By Dr Edward Nazareth

Jun 24: During the onset of the first phase of unlocking the lockdown in India which commenced from June 1, the Central government hinted that schools may be reopened in a phased manner from July 1. When the news of the possibility of reopening of schools spread, more than 2 lac parents signed an online petition against it in a single day. "It’s insane. It’s like playing with fire when we ought to douse it with full force," some of the parents reacted to the news.

Some of the surveys conducted subsequently, to know the mind of the parents have reported that more than 90 per cent of the parents are not willing to send their wards to school even if the schools are reopened soon.

Apprehensions are again expressed as the SSLC final examinations are not cancelled in Karnataka like neighbouring states and they are to begin from June 25, 2020. As the number of positive cases infected by COVID-19 virus is steadily mounting up, it is quite natural for parents to worry about the safety of their children rather than their academics.

In this background, the important issues that may be looked into are: How vulnerable are the children to COVID-19 infection? Are we in a position to reopen schools now? What are the possible negative effects on children if schools are not reopened in the near future?

COVID-19 infection in children

Amongst the reported COVID-19 infected cases from China and USA, the number of children infected is far less compared to adults. In China, of the positive cases reported, 2.4 per cent were children and adolescents, and in the US, the Centers for Disease Control and Prevention (CDC), reported 1.7 per cent cases of children and adolescents.

One explanation for these low numbers is that, as the children show milder symptoms compared to adults, they are less likely to be tested. However, data from countries that have conducted widespread community testing for the virus suggest that children are less likely to be infected. In South Korea, children younger than nine years accounted for just 1 per cent of laboratory-confirmed cases of COVID-19, whereas children aged between 10 and 19 accounted for 5.2 per cent of cases. In Iceland, young children were less likely to test positive for COVID-19 than adolescents or adults, and no cases were found in children less than ten years of age in random population screening. Similarly, in the Italian town of Vò, where 2.4 per cent of people of all ages were infected, no cases were found among 374 children less than ten years who were tested for the virus.

The researchers have proposed a reason for this. The COVID-19 virus can invade any cell in the human body that manufactures the ACE2 protein. In children, these proteins are not fully matured, functional and/or sensitive compared to adults. As a result, even if they are exposed, the COVID-19 virus may not enter into their body. The other reason cited is that, as children often experience respiratory infections, they may be able to produce more antibodies to face COVID-19 virus.

Similar differences between adults and children were also observed during the severe acute respiratory syndrome (SARS) pandemic in 2002-2003; children and adolescents were only moderately affected then as well.

One more observation is that the disease also has a very mild course in children compared to adults. In a study involving more than 2000 infected children in China, 94 per cent of children were either asymptomatic or had mild to moderate illness. Though 6 per cent of the infected children had a severe or critical illness, only one teenager died (of the 2000 children in the study). Most of the children recovered within a week or two. In the United States also, less than 2 per cent of the infected children required hospital admission.

The symptoms of COVID-19 infection in children vary slightly from those seen in adults and tend to be milder. Cough or fever is observed in only around half of symptomatic children, less frequent than in adults. In contrast, upper respiratory symptoms such as a running nose or sore throat occur in 30-40 per cent and diarrhoea and/or vomiting are found in around 10 per cent (sometimes this is the only symptom), more often than in adults.

Like in adults, the presentation of disease can vary from child to child depending on the immunity status. Children with underlying medical conditions like diabetes or asthma show more severe symptoms as compared to healthy children.

Indian children and COVID-19 infection

As of today, COVID-19 infection is mainly confined to major cities in India, while villages, semi-urban areas are not significantly affected. The average children in urban areas are healthier compared to those in the villages. Their health status may be comparable to children from developed countries like the USA. But, most of our children are in rural areas. The average health status of children from rural India is far from acceptable norms.

The fourth National Family Health Survey (NFHS-4), 2015-16, has revealed a pathetic state of the health of children in India. Around 38 per cent of children under five are stunted (short height for age), 28 per cent are wasted (thin for their height) and around 36 per cent under five are underweight. Around 59 per cent of children are also anaemic due to iron deficiency which weakens their immune system and increases their vulnerability to infectious diseases like COVID-19. Only 62 per cent of children below the age of two years receive all basic vaccinations, and only 10 per cent receive a minimum acceptable diet in India. The vulnerable status of children in rural India also reflects the overall condition of the nation.

In China, the children were less infected and had fewer complications. Compared to India, the health index of the children in China seems to be far better. According to a report published in 2018, only 3.13 per cent of children in China are underweight. Further 5.44 per cent of children are anaemic, 1.11 per cent and 1.43 per cent of children are stunted and underweight respectively. More than 95 per cent of them are immunized.

With this information at hand, we cannot predict the possibility of low infectivity and vulnerability amongst the children in India, especially children from a rural background. If the schools are opened in the rural and semi-urban areas many of our children might get infected and might show complications. Because of poor nutrition status and underlying anaemia, children from rural India may have severe complications because of low immunity.

