Medical Examiner

Should Schools Close for COVID-19?

Administrators and public health officials are making a complicated set of decisions without a ton of hard data.

A row of kids holding backpacks.
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As the mom of two elementary schoolers and an accomplished worrywart, I am constantly thinking about what I should be doing to protect my family. And these days, that means what to do to protect them from the coronavirus. But for six hours every weekday, my kids aren’t under my supervision—they’re at school. So I wonder: Are schools doing enough to prepare for and respond to COVID-19? What, ideally, should they be doing? And what can I do to make sure my child’s school is doing what’s best? I suspect I am not alone.

First, some reassurance: Your kids are probably going to be fine. Recent data from China suggest that although kids can and do get COVID-19 at about the same rate as adults, the infection is usually mild; symptoms include a mild fever, runny nose, and dry cough. Or maybe not even a fever—new research published on Sunday suggests that some young adults with COVID-19 only get coldlike symptoms, which could be true for kids as well. Children with chronic illnesses or immune issues are almost certainly more at risk, but for the vast majority of children, this bug will be no big deal. Most adults, too, who develop COVID-19 will survive and recover; it’s older adults (and adults with health concerns) who are at greater risk.

So what schools do right now really matters. Even if kids aren’t particularly at risk, what happens with COVID-19 in kids could speed up or slow down the overall spread of the infection—and if we could keep things going slow, communities will more easily handle the outbreak, and the medical system will be better equipped to care for patients who really need support to get through the virus. If a hospital only has 15 intensive care unit beds, for example, and 100 people in the community will at some point get COVID-19 and need them, it’s far better to have a few cases trickling in every few days than to get all 100 coming in sick at once. How well kids wash their hands, how well schools clean their facilities, and whether and how long schools stay open during the outbreak could change the shape of the epidemic curve in ways that could save—or cost—many lives.

Even if kids aren’t seriously affected by COVID-19 themselves, they could spread the infection to people who would be. Data from the Chinese Center for Disease Control and Prevention, described in Business Insider last week, suggest that the infection kills 14.8 percent of people over 80 who catch it, 8 percent of people between the ages of 70 and 80, and 3.6 percent of people between the ages of 60 and 70. (These percentages may end up being different for the U.S., but we don’t know yet.) The seasonal flu, by comparison, has killed an average of 1.7 percent of people 65 and older since 2010. If we can keep the virus out of our kids, we could potentially reduce the danger posed to our beloved teachers, grandparents, and other senior relatives and friends who are at higher risk.

Last week, based on Chinese data, a World Health Organization official argued the opposite—that kids and schools probably don’t play much of a role in the COVID-19 epidemic and that school decisions, including closures, may not matter much. Every infectious disease doctor and epidemiologist I interviewed disagreed, saying that with the data we have, we can’t make such a claim. The notion that kids don’t transmit the virus is based largely on the fact that very few Chinese children had tested positive for COVID-19 in a particular dataset. But we don’t know, at this point, how many kids in China were tested overall—and given that kids have such mild symptoms, it’s entirely possible that many had the virus without even realizing they did. “If you say, ‘Oh, no, infection never happened in kids,’ and 0.1 percent of all tests were done in those under 20, you can’t really say anything—you weren’t looking for it,” says David Fisman, an infectious disease epidemiologist at the University of Toronto who has been studying the spread of COVID-19. Plus, much of the Chinese data has come from communities that closed their schools, so they were already taking steps to minimize transmission in children. And as mentioned above, more recent Chinese data suggest that kids do get the infection about as often as adults.

Experts also say it’s far too early to make assertions about how this virus does and does not transmit. “Coming down hard on any statement about a virus that’s been in humans for 16 weeks is problematic,” Fisman says. Scientists have been studying influenza for more than a century, but they still aren’t very good at predicting what it’s going to do. “So to say, ‘Oh, yeah, no, we know the epidemiology of this weird little virus that hopped species 16 weeks ago, we know how this works’—come on. None of us know,” he says.

