Playing the Odds: Should You Send Your Kids Back to School?

This spring, as Europe staggers under the weight of another COVID surge, the US is embarking upon a major reopening of schools, restaurants, and other venues where people mingle. No less mighty personages than President Biden and, locally, Governor Inslee have thundered their belief that now’s the time to get more kids back to in-person learning.

There are good reasons to offer in-person learning: many kids aren’t learning as well remotely (though some are), The distribution of quality learning experiences is unequal and inequitable, kids are socially deprived and subject to depression and thoughts of self-harm in some cases, and parents are stretched and stressed. There are also good reasons to keep schools closed: risk that schools can become super-spreader sites which vector the virus between staff, students, and families across entire school districts, the vulnerability of teachers and other school staff, especially older ones, to a dangerous disease, and the ignorance that still attaches to our understanding of this virus and its pandemic. Moreover, school openings and closings have become, like everything else, politicized, and school districts are nothing if not political sensitive plants.

In Washington State, Governor Inslee has invoked emergency powers of somewhat nebulous provenance to order school districts to offer at least partial in-person learning to the younger grades at first, with the intent to open up for older kids in successive waves. Districts including Seattle will comply, and others may not.  What’s on offer first is a choice between sticking with 100% remote learning, or participating in a hybrid program that includes 4 half-days of in-person learning as well as remote learning.

In Seattle, the hybrid program will begin this week for certain special needs kids, and is scheduled to launch April 5 for K-5 students. The schools will require masks, 3’ separation in classrooms and 6’ separation elsewhere, and plenty of handwashing (not to mention anxious handwringing). All K-12 personnel are currently eligible to receive vaccinations, though I have not yet seen data about what percentage of K-5 staff is expected to be fully vaccinated by April 5.

The conclusion by political leaders that it is safe to reopen schools substantially depends on the CDC’s assessments, based on data collected primarily during 2020, of the impact of the pandemic on schools. Here’s a link to the CDC’s report. Here’s the short version of what’s been learned:

• COVID is far more lethal to older people than younger people (half of deaths are among people 80 or older).
• Children very rarely die of COVID, and cases among children are more likely to be mild or asymptomatic.
• Children may be infected at a lower rate than adults, but this is not certain; if the infection rate is truly lower among children, it is not radically so.
• Adolescents appear more susceptible to COVID than younger children.
• Infections can be caused by cumulative “viral load” from multiple exposures over a period of up to six hours. (from a different report)
• Rates of infection in schools tend to mirror the infection rates in the surrounding communities.
• Staff-to-staff infections are more common than staff-to-student, student-to-staff, or student-to-student.
• Schools that do not take sufficient precautions can become super-spreader sites.
• Schools that adopt “layered protection” are less susceptible to outbreaks (layered protection means proper masking AND distancing AND test/trace/quarantine AND frequent thorough handwashing AND better ventilation—at least two of these, preferably more).

Many states and school districts have reviewed this information and concluded that schools can safely reopen so long as layered protection is in place, the time each student spends in school each day is significantly shorter than six hours, and school staff are, as much as possible, vaccinated. Unfortunately, the information underlying this conclusion is dated, because of four recent developments:

1. The rise of the virus variants: new versions of SARS CoV-2 are spreading rapidly in the US, thanks to competitive advantages based on mutations. Suddenly, the biodigerati are finding ways to toss terms such as B.1.1.7, P1, and B.1.351 into casual conversation. If you’re not keeping up, B.1.1.7 is the UK variant, P1 is the Brazil variant, and B.1.351 is the South Africa variant. There are more: New York City and Los Angeles each have one, naturally. These new variants share a greater ability to transmit themselves between hosts, which means their share of the infections “market” is growing fast, with the UK variant taking the lion’s share so far. Scattered among them also are other odious superpowers: causing more lethal cases, ignoring naturally acquired immunity, and reducing the efficacy of vaccines, to name three.
2. Vaccines are being rapidly deployed. The US is racing forward with vaccination, and has now given at least one dose to about a quarter of the population. These vaccines are a remarkable achievement, though they are not, as far as we know, a lights-out permanent solution. The simplest way to understand the pandemic big picture right now is to view it as a race between viral variation and mass vaccination.  The faster we vaccinate, the lower the risk of further mutations producing a new variant which renders the current vaccines obsolete.
   
   To reduce the death rate as quickly as possible, vaccination is proceeding from oldest to youngest. Most of the doses so far have gone to people over 65. None have gone to children; the earliest we can expect them for adolescents is August, and for 5-12-year-olds early in 2022.  The pace of vaccination in the US has produced a wave of euphoria, leading states like Texas to declare the pandemic over, and even states like Washington to open up businesses faster than our current pandemic status warrants. As a result, we seem to be entering a season where COVID deaths will go down, but infections may go up.
   
   Protecting seniors from infection via vaccination doesn’t do much to the overall infection rate, since they don’t account for much of the total, but it drives the death rate down. The big winners in the COVID infection sweepstakes are people in their 20s, 30s, and 40s. Infection rates are currently increasing nationally, in Washington State, and in King County, where it’s up 38% over the past two weeks.
3. Vaccine hesitancy and vaccine resistance is persisting in the US. Recent polls show between 30% and 42% of American adults are either not ready to accept the vaccine yet, or determined to never accept it. This is a serious concern because herd immunity for the highly infectious variants might require 90% of people to be immune in a situation where “natural” immunity has been outflanked by the variants. If America’s sprint to vaccine ubiquity stalls at 58-70%, we’ll be dealing with recurring outbreaks for years to come, or worse. Recall that the CDC found that school infection rates tended to follow community infection rates. If communities are prone to outbreaks thanks to local pockets of vaccine resistance and hesitancy, their schools will also be vulnerable.
4. We’re becoming aware that “Long COVID” is a major problem. In the early stages of the pandemic, preventing death was our overwhelming concern.  It took months for doctors to begin to notice Long COVID, and there was no early consensus about whether it was real, what it was, how prevalent it might be, how long it might last, or how to treat it. We’re on a steep learning curve now.
   
