 2 minutes in order to truly disinfect their skin.
- Coughing or sneezing into a tissue or the crook of an elbow can help reduce the spread of airborne virus droplets. However, the CDC notes that if students use a tissue, they should immediately put it in a lined trash bag—not stuffed on their desks or in a pocket—and disinfect their hands.
- As much as possible, adults and children alike should practice to avoid touching their faces. Of course, teaching younger students can be easier said than done.
“I saw that our guidance from AAP has something about teaching children not to touch their face and you know, I can picture trying to do that with a 3-year-old. It’s hard enough to get adults not to touch their faces. So you do your best,” O’Leary said.
He did have one tip: Ask students to sit with their hands clasped together or holding something when they are not actively doing work. This makes it more likely they will remember not to touch their face, or that they might use the tip of a pencil to scratch an itch rather than their hand. Of course, students will still need to be reminded not to chew on the ends of their pencils.
While challenging, disease-prevention training in schools can make a difference. For example, the Pittsburgh Influenza Prevention Project randomly assigned five elementary schools in the city to receive training in flu prevention during the 2008-09 flu season: how to cover their mouths with the crook of their elbows when they sneezed or coughed, for example, and how to properly wash their hands with soap and water for at least 20 seconds. The treatment schools also were provided and encouraged to use hand sanitizer throughout the flu season. Five control schools were monitored but given no hygiene training or supplies.
The researchers found students in the schools that had received the health program had 25 percent fewer absences and less than half as many laboratory-confirmed cases of influenza A as those in schools who had not participated in the intervention.