COVID-19 is not the same as the flu. But based on what we know about how the flu and other respiratory infections spread, children are likely to be vectors. For one, kids are terrible at personal hygiene (my 5-year-old meandered up to me yesterday morning without realizing she had blood and snot coming out of her nose), and many adults are more than happy to cuddle with kids, snot-and-blood-encrusted and all. If you saw an adult walking down the street, hacking, with mucus all over their face, you’d know to keep your distance. But if it is your 3-year-old, “you’ll wipe your sleeve on their face and give them a hug,” Fisman says. Even if kids with COVID-19 aren’t as contagious as adults, given the eagerness with which they share their germs, they could still be important infection-spreaders. And “even a low level of transmission from kids to other kids, or kids to adults, would be worrying,” says Josh Michaud, associate director for global health policy at the Kaiser Family Foundation.

If kids spread COVID-19, then it stands to reason that where they go and whom they spend time with will have important implications for the spread of COVID-19. Plus, if kids only get mild symptoms such as cold symptoms or a dry cough, then they could easily end up attending school with COVID-19, and no one would know. Young kids rarely if ever get symptoms of a common and usually mild virus called cytomegalovirus, for instance, but they are key transmitters of the infection to others.

So—what should schools be doing? The motto that Bill Hanage, a scientist at the Harvard Center for Communicable Disease Dynamics, shared with me is “Don’t panic; do prepare.” The U.S. Centers for Disease Control and Prevention has published guidance for schools, which includes cleaning with approved disinfectants and recommended procedures; reviewing, updating, and implementing emergency operations plans; monitoring absentee rates to see if they start to increase; creating communication plans; and instructing students on proper hand-washing and other hygiene techniques.

It’s hard to know how well schools are following these recommendations. According to a recent Boston Globe investigation, many Boston-area schools don’t have soap, toilet paper, or hot water. A woman whose husband is the head custodian at a public school in New Jersey told me that the school’s supplier for Clorox wipes is now on back order until July. Two parents told me that, as of Monday afternoon, they had yet to receive any communication—emails or letters­—about COVID-19 from their school administrators. One school in Pittsburgh sent a letter to parents on March 4 noting that the school would continue to recognize students for good attendance habits, a policy that directly contradicts CDC guidance (the goal should be to encourage sick kids to stay home, not the opposite).

Since it can be so hard for schools to control the spread of germs, should schools proactively close? It’s a tough question because closing school is not without risks and costs of its own. Administrators and parents certainly need to prepare for the possibility of sudden school closures, though. Schools are making these decisions under the guidance of local health departments, but recommendations could change suddenly, especially considering that testing for COVID-19 is now (finally, sort of) ramping up. It’s likely, epidemiologists say, that we will soon discover that COVID-19 has been spreading in many communities for some time, and this new information may prompt closures to slow the spread. For school administrators, it’s a “sensible position to be assuming that you will [close] at some point, and to be ready for it,” Hanage says.

It’s hard to predict exactly how effective school closures will be in terms of slowing the spread of COVID-19. We can extrapolate from data that have been collected regarding pandemic flu, but this new virus may not act the same way. “We are a little bit in uncharted waters, because most of the data is from influenza and this isn’t influenza,” says Eli Perencevich, an internist and epidemiologist at the University of Iowa. Plus, schools usually close at the same time that local communities implement other social distancing measures (such as canceling sports events and advising workers to stay home), so it’s hard to tease out the effects of one thing when many things are done at once. Still, research suggests that school closures may help slow the spread of particularly severe and fast-moving pandemics. A 2007 study published in the Proceedings of the National Academy of Sciences of the United States of America found that U.S. cities that implemented aggressive social distancing measures, including school closures, during the 1918 flu pandemic experienced less flu transmission and flu-related death than other cities did. But again—we don’t know whether it’s appropriate to apply these findings to COVID-19.

Two questions undoubtedly giving school administrators ulcers: When should schools close, and for how long? In general, research suggests that “closing early, before the peak of the outbreak, is associated with more benefit,” Perencevich says; the 1918 flu study mentioned above came to the same conclusion. This doesn’t mean that schools should close before the virus hits the local community—but they should ideally close before the spread has peaked. In a 2019 study, researchers at the CDC and other institutions argued that the benefits of school closures for controlling influenza are largely dependent on how much testing is being done, because testing is the only real way to target the areas that need to be closed. “Precise targeting requires prompt laboratory confirmation of initial cases in each and every community, coupled with quick dismissal of an affected school before virus spread occurs within the school and between the school and the surrounding community,” the authors wrote.

