Are Kids Spreading SARS-CoV-2 in School and Daycare Centers

If kids aren’t spreading SARS-CoV-2, then why are three percent of the students at a high school in Texas sick with COVID-19?

Why are people starting to think that kids are spreading SARS-CoV-2, the virus that causing COVID-19, in school and daycare centers?

There have been over 500,000 cases of COVID-19 in children in the United States.
There have been over 500,000 cases of COVID-19 in children in the United States.

Probably because we are seeing more and more cases in kids, especially kids in daycare centers and schools in states with spiking cases.

SARS-CoV-2 in School and Daycare Centers

For example, let’s take a look at what’s going on in Texas…

“As of Friday, 410 total cases of coronavirus — 267 staff members and 143 children — had been reported at 318 licensed child care operations across the state, according to the Texas Health and Human Services Commission.”

Texas child care centers see sharp increase in coronavirus cases after months of relative calm

So far in Texas, 83% of child care centers (12,196 facilities are open) haven’t reported a COVID-19 case.

But 17% have…

Either in a child or adult.

Altogether, since March, there have been 1,271 cases in children and 2,416 cases in adults in 2,034 different daycare centers in Texas.

So far the largest cluster was in a Houston daycare, in which 17 adult staff members and 6 kids tested positive.

In another large cluster, in Pleasanton, 11 kids, but only 2 adult staff members tested positive.

COVID-19 has also already led to several school closures in Texas, just weeks after the start of the fall semester.

In one high school in East Texas, the number of active COVID-19 cases has already reached 3%. The school was only open for about three and a half weeks before having to move to online only education.

Are Kids Spreading SARS-CoV-2 in School and Daycare Centers?

A rise in cases in daycare centers doesn’t necessarily mean that it is the kids that are doing the spreading though.

Are staff members getting exposed and bringing SARS-CoV-2 to work with them, exposing the children? Or are the children acting as the spreaders?

A new study, Transmission Dynamics of COVID-19 Outbreaks Associated with Child Care Facilities — Salt Lake City, Utah, April–July 2020, provides some answers.

Children who likely got COVID-19 at two Utah daycare centers spread it to other family members at home.

These outbreaks all started with an infected staff member, but quickly spread to other staff members and children.

“Analysis of contact tracing data in Salt Lake County, Utah, identified outbreaks of COVID-19 in three small to large child care facilities linked to index cases in adults and associated with transmission from children to household and nonhousehold contacts. In these three outbreaks, 54% of the cases linked to the facilities occurred in children. Transmission likely occurred from children with confirmed COVID-19 in a child care facility to 25% of their nonfacility contacts.”

Transmission Dynamics of COVID-19 Outbreaks Associated with Child Care Facilities — Salt Lake City, Utah, April–July 2020

Not surprisingly, cases then spread outside the daycare centers, to some of the parents of these children and other family members at home.

Of course, that this study found evidence that children can spread SARS-CoV-2 isn’t surprising because it isn’t the first to make this claim.

“These findings demonstrate that SARS-CoV-2 spread efficiently in a youth-centric overnight setting, resulting in high attack rates among persons in all age groups, despite efforts by camp officials to implement most recommended strategies to prevent transmission. Asymptomatic infection was common and potentially contributed to undetected transmission, as has been previously reported.”

SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 2020.

There is also the report about children at the overnight camp in Georgia in June, which found an overall attack rate of 44% among the campers.

And the report about the Rhode Island COVID-19 daycare outbreaks.

“A total of 101 possible child care–associated COVID-19 cases were reported during June 1–July 31. Among them, 49 (49%) symptomatic persons were excluded after receiving negative laboratory test results, 33 persons (33%) had confirmed cases, and 19 (19%) were classified as having probable cases.”

Limited Secondary Transmission of SARS-CoV-2 in Child Care Programs — Rhode Island, June 1–July 31, 2020

Fortunately, community transmission of SARS-CoV-2 was lower in Rhode Island than many other states at the time, which is likely why “possible secondary transmission was identified in four of the 666 programs that had been allowed to reopen,” and not more.

Of course, these results stand in contrast to early reports in other countries which found that children didn’t seem to be spreading SARS-CoV-2.

“These data all suggest that children are not significant drivers of the COVID-19 pandemic. It is unclear why documented SARS-CoV-2 transmission from children to other children or adults is so infrequent.”

COVID-19 Transmission and Children: The Child Is Not to Blame

Early reports that were maybe flawed because children simply weren’t being exposed to SARS-CoV-2 at the time because of school closures and other factors.

