At a time when coronavirus cases in India are showing a rising trend and when daily fresh cases reported are over 60,000, which is the most in the world, any decision to open schools before the spread is reduced can turn disastrous. The Israel experience of how cases spiked when schools were reopened in end-May when daily fresh cases were just under 10 should serve as a grim reminder.

With nearly 5.2 million, the U.S. has reported the highest number of novel coronavirus cases in the world. In comparison, with nearly 2.4 million cases, India has recorded less than 50% of the U.S. case load. But for the last couple of weeks, the number of daily fresh cases reported in the U.S. has been reducing even as we have been seeing an ever-increasing trend in India. Since August 2, India has been reporting the most daily fresh cases in the world, and since August 6 the daily new cases have been staying above 60,000, except on August 10 when cases dipped to over 53,000.

The epidemic, which was initially restricted to metro cities, have since spread to tier-2 and tier-3 cities and towns. Currently, two-thirds of total cases reported are from 50 districts, most of which are highly urbanised.

According to Dr Rijo John, Health Economist and Consultant, the seven-day average growth reduced marginally to 2.7%, implying a doubling time of about 26 days. The seven-day average test positivity rate is still high at 9.3%, meaning there are thousands of infected people in the community who are yet to be diagnosed. The over-reliance on rapid antigen tests with low sensitivity by at least half-a-dozen large States could be one reason why the test positivity rate has come down in recent weeks without actually diagnosing all the tested people.

But on August 10, Education Minister Ramesh Pokhriyal Nishank said a decision on reopening of schools and colleges is likely within 10-15 days. The decision is to be taken in consultation with educational institutions, State governments, and the Health Ministry. Given the perpetually increasing trend in cases reported daily and wider spread in the country, should it ever be a time to considering reopening schools and colleges in India?

Dr Tom Frieden, former Director of CDC warns about the danger of opening schools when the virus spread in the community is high. In a tweet he says: “As was clear with premature reopening in Arizona, Texas, Florida, etc., opening schools and colleges with high case numbers is asking for trouble. Opening schools in places where positivity rates are high isn’t going to end well.”

How safe are Indian children

“We don’t know how safe children in India are. Currently, we are looking at evidence from other countries. Since the spread of the virus is high in India, there is great possibility of children getting infected if schools reopen now,” says Dr Giridhara Babu, epidemiologist at the Public Health Foundation of India, Bengaluru.

Dr Babu also says that one-third of children in India are malnourished and this has implications in disease presentation. “Immunity stands compromised in children who are malnourished. So there is a greater risk of complications when such children get infected,” says Dr Babu. “Also, morbidity in children post-recovery from COVID-19 is not known in India. Any decision to reopen schools should be taken once the virus spread is reduced.”

Over 20 countries had opened schools by early June, while some such as Taiwan, Nicaragua, and Sweden never closed their schools.

Israel experience

Any decision to reopen schools and colleges should take into account how such an exercise in Israel turned out to be a disaster. After shutting down schools in mid-March and introducing remote learning for its two million students, Israel reopened schools on May 17 in one go. The provocation to reopen schools was the sharp drop in daily fresh cases from 734 on April 1 to less than 10 in early May. The coronavirus spread was hence considered to be contained. Shopping malls, places of worship, restaurants, bars, hotels and gyms had already reopened.

On the day in late May when Prime Minister Benjamin Netanyahu asked people to “Go out and have a good time”. That same day, a seventh-grade student tested positive for the virus, The New York Times reports. The next day another student tested positive. Other schools too reported cases and by late-June, 977 pupils and teachers were infected and more than 240 schools were closed and over 22,500 teachers and students were quarantined.

One reason why the cases spread was when the heat wave that swept through Israel children were allowed to remove face masks and schools went back to using air-conditioners in class rooms.

Experience of other countries

Israel is not an outlier. A few studies have found how vulnerable children are to novel coronavirus infection. A study published in The Lancet Infectious Diseases found children in Shenzhen, China were as likely to be infected as adults —  infection rate 7·4% in children less than 10 years compared with population average of 6·6%. The study assessed 1,286 contacts of 391 initial cases.

A pre-print posted in medRxiv examined 2,496 contacts of 313 domestically acquired cases in Japan between January and March and found a much lower attack rate in children (7.2% males, 3.8% females) compared with adults (22% in people aged 50-59 years).

A report in the journal Science cites numerous examples of coronavirus cases in children from several countries. The reported spike in cases in Germany is of particular interest. The proportion of all new infections in children in Germany under age 19 increased from about 10% in early May, when schools reopened, to nearly 20% in late June, the journal reports.

Cases in children spiked in the U.S.

While initially children were considered to be less likely to be infected compared with adults, data from the U.S. and other countries contradict this notion. Data released by the American Academy of Pediatrics show that nearly 1,00,000 (97,078 to be specific) cases in just two weeks in end July — July 16-30. Across the country, the total number of COVID-19 cases among children rose from 1,79,990 on July 9 to more than 3,80,000 on August 6 — an increase of about 90%, AAP said.

The rise in cases was mainly fuelled by States in the South and West, including Florida, Missouri, Oklahoma, Georgia, Montana and Alaska. In Florida, for instance, the total number of cases in children under 17 years rose from 16,797 on July 9 to 39,735 on August 9 — an increase of 137%, according to Florida Department of Health data, says a CNN report. The nearly 23,000 cases in children in Florida accounted for 5.5% of all cases in the State.

While children are less likely to have severe form of the disease, they surely can spread the virus to others, particularly adults and older children in households.

Children are infectious

A study undertaken in South Korea found that household contacts of children had higher rate of getting infected. According to the study published in the journal Emerging Infectious Diseases, 18.6% of household contacts of child index cases got infected. The study also found that for “most age groups, COVID-19 was detected in significantly more household than nonhousehold contacts”.

Another study published in the journal JAMA Pediatrics found children younger than five years harbouring more viral RNA in the upper respiratory tract than adults and even older children. The amount of coronavirus RNA could be 10- to 100-fold more in younger children than adults, they say. But the study looked for only viral RNA and not for live virus and hence infectiousness could not be established.

Minimising risk

According to CDC, the risk is moderate even when class sizes are smaller and children are divided into small groups with each group staying together with the same teacher and maintaining physical distancing of six feet. The risk becomes high when classes are conducted at full student strength, no physical distancing is maintained and all types of activities are allowed.

“Opening safely, experts agree, isn’t just about the adjustments a school makes. It’s also about how much virus is circulating in the community, which affects the likelihood that students and staff will bring COVID-19 into their classrooms,” a report in the journal Science says.

With students cramped into small class rooms in India, maintaining physical distancing will be impossible without reducing the class size. One way of reducing class size to about a dozen than the normal over 30 students, as done in many schools in countries that reopened, is by having staggered schedules which allows some students come to school on certain days of the week or by dividing them into two groups, with one group attending in the morning while the other attends in the afternoon, as was done in Tokyo with high school students.

When mask wearing is hard even for adults and too for a shorter duration of time, it is not known how well the adherence will be in children.

With availability of water an issue even in major schools even in cities, regular washing of hands with soap may be difficult. “Access to water, sanitation and hygiene services is essential for effective infection prevention and control in all settings, including schools,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It must be a major focus of government strategies for the safe reopening and operation of schools during the ongoing COVID-19 global pandemic.”

In the absence of water and soap, use of sanitisers may be the only option. How many schools can provide sanitisers in huge scale? And if children are required to bring sanitisers themselves, how many children can afford them?