The problem, of course, is that we don’t have a clue where the coronavirus is spreading right now because we haven’t been testing for it. As of Tuesday at 3:10 p.m., only 4,788 Americans had been tested for COVID-19, according to the COVID Tracking Project; by this point in its outbreak, South Korea had tested more than 100,000 people. Unless testing ramps up significantly and quickly, school closures could come too late to do much good.

Given all of this, some scientists argue that schools should consider closing on the early side. “I would say the cost of doing it too early is tiny in comparison to the cost of doing it too late,” Hanage says. Michaud agrees. “It may be wise to err on the side of caution—meaning closing schools before you think you might need to,” he says. “We’ve seen the explosive growth of the epidemics in other locations, we don’t want to see that repeated right here, and closing schools could be an important tool in order to prevent that.” That said, there may well be downsides if schools close too early; then they could feel pressured to open up again before the epidemic has died down, which would be counterproductive too. This gets into the issue of duration: We don’t yet know whether school closures should last for a few days or for a few weeks.

The significant societal costs associated with school closures need to be part of the equation too; the benefits of closing need to be considered alongside the costs of doing so. Schools provide free or discounted lunches to 22 million American children and free breakfasts to more than 11 million kids. According to an article published Monday in the New York Times, New York City public schools will only close for COVID-19 as a last resort in part because 114,000 NYC students are homeless and rely on schools for meals, medical care, and laundry. Put another way, schools have become a vehicle through which many American children get not just education, but food and shelter.

There are no easy answers for how communities could continue to provide for kids who might suffer because of a school closure. In part, options depend on whether school facilities close entirely or schools only cancel classes but keep their facilities open and allow staff to continue to work—in which case, meals could at least be produced and, possibly, distributed. Bioethicist Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, who wrote a piece for Education Week on this topic last week, suggested to me that concerned parents might want to contact their school administrators or members of their board of education to make sure they’re making plans to provide for students in need, and that they should also contact local food banks or nonprofits to see if they could help in an emergency. Community organizations should also consider providing child care for first responders and health care workers who need to work but whose kids have been sent home from school. “Think locally and raise attention to the issue, and recognize and be respectful that our school leaders are swamped right now,” Faden says. (There’s the problem of educating kids during a closure, too: Some schools are looking into remote learning options, but if the infrastructure to support it is not already in place, this may be an impossible task—and one that could potentially exacerbate equity issues if some students do not have access to computers or the internet.)

In many ways, what’s hardest about these school decisions for parents is that they are largely out of our hands. We’re responsible for our children, yet we don’t have much say in what our kids’ schools are doing. Sure, we can contact our administrators with suggestions, but they, too, have their hands somewhat tied, in that they are largely expected to follow the recommendations of local health departments. When I put my kids on the school bus every morning, I’m essentially crossing my fingers, hoping that other people are making the best decisions for my kids and our community.

If that makes you feel anxious (it does for me!), it’s useful to remember that there are meaningful steps we can take to keep our families and broader communities safe. We can wash our hands well and teach our kids to do the same. We can use disinfectant wipes or diluted bleach solutions to wipe down household surfaces that are frequently touched—doorknobs, bathroom fixtures, light switches, and children’s toys. We can encourage our family members to spend time outside, as UV light kills the virus that causes COVID-19. We can limit voluntary travel.

Considering that COVID-19 causes such mild symptoms in kids, we may also want to keep our kids home from school when they have runny noses and coughs. As a working mom, I realize this is a huge ask, and it may be impossible for some. But “anyone now who has a cold in the United States, for the next couple months, we have to assume could spread this virus,” Perencevich says. Some schools are establishing policies to this effect: On Monday, the San Diego Unified School District announced that it had begun sending kids home if they had any respiratory symptoms, under guidance from the California Department of Public Health.

If you have plans to spend time with older friends or relatives in the coming weeks, you might also want to postpone, especially if you learn that the virus has been circulating in your or their community. “If you’re lucky and you can [connect remotely], it’s not as great as a real hug from Grandma, but I think it makes sense,” Perencevich says. “I don’t want my kids to bring coronavirus to their grandparents.” These are hard choices. My family has had plans to visit my parents in Florida over spring break in April. My kids can’t wait to see them and spend time at the beach. But if we discover through more testing that the infection has been spreading, as I expect we will, we are probably going to cancel. My kids will be heartbroken, but it feels like the right decision. No one said epidemics would be easy. I’m just thankful that the vast majority of our kids will, ultimately, be all right.