“Here, we report that replication of SARS-CoV-2 in older children leads to similar levels of viral nucleic acid as adults, but significantly greater amounts of viral nucleic acid are detected in children younger than 5 years.”

Age-Related Differences in Nasopharyngeal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Levels in Patients With Mild to Moderate Coronavirus Disease 2019 (COVID-19)

So with conflicting reports, what are we to believe?

What to Know About Kids Spreading SARS-CoV-2

We will have to see more research, but with cases continuing to increase in daycare centers, schools, and colleges, it is very hard to believe that kids aren’t spreaders of SARS-CoV-2.

Not that they have to be…

There is an easy way to keep kids from spreading SARS-CoV-2 at daycare, school, and college.

Even easier than making them wear masks.

A recent study in Germany found that child-to-child transmission of SARS-CoV-2 in schools/childcare facilities appeared very uncommon, but this was at a time of very low rates of community transmission.
A recent study in Germany found that child-to-child transmission of SARS-CoV-2 in schools/childcare facilities appeared very uncommon, but this was at a time of very low rates of community transmission.

Yes, that’s keeping the COVID-19 case count down in your community!

More on Kids Spreading COVID-19

Are Kids Spreading SARS-CoV-2?

While new studies suggest that kids may transmit SARS-CoV-2, some other studies say they don’t…

Why do some folks think that kids aren’t spreading SARS-CoV-2, the virus that causes COVID-19?

Paul Thomas doesn't talk about any of the studies that do suggest children can spread novel coronavirus to others.
Paul Thomas doesn’t talk about any of the studies that do suggest children can spread novel coronavirus to others.

The usual suspects…

Are Kids Spreading SARS-CoV-2?

As Paul Thomas highlights, there have been studies and case reports that suggest children are not spreading SARS-CoV-2 to others.

“Studies of multiple family clusters have revealed children were unlikely to be the index case, in Guanzhou, China, and internationally A SARS-CoV2 positive child in a cluster in the French alps did not transmit to anyone else, despite exposure to over 100 people.”

An evidence summary of Paediatric COVID-19 literature

On the other hand, there are studies that suggest they do.

Another study found viral loads in children which suggests that they could pass the virus on to others.
Another study found viral loads in children which suggests that they could pass the virus on to others.

Something Paul Thomas doesn’t mention!

“Prolonged shedding of SARS-CoV-2 in stools of infected children indicates the potential for the virus to be transmitted through fecal excretion.”

Prolonged presence of SARS-CoV-2 in feces of pediatric patients during the convalescent phase

So what’s the answer?

Like much about COVID-19, we don’t know yet.

“Asymptomatic infection is least likely to pass on the infection, with a chance of 33 per 100,000 contacts.”

Modes of contact and risk of transmission in COVID-19 among close contacts

It would make some sense that kids might not be a big source of COVID-19 infections though, as they often are asymptomatic or only have mild symptoms when they get sick.

“Two new studies offer compelling evidence that children can transmit the virus. Neither proved it, but the evidence was strong enough to suggest that schools should be kept closed for now, many epidemiologists who were not involved in the research said.”

New Studies Add to Evidence that Children May Transmit the Coronavirus

But we won’t know until more research is done, especially as much of the current research is contradictory.

Research that will be important as we consider opening up schools again.

More on Kids Spreading SARS-CoV-2

What Did the AAP Say About Sending Kids Back to School?

The AAP has offered guidance for a safe way to get our kids back in school during the COVID-19 pandemic. Will schools follow any of it when they open up?

The American Academy of Pediatrics recently issued some guidance about what to do about kids going to school this fall.

The AAP said a lot more than that parents should send their kids back to school. They offered guidance on how to safely send kids back to school...
The AAP said a lot more than that parents should send their kids back to school. They offered guidance on how to safely send kids back to school…

Not surprisingly, folks are a little confused about what they actually said…

What Did the AAP Say About Sending Kids Back to School?

It is true, the AAP guidance does favor opening up schools this fall.

“With the above principles in mind, the AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.”

COVID-19 Planning Considerations: Guidance for School Re-entry

But, that isn’t all they said…

The goal is for kids to be in school this fall...

To get to that goal of opening schools, the AAP offered a list of key principles that schools should follow, including that:

  • school policies are going to have to be “flexible and nimble” so that they can quickly change as we get new information, especially “when specific policies are not working”
  • schools develop strategies that depend on the levels of COVID-19 cases in the school and community
  • schools make special considerations and accommodations for those who need them, “including those who are medically fragile, live in poverty, have developmental challenges, or have special health care needs or disabilities, with the goal of safe return to school”

So clearly, this is not a one-size-fits-all, lets open up schools no matter what kind of thing.

