Can schools be reopened during the pandemic?
It is more than a year since the first nationwide lockdown to contain COVID-19 in India started in March 2020, when schools were closed  By the end of June 2021 over 150 million children in 19 countries were either attending virtual classes or had no schooling at all. It has been more than a year since the first nationwide lockdown to contain the COVID-19 pandemic in India in March 2020 when schools were closed and online classes came in vogue. Parents, teachers, administrators, governments and children themselves have raised major concerns over this potentially life-altering decision for the school-going children. The recent second wave of the pandemic has made everyone all the more anxious and apprehensive about the safety and wellbeing of children. This situation has not only led to the loss of education but also their social and mental wellbeing with hitherto unknown long-term consequences. Lessons learnt  Moving beyond the emotional conundrum, let us look at what we have learnt over this past year about COVID-19 and its impact on children so as to make a scientific rationale towards the return of young pupils to the classrooms and hallways of school buildings. Children get infected with the SARS-CoV-2 virus but the overall risk of infection remains much lower than that of the adults. Studies suggest that children are half as susceptible to infection as adults mainly due to the biological difference of having fewer ACE2 receptors and that too mostly in the upper respiratory tract. These are the receptors in human cells through which the spike protein of the virus binds to the cells. Although mutations in spike proteins have been identified among the virus variants such as beta and delta, it is expected that children will continue to be less susceptible as long as ACE2 receptors remain the major binding sites for the virus. It is known that 90% of infections among children remain asymptomatic or mild, and although the few children with severe disease will need hospital care, only 1-2% require intensive care unit management. Children with underlying health conditions could be at higher risk for severe disease. With a low incidence of 12 per 100,000 children, according to the Indian Academy of Pediatrics, the most life-threatening complication that can occur is called multisystem inflammatory syndrome in children (MIS-C) but most children have recovered well with few deaths mostly attributable to management issues. The last nationwide serosurvey (December 2020-January 2021) reported that the proportion of children 10-17 years old with prior infection was similar to the adults at around 25%. This indicates that children were not at a higher risk of infection than the adults. It has been suggested that children had a relatively higher infection rate during the second wave of the pandemic. However, we did not see any rise in the overall proportion of COVID-19 positive children in the country. Global studies  Globally and in India schools have never been reported as the focal point of any super-spreader event. Data over the past year from several countries where schools were functional at various levels clearly show that the rate of COVID-19 transmission among students in schools was much lower than in the community. These include studies from the U.S. of more than 90,000 students and teachers in North Carolina, and over 20,000 students and staff from 17 schools in rural Wisconsin. Researchers in Norway, Salt Lake City and New York City, U.S. found attack rates ranging from 0.5% to 1.7% in schools suggesting that infected students do not tend to spread the virus at school. Very low secondary attack rates  the risk of spread from one infected person to others in a closed setting  have been reported from school-based investigations in Australia, France, Germany, Ireland, Singapore and the U.S. However, attack rates of around 15% were reported from Israel when schools reopened in mid-May 2020 and were attributed to poor implementation of mitigation measures. We also need to watch out for the emergence of variants and the influence on transmission and detection of the virus in children. The level of community transmission in a district should be the key parameter to guide a graded approach to reopening of schools. For this purpose, a matrix of two indicators  the reported number of cases per 100,000 population and the test positivity rate  could be helpful to categorise districts. Pragmatic thresholds for each will need to be deliberated upon by public health experts. Districts with the lowest case burden as well as positivity rate would be the ideal places for resuming in-person classes. Safe return plan  We need to have a safe return plan. This would entail stringent adherence to universal masking for staff and students, hand hygiene, physical distancing (more so between students and staff than between the students themselves) and adequate ventilation (keeping doors and windows open, use of fans and no air conditioning). Outdoor areas may be used as classrooms, when possible. Classroom routines will have to be redesigned to limit student interaction inside and outside classrooms, such as staggered timetables for different classes, fewer classes per day, shorter duration of classes etc. High levels of testing and contact tracing within schools would be critical after reopening of schools. Children are likely to remain asymptomatic even when infected, and hence facility for routine testing of students once or twice every week is a must. Although PCR testing is the current norm, antigen tests with high sensitivity and specificity and authorised for children and asymptomatic individuals are in the pipeline and could greatly increase access to testing in school settings. Protocols for contact tracing of infected students or staff, quarantine, isolation, temperature checks and symptom screening should be in place. Younger children seem to be less likely to get sick or transmit the virus than teenagers and adults. Modelling studies indicate that reopening secondary schools will impact community transmission more than reopening primary schools. These findings suggest that reopening of primary schools should take precedence over secondary schools until the community prevalence becomes relatively low to allow secondary schools to reopen. Vaccination of teachers and other school staff should be prioritised. It would not only influence transmission inside school premises but overall high vaccination coverage will reduce the COVID-19 burden paving the way towards safer schools. As parents, educators, health officials and public administrators now is the time to ask not if our schools should reopen but how and when we can make it happen. The intellectual, social, emotional and mental development of our children is at stake. (Dr. Tarun Bhatnagar is a senior scientist at Chennais National Institute of Epidemiology, an ICMR institution.)