   It recently received its own official World Health Organization acronym: PACS, which stands for “Post-Acute COVID Syndrome.” PACS differs from COVID itself in two critical ways: its victims are not strongly concentrated among any one age group, and it occurs following both symptomatic and asymptomatic COVID cases. Moreover, it presents with over 100 different symptoms, it appears to affect 10 organ systems (including brain, heart, lungs, and kidneys), its median duration is seven months, we don’t know how long the longest cases will last, we don’t know what causes it or how to treat it, and it can cause permanent damage. Most shocking, perhaps, is its prevalence: between 10% and 30% of people who contract COVID go on to show symptoms of PACS.
   
   There are an estimated 18 million current cases in the United States, a number ten times higher than the current total number of cancer patients. These cases range from mild to very debilitating. Widely reported symptoms include lack of stamina (can’t walk across a room or climb stairs, for example), and “brain fog.” Rarer symptoms include paranoia and delusions, and all-over pain, as in Fibromyalgia. Data about PACS among children is limited, but what data there is suggests that it is no less likely to occur among children who contract COVID than among adults. The significance of PACS has not full sunk in for many people, stunned as we are by over half-a-million deaths and a year of extreme economic, social, political, and emotional dislocation. It may be the worst thing about this virus in the long run.

This is the pandemic seascape into which the ship of elementary education is about to sail: surging variants, a rising tide of vaccination (oldest first), reduced caution, vaccine hesitancy/rejection, new awareness of the threat Long COVID represents, and perhaps too little awareness of how these factors might combine to put children returning to school at risk.

If you are a parent, the focus of your concern should be the risk that your child will contract PACS, followed by concern that your child will increase the PACS risk for the rest of your family. Since PACS can occur following any COVID infection including the asymptomatic ones, the chances of contracting PACS once a kid contracts COVID itself are probably similar to the adult odds of 10-30%. The bottom-line question for parents is how different are the chances that your child will catch COVID if he or she goes to school this spring or stays home?

The risks in schools have many factors unique to each situation—building ventilation, staff vaccination levels, behavior of the families of other students, grade levels, effectiveness of enforcement of mask-wearing, distancing, etc. Many of these variables are beyond your control. The CDC also concluded, back in the good old pre-variant days, that school infection rates tended to rise and fall in loose lockstep with community infection rates. If that holds true in the new kingdom ruled by variants, your kid’s chances of being infected as a school-goer would be roughly the same as the risk of being infected while out-and-about in the community. If you keep your kid home and run a loose ship, there may be little difference in risk of infection between being in school and being at home. However, with a kid at home you may be able to take precautions enough to lower individual risk significantly, especially once you-the-parents are vaccinated.

If we are now seeing the beginning of a significant upturn in cases toward the possible April-May surge that some epidemiologists have predicted, the risk of Long COVID will rise in proportion to cases, and will rise in schools, on average, in proportion to community prevalence.   The current rate of infections in King County is 11/day/100,000 population (averaging previous 14 days). If a surge doubles that (which would still be below the winter peak average of 31/day/100K) and the surge lasts 60 days from April 1 to May 31, that’s a total of 1,320 new cases per 100,000 population.

That’s also any one person’s odds of getting sick: 1,320 out of 100,000. Kids may become infected at a somewhat lower rate. To take that into account, perhaps a kid’s odds are 1,000 out of 100,000. If you nudge that number up again to 1,200 to include a bit of risk in June as well, your kids have between 120 and 360 chances in 100,000 of contracting Long Covid during the last two few months of the school year. To put that in perspective, it’s much higher than such childhood death risks as auto accidents or firearms (each about 1 in 100,000 over the same time period).

Given the downside of Long COVID, if you think you can cut the odds of infection by twofold, fourfold or more by keeping your kid(s) home and well-managed, it would be worth it.  One wants REALLY long odds against possible permanent damage to the brain and other major organs for one’s third-grader. Your child may suffer some quality of learning and social costs by staying home, to be weighed against this Long COVID risk.

By July, there’s a good chance that rising level of vaccine-driven immunity among adults (with some help from the weather) will have greatly lowered the virus prevalence in the community, making for a relatively safe summer for all. With luck, schools will be a lot safer to attend in September than in April.

This is not to say that the schools should not be open this spring, though they have probably not fully factored in the impact of the variants and our emerging awareness of Long COVID. There are kids for whom attending school now is a lower-risk proposition than staying home, and it’s good that the schools will be there for them. If you decide to keep your own kids home, you’re not voting against the policy of school opening. In fact, you’re making it just a bit safer for those who DO attend.

Few decisions are harder than those which involve increasing your chances of changing the odds that an unlikely bad event might happen. The decision is complicated here by the lack of data, because the virus is new and surprising. If it were me, I would keep kids home if possible.  If you can’t, work with your kids to wear the best possible masks and keep them on. Urge your school to find ways to teach outside as much as possible, and be sure not to let your guard down when the kids are home. Summer’s coming and the time will soon be right for dancing in the streets, in small groups of vaccinated people.

CDC’s COVID & K-12 information page

https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/transmission_k_12_schools.html