Lost in the storm over school mask mandates is a question I suspect a lot of parents are wondering about but are afraid to ask. So I will.
Should children be attending school in-person this fall?
I can’t believe I’m asking the question myself. When school ended last June, I thought we’d have a lid on this pandemic by now. Instead it feels like we’re caught in a COVID twilight zone. The pandemic is as bad as it’s ever been in many places thanks to the highly contagious Delta variant, but it’s mainly a pandemic of the unvaccinated. The problem is there’s no vaccine for children under the age of twelve, and while it appears kids who catch the virus don’t get as sick as adults, it seems more kids are getting sick. No one wants to keep kids home from school again as the new school year starts, but at the same time no one seems to even want to entertain the possibility that may be necessary in some places at this time in the pandemic.
Before we begin, I must confess I’ve always been in the “err on the side of caution” camp when it comes to in-person learning during the pandemic. I completely understand the arguments for sending kids (especially younger kids) back to school. My concern—and it’s been my concern not just with schools but with American society in general during the pandemic—is that the loudest voices on the side of reopening have also been those who have downplayed the threat of the virus the most (it’s no worse than the flu!) and who have opposed basic mitigation strategies like mask mandates. I don’t trust those parents to do the right thing by other people’s children. (Cue Taylor.)
For today’s article, I’m just going to take you through a lot of what I’ve been reading on this subject. Let’s start with this July 7, 2021, article by Cassandra Willyard from Nature titled “COVID and Schools: The Evidence for Reopening Safely”. Willyard succinctly lays out the reasons for getting kids back into school:
[K]eeping kids out of school comes with its own set of risks. Many parents have seen the social isolation take its toll and witnessed their children struggling to stay engaged with lessons delivered by screen. Emerging studies suggest that kids in remote-learning situations are falling behind academically, especially children who were already struggling. Schools provide more than education. They serve as a safety net for many kids, offering free meals and a safe place to spend the day. Educators and school counsellors are often the first to spot signs of domestic or sexual abuse and intervene. What’s more, the closure of schools has been a disaster for many working parents. Those with young children were left trying to juggle virtual school, normal parenting duties and their own jobs.
In her article, Willyard cites numerous studies showing that transmission rates in schools are extremely low and that students are actually safer in the closed environment of a school system than they are in their communities. Of course, the problem with relying on Willyard’s piece is that it was published in early July, when the Delta variant had hammered the United Kingdom but had yet to become the dominant strain of the virus in the United States.
It’s probably too soon to be able to generate any reliable analytical studies on the effects of Delta on children, so we have to do our best with descriptive statistics and anecdotal accounts. Let’s begin with a few big numbers. Last week, the American Academy of Pediatrics reported 180,175 new COVID cases among children, marking the third highest one-week total of the pandemic. As Figure 6 in the report shows, that number is up from 38,654 cases a month ago and 8,447 cases two months ago, which was also the lowest tally since early April 2020. (A quick note: Unfortunately, states define “children” by different age ranges so these studies aren’t always measuring the same populations. Beyond the broader measurement of children, it would be nice to see numbers focused on children under the age of 12, since they’re not eligible for vaccines.)
Cases are not as concerning as hospitalizations, though. According to a Reuters article by Gabriella Borter from ten days ago, the United States set a record for the daily number of pediatric COVID hospitalizations at 1,902. To put that in perspective, that’s only about 2% of all COVID hospitalizations nationwide, but it’s also true more kids are getting seriously sick from COVID at this time than at any other time during the pandemic. Meanwhile, the mortality rate for children remains infinitesimally small (0.00% - <0.03%) although no one should downplay how serious or long-lasting a bout with COVID can be. It does appear, though, that while more kids are contracting COVID, they are not necessarily getting sicker when they do.
Elliott Ramos of NBC News reported the surge in hospitalized children happened fast over the course of just a few weeks and so far has been concentrated in states with low adult vaccination rates. (In Louisiana, for instance, 28% of all new cases [not hospitalizations, but cases] were among those younger than 18.) It is also worth noting that about half of all children who have been counted as hospitalized in the past month are unvaccinated teenagers; that would make the other half either breakthrough cases among vaccinated teenagers or children under the age of twelve who are not yet eligible for vaccines.
