COVID: Back to Work and School?

One of the recent controversies regarding COVID 19 are school openings: should they open or should they not. Many larger inner-city school districts are staying shut down, such as Dallas, and some suburban ones too. California and New York have continued the shutdown but are all these continued shutdowns based on good clinical data. Recent articles on going back to schools have not backed this closure idea.

German and European Studies

A recent German study showed that children  “are unlikely to be the main drivers of the pandemic. Opening up schools and kindergartens is unlikely to impact COVID‐19 mortality rates in older people.” They evaluated several studies and showed that the transmission rate of COVID 19 from children was very low.

In another German study, they found that sending kids to school did increase COVID 19 incidence amongst the children,[1] but they were mostly asymptomatic. This confirms the previous study that suggests that children, especially asymptomatic children, transmit the virus but symptoms are minimal. Of specific note, the children did not increase the spread of the virus to older people at the school and are not a danger to older people as the media would want you to believe.

In the same metanalysis as above, they found that Denmark and Norway did not see a significant increase in COVID-19 cases in children nor adults when children went back to school.

Asian Studies

A very large study in South Korea found that very young children, between the ages of 0 to 9 years old spread the COVID-19 virus from 1% to 9%,[2] and the cases were mostly asymptomatic. This would suggest that their immune system is boosted and they are able to fight the virus off with minimal symptoms. This correlates with other studies that suggest that asymptomatic cases rarely transmit the virus, as reported by the CDC.

The study evaluated household contacts and non-household contacts. The children had normal contacts with others in their household with a closed environment and close contact. Non-household contacts were like passing by people or being with them for very short periods of time.

Below 9 years old there was a 5% transmission rate with household contacts and a 1% transmission rate for just passing by a person. As the age went up, transmission rates for household contacts went up to around 18% with household contacts but stayed low at 1% until age 40 for non-household contact. The rate then rose slightly and gradually around 1% more per decade after 40. This should decrease the anxiety so many people have about being around people in a store.

These transmission rates were also noted in a Chinese study showing a 1% to 5% transmission rate among 38,000 Chinese people in close contact with infected patients. In addition, they noted that people were most infectious at the onset of symptoms when they spiked a fever and started coughing. However, their ability to spread the virus dropped after that significantly and the transmission from presymptomatic people is rare.[3]

Thus, with such low transmission rates especially since they are mostly asymptomatic, this data suggests that we should open schools at least for younger age students. Even with an 18% transmission rate in older children, shouldn’t it be wiser to allow them to build up their immunity at their younger age? You can still protect older adults >35 or those who have comorbidities. Of course, it is wiser to remove the comorbidities by making them become healthier as I have discussed in prior blogs.

What if my Child has a Co-Morbidity?

Many people are afraid to send their children to school because their child has a comorbidity and they have heard that the people who get the severe form of COVD 19, including death, are the ones with comorbidities.

However, studies are now showing that kids with a comorbidity of respiratory problems, such as asthma, or immunocompromised disease, such as cancers, are not more susceptible to severe COVID-19 as once thought.[4] Rates are about the same whether they have these comorbidities or not, which should ease the anxiety many parents have regarding sending their kids back to school in the face of COVID 19 with comorbidities present.

Deaths of children is exceedingly rare. One study of Public Health involving 7 different countries found 44 COVID 19 deaths  in over 137 million children age 19 and under. That’s a death rate of 1 in 3 million.[5] The author’s advice is “that parents should not worry unduly about what might happen to their kids should they catch the virus.”

Back to Work New Guidelines

Recent studies have prompted the CDC to report new guidelines for those recovering from a coronavirus infection.[6] They now say that you can resume normal activity 10 days after you started to have symptoms as long as you have no fever or other symptoms, such as shortness of breath or diarrhea for 24 hours.

This is because accumulating evidence supports ending isolation and potentially some of the earlier precautions the CDC had recommended. Concentrations of the virus do decline after onset of symptoms of COVID. In addition, the ability to transmit the virus appears to decline too, supported by evidence that the amount of viral load declines after onset of symptoms. They could not recover any viruses after 10 days from onset in 88% to 95% of specimens.

Studies showed minimal infection transmission over 6 days after the illness, and even though some people had repeat positive tests for COVID after 10 days, the labs could not recover the virus from the people. Even if patients had a recurrence, they could not  recover the virus. No recovery of the virus, no further transmission.

