COVID-19 & Schools: Q&A With A Pediatric Infectious Disease Expert

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With 46% of Americans believing that K-12 schools should only open with major adjustments, according to an Associated Press/NORC poll released July 22, and nearly two out of every three educators (65%) telling EdWeek’s Research Center that schools should remain closed as WebMD reported, schools have become the new focus of transmission risk.

To determine what some of those risks might be and how they can best be mitigated, Heavy spoke with Dr. Silvia Chiang, assistant professor of Pediatrics at Brown University’s Warren Alpert Medical School and attending physician at Hasbro Children’s Hospital’s Pediatric Infectious Diseases ward.

Here’s what we asked her:

Q&A With Dr. Chiang


What’s the biggest risk with schools reopening?
“It’s a very, very complicated issue and unfortunately, there are a lot of unknowns. I think that the biggest hazard is having kids all go back to school at once while community transmission of the virus is rising or already very high.”

What about hybrid reopening models?
“School districts may shift into different models (all in-person, all virtual, hybrid) depending on the level of community transmission. Decisions about the best approach to school reopening must take into account the level of community transmission of the virus.”

What are some of the best ways that schools with in-person classes can keep kids safe?
“I honestly think that the things we talked about; the distancing, mask-wearing, washing hands, trying not to touch their face, staying in small and stable, doing sports that are lower-risk, I think those things are going to be the most important ways to prevent transmission of the coronavirus.”

Chiang also said that schools should ensure CDC guidelines are being followed, social distancing and separation are practiced (such as keeping children in small groups to make contact tracing easier), proper ventilation is in place, regular testing and screening are done and large groups are prevented from moving around mingling can all lower the risk that schools become sources of outbreaks. For more on what she suggested parents can check to see if their schools are taking good precautions, read here.

Should parents of school-age children be worried about children in a building with the virus potentially being airborne?
“There’s still a lot of unknowns with this particular part (airborne) of transmission. In infectious diseases, there are people who have specific expertise in infection control, I am not one of them. There has been a lot of news coverage about the airborne vs. droplets issue. My impression is that sometimes when people think about the airborne vs. droplet issue, they think about it as an either/or choice, but it’s more of a gradient. SARS-CoV-2 can be transmitted through aerosols, such as during certain medical procedures. However, based on my conversations with infection control experts, it’s probably not a huge contributor. The main transmission mode is likely large droplets. When you’re talking about a pathogen that is spread primarily through aerosols, the first disease that comes to mind is measles. If SARS-CoV-2 were transmitted like measles, you would expect to see a much faster and a much higher rate of transmission. I don’t think that most scientists ever doubted that SARS-CoV-2 could be transmitted through aerosols under certain circumstances, but the main question is under what circumstances and how often does airborne transmission contribute to community spread. If schools could have classes outdoors and with the open air and air currents, it’s easier for droplets to disperse. I think that if you are in a place with poor ventilation … yes, it may make the likelihood of transmission higher, but we’re still figuring out by how much.”

Should parents of school-age children be worried about school surfaces?
“To what extent do surface transmissions play a role in the epidemic is a really interesting question. We think that mostly, it’s person-to-person contact, but spreading the virus through high-touch surfaces is very possible. I do think schools should probably be cleaning more frequently. The CDC does have recommendations about how often surfaces should be cleaned in schools. Hand hygiene is also very important.”

Should parents of school-age children be worried about cafeterias?
“So far, I haven’t seen evidence that anyone has gotten SARS-CoV-2 through fecal-oral transmission. It has definitely been found in stools. We don’t have any evidence people can get infected that way, that doesn’t mean that they can’t. Having kids eat in the classrooms where they are for the day. Another possibility is if the school had outdoor space, the kids could all go out and eat there, weather permitting, while staying in their groups.”

Are children really less likely to exhibit symptoms?
“The younger you are, the more likely you are to have mild symptoms or no symptoms.”