Another article from NBC News by Phil McCausland (which contains a lot of state-by-state analysis) attributes the rise in children’s COVID cases to household transmission from an unvaccinated parent to a child:
Multiple doctors in the half-dozen children’s hospitals NBC News reached out to said they have seen children infected because a member of their household, often a parent, brings the coronavirus home. Oftentimes, it is because an adult in the home is unvaccinated.
“Absolutely, household infections are the beginning of this pandemic, that is a major driving force in the spread of infections. We see it often within households, parents to children,” said Dr. Jim Versalovic, the chief pathologist and interim chief pediatrician at Texas Children’s Hospital in Houston. “We have certainly seen siblings — more than two at times — with an infection at the same time, so spread within households is certainly a very real phenomenon.”
That article, however, was from August 9, which predates the resumption of school. Some schools that have reopened since that time have had trouble keeping students in class. In Mississippi—which has the lowest vaccination rate in the country—4,521 students and 948 teachers and staff have tested positive since reopening mid-August, leading to over 5% of its students (in raw numbers, about 20,000 students) having to quarantine. Some school districts in Texas and Florida have also struggled with positive cases in schools.
What we don’t know is if the reason those schools have had such a hard time staying open this early in the school year is because of student-to-student transmission or because of low adult vaccination rates, which may have led large numbers of parents to sicken their own children. If student-to-student transfer is rare, it may only be necessary to quarantine COVID-positive students rather than whole classes of children for extended periods of time. It would also reinforce the idea that the best way to keep kids from getting sick would be for their parents and other adults in their lives to get vaccinated.
Meanwhile, masking in schools remains advisable. A recent study published by the CDC has suggested the most important mitigation strategy in school settings is the masking (and, it would follow, vaccination) of staff. While that study did not reach any conclusions about the effects of other mitigation strategies such as ventilation, social distancing, or student masking, its ambivalence toward student masking shouldn’t be taken too seriously since it did not look at student masking in isolation.
In another study published earlier this month, a team of researchers at Georgia Tech and North Carolina State modeled the spread of the Delta variant in school settings and found that an elementary school of 500 students could expect approximately 90% of susceptible students to contract COVID in one semester in the absence of mask wearing and testing. That number would drop to 30% if students wore masks and were tested regularly. While the GT/NCS model makes the case for masks, it is disconcerting that nearly 1/3 of susceptible students would still contract COVID despite mask mandates. Perhaps the model overstates the potential transmissibility of the virus (it assumes every COVID-positive student will infect four others even though children have historically not been major transmitters of earlier versions of this virus) but it is enough to make one worry that schools might become super-spreaders in the time of Delta.
When asked about unvaccinated school children in a television interview from August 12, 2021, Director of Infectious Disease and Policy at the University of Minnesota (and Luther College grad) Dr. Michael Osterholm said
We have to understand the variant we are dealing with now is not the same one that many of the studies that were done showing very low risk of transmission in schools last year[.]. And so I think that what we have to understand now is that with both Alpha and Delta we have demonstrated…increasing transmission between kids, by kids, for kids and we surely can expect to see major outbreaks in schools with transmission, just by kids transmitting to kids. Mississippi, which opened schools last week, in the first week reported over a thousand cases in schools. And I think this is just a harbinger of what’s to come for us.
In terms of masking, I think masking is important. We have to have adequate masking. This is an aerosol transmission virus. And frankly, we need the very high level of masking protection. [T]here is only limitable availability for children to actually have that. There are KN95 masks that are available online that actually do fit for children’s faces that attach behind the ears. They are not as good the N95s that we urge adults to use, but that’s the best that we can do right now. I think the idea of crowding and ventilation of schools is still a big challenge. The CDC guidelines are clearly outdated when they said you can be six or even three feet apart. With these aerosols we know that’s different.
If Osterholm is worried, then I’m worried, too.