Concerning recurrent infections months after having COVID-19 infection, the good news is that there have been no confirmed cases of COVID 19 reinfection. This suggest development of some type of long-term immunity to the virus. This has been confirmed in studies where reinfection in monkeys who had prior COVID19 subsequently did not cause recurrent disease.[7]

Because of these studies, the CDC says now that you don’t have to have a follow-up test to see if you have cleared the virus. Most people clear the virus from 1 to 2 weeks after the initial infection, depending on your age, with younger people (age < 35) clearing it faster than older ones.

Regarding asymptomatic cases, if you test positive for COVID-10 infection, retesting is not recommended, and they should be able to return to work 10 days after that positive test. In addition, if you were in close contact with a person with known COVID-19 infection, quarantine is no longer recommended because transmission rates are low.

These new recommendations are great for knowing that you can go back to work after 10 days from the beginning of symptoms or just a positive test,  instead of having to wait for the repeat test to come back. Unfortunately, COVID 19 tests are taking 5 to 10 days to come back, so this is a very significant breakthrough to allow people to get back to work and productive for their jobs and their families.

Covid 19 Symptomatic Cases are Dropping

In a prior blog I discussed the fact that even though the incidence of COVID-19, or at least the number of positive lab tests, are increasing rapidly, the number of people presenting to their doctor with flu-like symptoms (which includes COVID 19) has rapidly dropped over the last few months.

[1] Stage HB, Shingleton J, Ghosh S, Scarabel F, Pellis L, Finnie T. Shut and re-open the role of schools

in the spread of COVID-19 in Europe. medrxiv [Internet]. 2020 Jun 26; doi.org/10.1101/2020.06.24.20139634

[2] Park YJ, et al. Contact tracing during coronavirus disease outbreak, South Korea, 2020. Emerg Infect Dis. 2020 Oct. doi.org/10.3201/eid2610.201315

[3] Cheng H-Y, Jian S-W, Liu D-P, et al. for the for the Taiwan COVID-19 Outbreak Investigation Team. Contact tracing assessment of COVID-19 transmission dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Intern Med. doi:10.1001/jamainternmed.2020.2020.

[4] Munro APS, Faust SN. Children are not COVID‐19 super spreaders: time to go back to school. Arch Dis Child. 2020. https://doi.org/10.1136/archdischild‐2020‐319474

[5] Bhopal S, Babaria J, Bhopal R. Children’s mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers [published online ahead of print, 2020 May 30]. Public Health. 2020;185:19-20. doi:10.1016/j.puhe.2020.05.047

[6] https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html

[7] Chandrashekar A, et al. SARS-CoV-2 infection protects against rechallenge in rhesus macaques. Science  20 May 2020:eabc4776. DOI: 10.1126/science.abc4776

This would suggest that most of the positive COVID 19 tests are in asymptomatic patients. The WHO has said that asymptomatic cases rarely transmit the virus. This is confirmed by the above Korean study.

How Much Risk Should We Accept?

Anything we do in life comes with a risk. Whether it is climbing on a ladder, boating on a lake, swimming in a pool, or driving a car, all come with a risk. It has been said that we shouldn’t open our schools until they are “safe”, but what is that level of safe.

Each individual parent should evaluate their acceptable level of risk and balance this with other factors in their life. Not sending their child to school takes away the increased learning the child would get at school, the personal education given, the social structure of interacting with other kids, participating in the group activities that all schools have, and many other advantages.

Many parents work too and need the school time to be able to work to help feed their family. Keeping kids home may ruin family life and marital relations. Divorce rates went up 40% in Italy after the lockdowns there. In addition, suicide rates have increased due to the lockdown, in children and adults, including rates of depression and other mental disorders. Child abuse has increased too.

Conclusion

Putting all this together, there are many benefits to sending children to school, while the risks are of contracting and transmitting the virus to others is rather minimal. Most of the data suggests low rates of transmission, around 5% in children <9 years old. Children (and adults) should be allowed to develop their immunity for the younger you get COVID 19, the less the severity of the disease.

Each parent must decide for themselves the best course of action, but they need to know the science so they can make these informed decisions. Each must weigh the benefits versus the acceptable risks for them, knowing that nothing is totally safe to do.

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