How much do children spread COVID-19?
“It doesn’t seem like kids younger than ten years spread the virus as much as adults, but this conclusion is very, very preliminary, and we need more studies to clarify this issue. We’re probably going to find that adolescents can transmit SARS-CoV-2 as well as adults.”

What if a parent or a grandparent or other guardian of a school-age child has conditions that put them in the vulnerable category; what is your advice for them?
“I think if there is high community transmission, I would think twice about having a kid go to school. Another option is to try to physically separate the vulnerable person and the student inside the home. However, you can only do this if you have a certain size house; if you live in a small apartment with multiple family members, that’s very difficult.”

What are some of the challenges of homeschooling?
“If you have a family with a high SES and well-educated parents who are able to help with homework and have a stable internet connection, virtual schooling is easier, though still challenging. If you have parents with a low SES, if you have parents who work full-time or have two jobs and maybe they can’t help with homework as much or maybe these kids have to rely on school meals, that’s a tough situation; I think school is really, really important and perhaps more important for kids in that situation. There’s going to have to be very careful considerations of risk-benefit.”

How could schools handle high school students who work?
“I don’t think that those students (high school students with jobs) should be excluded from school, but I think that both in the classroom and at their job, there should be precautions taken to minimize their chances of catching and spreading the virus.”

There’s a number of adults who are not following CDC guidelines despite knowing the risks. When we think about children and teenagers, what kind of behavior can we reasonably expect from them?
“I worry about it. I do worry about it. I love adolescents, my work is in helping adolescents with TB. But adolescents are still maturing and they’re still growing into becoming responsible adults and sometimes, they may feel invincible. And also, that desire to be with their peers is very strong and very understandable. I do think it will be very hard to restrict which friends adolescents can have contact with.
I think that young children are quite teachable, they really want to learn and they’re very eager to please. Of course, they have less self-control. It is really hard to have young children not touch their face.”

Could a vaccine change all of this calculus about school reopenings?
“I listened to a webinar with leaders at NIH and WHO, and they said we need three things: a good vaccine, good public health measures, and some level of herd immunity. With those three things, we can get the transmission level very low. Good vaccines are going to be key. The higher the vaccine efficacy and the higher the uptake among the population, the more protected we’ll all be.”

Parents Are Worried, And Kids Are Too

Portland special education teacher Mercedes Munoz told MedPage that keeping children out of school would likely widen the education gap and could stunt children’s social growth and development of health identities. And according to an ACLU survey that asked kids to rate their mental health pre- and post-school closures, the number of students who rated themselves at a seven (on a 1-10 scale with 10 being the best) or higher dropped from 65% to 40%, while the number of students who rated their mental health at three or lower tripled to 23%. UNICEF offers a guide for parents on how to check in with their children’s mental health during this back-to-school period.

And while some parents are opting to homeschool their children because they have access to the tools to do so, parents and many educators are arguing that schools must reopen for the health and educational well-being of children.

The Centers for Disease Control and Prevention, World Health Organization and American Academy of Pediatrics, have also all released guidelines for school reopenings. However, what needs to be done and what actually will remains to be seen. And what Americans consider essential to the process is also variable.

According to that AP/NORC study, here is what Americans considered most and least essential for school reopenings: daily disinfecting (83%), mandated student and staff mask-wearing (69%), daily temperature checks of students and staff (66%), rearranging classrooms to ensure students are six feet apart (63%), hybrid of virtual and in-person learning (60%), classroom lunches over cafeteria lunches (46%) and canceling extracurricular activities (39%).

But, regardless of what schools do, there is no way to tell what the outcome will be, as Dr. Fauci – director of the National Institute of Allergy and Infectious Diseases and a member of the president’s Coronavirus Task Force – told the Washington Post: “It’s not going to be easy because we’ve never done it before. This is uncharted waters — always remembering the primary issue is the safety and welfare of the children as well as the teachers who are going to be interacting with the children.”

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