So let’s talk about masks. This article at WebMD offers a good overview of what to look for in masks. Adults should probably be wearing NIOSH approved N95 masks. If you look for them on Amazon, you’ll quickly realize it’s easy for anyone to manufacture something that is supposedly an N95, but this list tells you which N95s are approved by the CDC. N95s don’t work well for kids, so children should try to wear kid-sized KN94 or KN95 masks. The WebMD article contains a link to a Google Doc with recommendations on children’s masks by Linsey Marr, an environmental engineer at Virginia Tech who tests masks. Marr’s document links further to a list compiled by Aaron Collins, aka “@masknerd” on Twitter, that breaks down the quality and features of various kids masks, many of which can be purchased on Amazon. If you are worried that buying N95s or KN masks will deprive hospitals of needed equipment, my understanding is that these kinds of masks are no longer in short supply and that hospitals are well-stocked. Also note that these masks are more expensive than standard surgical masks but they may be a decent investment if they can get you and your children through the Delta surge to your next booster or their vaccination.
And what about those vaccines for children under the age of 12? These two articles by NPR and The Atlantic both suggest Pfizer may be ready to submit the results of their trials to the FDA for emergency use authorization by the end of September. The Atlantic article goes into more depth on a potential delay to that schedule connected to a request by the FDA to recruit more children to the study to test for certain side effects connected to heart inflammation. On The Today Show this morning, Dr. Anthony Fauci said he hoped vaccines would be available for children by late fall/early winter and that there was a “reasonable chance” kids could be vaccinated by the winter holidays.
So that’s what I know. Delta has really thrown the start of this school year for a loop, and as more people begin spending more time indoors as fall approaches, I worry the current surge may stick around through the end of the year. How is that going to affect kids? I guess we’ll find out by watching places like Texas, Mississippi, and Florida, which have a head start sending kids back to schools. Additionally, many of the schools in those states will not have mask requirements, which lends itself to a rather wicked natural experiment. In the best-case scenario, we would find that Delta, like previous COVID variants, is difficult to transfer from child-to-child in elementary school settings, meaning schools will be reasonably safe. If that’s not the case, however—if Delta is more transmissible and rates of adult vaccination remain abysmally low, and if we start seeing evidence of in-school transmission, rising rates of sickness among school-aged children, or community spread that can be attributed to in-school transmission—it may mean back to Zoom school for a lot of kids, particularly if any of that occurred in schools with mask mandates. It would be tragic if it came to that, as it would mark the second year in a row when the irresponsible behavior of adults drove up COVID cases over the summer and ruined a school year for children.
A lot of parents are going into the fall with their fingers crossed. They know their kids need to be back in school. Delta’s a scary wild card, though, and with a vaccine possibly available for kids in the fall, the next 2-4 months will be a fraught bridge for families to cross. In the meantime, there are two big things we can do to better protect our kids. First, buy some quality kid-sized KN94/95 masks and lobby your school administration and PTA to stockpile them for use by children whose families might not be able to afford them. It also wouldn’t hurt to buy some N95s for yourself to keep Delta at bay until you can get your booster. And second, build a wall around those kids at school by getting the adults in their lives vaccinated. Press the school to mandate vaccines for teachers and staff and develop an outreach program to convince unvaccinated parents to get the shot. That last part will be exceedingly difficult at this stage of the pandemic—if you haven’t gotten the vaccine by now, what could possibly persuade you to do so; even Trump got booed and called a “dumbass” by Alex Jones for encouraging a crowd in Alabama to do so over the weekend—but perhaps if you told them that you got the vaccine not for yourself but for the health and well-being of every child in that school, including their own, they might finally reciprocate.
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Exit music: A tribute to Charlie Watts, the drummer for the Rolling Stones, who passed away today at the age of 80. As rock and roll progressed from the 60s to the 70s, rock drumming got more and more bombastic, but Watts preferred to keep it steady and subtle, always a member of the ensemble. When he was heavy or flashy, it was always in service of the song. Consider these examples. On “Get Off My Cloud”, his drum pattern establishes just how annoying it would be to live in a flat next to the Stones (while Mick Jagger sings about how annoying those neighbors are to him.) On “Honky Tonk Women”, Keith Richards’ blues riffs could easily slip away into a drunken puddle on the floor; instead, Watts gives it just enough shape to stabilize the song while also complimenting his guitarist by suggesting his own drum kit is on the verge of collapse. Finally, on “Tumbling Dice”, appreciate how his drumming slips in and out of the vocals and guitar lines, filling gaps at times while also leading the way in and out of musical sections. Watts could play loose, he could play tight, he could play the blues, he could play disco, he could charge ahead, he could lull you asleep, he could play with soul, he could make you dance. Robert Christgau doesn’t call him rock and roll’s greatest drummer for nothing.