Can children spread COVID-19 infection?

When the school going children get sick due to any virus infection, they pass on the viruses amongst themselves and infect the adults in their surroundings — Teachers, attendants, parents, and grandparents. Most of the parents, siblings as well as teachers get a common cold, viral fever within a month of reopening of the schools either after summer holidays or after mid-term holidays. Those who have school-going children might have had this experience. There is concern expressed that children may play the same role as with the COVID-19 virus if they can get infected.

Although the role children play in transmitting the COVID-19 virus is unclear, the researchers opine that children are less likely to acquire the infection when compared to adults, and less likely to bring the infection into households. There is little direct evidence to suggest that asymptomatic children are playing a major role in spreading the disease. One study which analysed the source of 31 household clusters of COVID-19 in China, Singapore, South Korea, Japan, and Iran found that children were the source of infection in just three of these cases. Although the role children play in transmitting the virus is unclear, evidence consistently demonstrates that children are less likely to acquire an infection, and less likely to bring infections into households.

We have two main considerations: Protecting children and their families from COVID-19 infection and preventing transmission through school children. Even if we trust reports that the disease is relatively milder and less lethal and that children are at a lower risk, the possibility of transmission from children cannot be ruled out. The children may remain asymptomatic but they can spread the infection to their teachers, classmates and especially to their parents and grandparents. Despite the limited data due to day-to-day changes in the statistics of patients infected, some of the researchers have opined that children, even if not infected themselves, can serve as carriers of the virus and can play a pivotal role in spreading the infection.

It is not easy to ensure hand hygiene, masks and social distancing amongst children and teenagers. The schools and colleges are social hubs; they can also become hubs of disease transmission. Although study reports from other countries suggest that transmission through school children might be limited; it is doubtful whether these results apply to Indian contexts. We may have to be cautious while taking decisions on these reports.

Closure of schools and pandemics

There are several reports published earlier which have supported that the closure of schools is an important aspect of controlling the spread of infectious diseases. The closure of schools in the city of Oita, Japan, was found to have successfully decreased the number of infected students at the peak of infection during the H1N1 pandemic in 2009. Early school closures in the United States also delayed the peak of the same pandemic. Scientists have endorsed the closure of schools in order to interrupt the course of the infection, slow the further spread and buy time to research and produce a vaccine.

Effects of indefinite school closure

The closure of schools for an unknown period not only affects the academics of the children, but it can also have a significant unfavourable influence on the health and psychosocial development of the children. UNESCO has published a detailed list of possible ‘side effects’ of closing schools for a prolonged period. I shall pick up a few relevant to us:

*Though children in the urban areas have access to online teaching, most of the children in the rural areas and those who are underprivileged lack these opportunities. Many of the underprivileged also get nutritious food in the schools through government-sponsored schemes. They are deprived of education as well as nutrition.

*The children from affluent families eat more frequently when they are at home, that too high-calorie junk food and tend to put on weight. Obesity in children can lead to a lot of health-related problems. This can already be seen in many of the urban families.

*Most of the working parents find it hard to manage the children at home during holidays. As the schools are now closed for an unknown period, they may have to leave the children alone at home or under the care of domestic help. This can lead to risky behaviours, including the increased influence of peer pressure and substance abuse. Some of the working parents may have to miss work in order to take care of their children. This results in loss of wages and tends to affect the economy of the family.

*When schools are shut down for an indefinite period, the school dropout increase and child labour grows, especially in rural areas.

*As they are separated from their classmates, children may develop psychosocial problems. Schools are also places of social activity and human interaction. When schools close, many children and youth miss out on social contact that is essential to learning and development. There is also the risk that children and youth may indulge in anti-social activities, teenage girls may be sexually exploited; UNESCO has also expressed concern over early marriages and teenage pregnancies.

*Distance learning or online classes also have problems. Even if the facilities are available, children may not concentrate as much as they do in a classroom. Some children log on to the virtual class and may do something else unless supervised by parents. A prolonged period of exposure to computers/laptops or mobile phones are also not good for the health of the eyes.

How to go about?

It is extremely difficult to suggest an acceptable solution for the problem now. As the infections are on the rise, it is not an appropriate time to reopen schools now. The infection rate may be low in children, they may have a very mild infection as per published data, but these may not be applicable to all our children especially those from rural areas. We also should remember, even if they do not show the signs of infection, they can spread it to their family members.

Once the number of positive cases starts declining, we may plan to reopen schools in a phased manner. The universities may be opened up first and we should observe how it goes. Then, gradually the high schools and higher primary schools may be opened.

Despite knowing the problems of indefinite school shut down, we should weigh the risks of COVID-19 infection in children with the benefits of academics and other issues. We should not reopen the schools in a hurry now and close them again for an unknown period.

(Data are collected and compiled from different authentic publications)