“Highest Risk: Full sized, in-person classes, activities, and events. Students are not spaced apart, share classroom materials or supplies, and mix between classes and activities.”

CDC on Considerations for Schools

The AAP didn’t say to simply open up schools without doing anything else…

“No single action or set of actions will completely eliminate the risk of SARS-CoV-2 transmission, but implementation of several coordinated interventions can greatly reduce that risk. For example, where physical distance cannot be maintained, students (over the age of 2 years) and staff can wear face coverings (when feasible). In the following sections, we review some general principles that policy makers should consider as they plan for the coming school year. For all of these, education for the entire school community regarding these measures should begin early, ideally at least several weeks before the start of the school year.”

COVID-19 Planning Considerations: Guidance for School Re-entry

They offered guidance on how to safely open schools.

Or at least how to open schools as safely as possible, as the alternative of keeping kids at home has risks too. And many people are skeptical that a strategy of closing schools is all that helpful in controlling the spread of SARS-CoV-2.

So the AAP guidance says that we open schools and also plan for:

  • Physical distancing – cohort classes, block schedules, rotating teachers instead of students, etc.
  • Cleaning and disinfecting
  • Testing and screening – schools will need a rapid response plan for when a child or staff member develops a fever at school.
  • Face Coverings and PPE – although it won’t be possible in all situations and for all children, “school staff and older students (middle or high school) may be able to wear cloth face coverings safely and consistently and should be encouraged to do so.”
  • Organized Activities – although this isn’t something most folks want to hear, they should understand that opening schools doesn’t mean that everything will be back to normal… “It is likely that sporting events, practices, and conditioning sessions will be limited in many locations.”

If we do all of that, will it really be safe to go to school with these guidelines?

Unfortunately, the most important part of the guidelines, the section on Testing and Screening, was a bit light on details…

“Parents should be instructed to keep their child at home if they are ill.”

COVID-19 Planning Considerations: Guidance for School Re-entry

The guidelines acknowledge that it will be too hard to do temperature checks and symptom screening each day and that schools should have a rapid response plan if anyone has a fever had school, but then what?

“Here in Colorado, I’ve been following our state health department website very closely. They update data every day and include the outbreaks in the state they are investigating. As you can imagine, there are lots and lots in long-term care facilities and skilled nursing homes, some in restaurants and grocery stores. There have been a total of four in child care centers, and we do have a lot of child care centers open. In almost every one of those cases, transmission was between two adults. The kids in the centers are not spreading Covid-19. I’m hearing the same thing from other states, as well.”

Why a Pediatric Group Is Pushing to Reopen Schools This Fall

So what’s going to happen if kids in school start to get sick and test positive for COVID-19?

Among the 950 COVID-19 in Texas daycare centers are 307 children.
Among the 950 COVID-19 in Texas daycare centers are 307 children. (Dallas Morning News)

The 60,000 members of the AAP who didn’t participate in writing the guideline know what’s going to happen…

A ton of parents from the school are going to call their pediatricians looking to get their kids tested!

What likely should happen?

That classroom or cohort and their close contacts should move to self-quarantine and home/online education until they pass the incubation period from their last contact.

“Put in place the infrastructure and resources to test, trace and isolate new cases.”

Safely Reopening America’s Schools and Communities

(I’m guessing we will get more details about this from the AAP soon and well before school starts. )

Most importantly though, our communities should do everything they can to keep their case counts down – wash hands, practice social distancing, wear a face cover.

And if we are going to send our kids back to school, we should make sure that we are protecting all of the folks making that possible.

Can we do all of that?

Sure!

Will we???

Sending Your Kids Back to School

Are you still unsure about whether or not you should send your own kids back to school?

I don’t blame you…

Some things to consider when making the decision:

  • is your child or any of their contacts at risk for a more severe case of COVID-19, including having an underlying, chronic medical condition, keeping in mind that the risk increases with age, especially once you reach age 65 years? If possible, online schooling might be a better option for students in high risk categories.
  • was staying home from school hard for your child? If your child had problems learning at home or the social isolation was an issue, than that would make going back to school even more important.
  • will your school or school district be “flexible and nimble” and respond to new information, rising case counts, and evolve their policies if necessary?

Most importantly, if you send your kids back to school, are you going to be constantly worried that they are going to get COVID-19 or bring home the SARS-CoV-2 virus? If so, then keep them home this fall.

On the other hand, if they are healthy, have no high risk contacts at home, and are eager to go back to school, then you should probably feel comfortable sending them if the school follows the guidance offered by the AAP.

More on COVID-19