Mumbai: After more than 18 months of pandemic-induced school closures, many of India's children are still at home, studying online. Being unable to interact with other children and the outside world for so long has had an adverse impact on children. Many children in both urban and rural India do not even have the means to access online education. Can India's 250 million children of school-going age, a cohort larger than the population of most countries, go back to school safely in the times of Covid-19? How can the safety of teachers, parents and families be ensured?

We ask Tanu Singhal, consultant, paediatrics at Kokilaben Dhirubhai Ambani Hospital in Mumbai, who trained in paediatrics at the All India Institute of Medical Sciences, and in infectious diseases and international health at the London School of Hygiene and Tropical Medicine. She is also an advisor on antimicrobial stewardship at the Indian Council of Medical Research. We also spoke with Chandrakant Lahariya, epidemiologist and public health specialist who has recently co-authored a book on Covid-19.

Edited excerpts:

Dr Singhal, give us the clinical view on children returning to school for in-person learning. What paediatric Covid-19 hospital admissions are you seeing at present?

TS: The only silver lining of the Covid-19 pandemic has been that children have been spared, and that has remained consistent right from the beginning. Whether during the first wave or the second wave in India, we found that children have been very mildly affected. Most had a fever for a couple of days and got better. Very few, mainly the ones who had some comorbidities, required hospitalisation and they also recovered well and went home. Multisystem Inflammatory Syndrome in Children, which is often talked about, is a rare complication of Covid-19. Children who came [to the hospital] with that complication also recovered quite well. In fact, it is estimated that worldwide, children constitute only 0.2% of the total burden of deaths from Covid-19. So, if 1,000 people die of Covid-19, 998 will be adults and two will be children.

At this time, we are seeing low numbers [of Covid-19 cases] so we're hardly seeing any paediatric infections. In fact, right now flu and dengue are ruling the roost. Already, however, we have started seeing problems related to children being stuck at home--for instance, a massive increase in obesity in children. Every day, we have children coming to the OPD [outpatient department] with multiple psychological problems and we have been needing to refer them to psychologists. I am talking about [children from] the upper socioeconomic [class]. Then, problems among children [from the] lower socioeconomic classes are even greater. So we are seeing more harm related to their isolation than from Covid-19.

Dr Lahariya, why have you been arguing for schools to be reopened, apart from the reasons that Dr Singhal has pointed out? What's the evidence to support the safe return of children to schools?

CL: We need to remember that, in early March 2020, when schools were closed, the Covid-19 virus was completely new and we were developing our understanding of it. Since then, 15 to 16 months later, we have learned a lot about how this virus behaves and its impact on children. Children do get infected at the same rate [as adults], but they do not develop moderate to severe illness, and mortality is really low. So the first aspect to remember is that Covid-19 infection does happen to children, but it not does not cause severe disease.

The second aspect we have learned is that, in many countries, schools were open even at the peak of the pandemic there and children were not getting affected. Studies have found that in settings where schools were open and where schools were closed, there was no difference in the transmission. That is from global evidence and there are many such studies.

Back in India, we know through the fourth nationwide serosurvey that children do get infected at a very similar proportion or rate as adults. About 60% of children aged between six and 17 years had been infected, per the fourth serosurvey, which is very similar to the adult population. But we also know that in India, children did not form a large proportion of the population that was hospitalised and mortality remained low.

The educational aspects highlight that children are suffering. Health issues [related to Covid-19] are not that much, but education and learning are also about physical, social and mental wellbeing. Children in school learn how to negotiate with each other, sports help to keep them physically active. So there is a major learning loss. And there are many arguments that the impact of this cumulative learning loss because of school closure would be far greater than any other impact of the pandemic.

To conclude, three issues have emerged in the last two-three months. One, experts have said that schools should be the first to open and the last to close because of [children's] low risk of moderate to severe disease. Second, children may need vaccines, but vaccination is not a prerequisite to open schools. And finally, often it is argued that there are some rare cases arising in children in different settings, but we are not talking about infection, which may or may not happen; we are concerned with moderate to severe illness, and there is no evidence that the severity of the disease has altered in children, either from the original strain of the virus, or the Delta variant. So altogether, the benefit of opening schools is far greater than any risk, and the risk is really minimal.

Dr Singhal, a concern among parents is the possibility of Covid-19 transmission between children and parents and other family members, or teachers to children and vice versa, once schools open. So children may get infected and not fall very ill, but they may transmit Covid-19 to adults around them. Is that a valid fear?

TS: We must understand that we are not in a phase of lockdown at this time, so adults have numerous opportunities to get a Covid-19 infection from other sources. It is not that they are all sitting at home. And in fact, they are better protected now than they were 16 months ago because now a large proportion of them have been either partially or fully vaccinated.

Even when children were at home and not going to school, we were seeing a lot of transmission, from adults to children and vice versa. So the message here is that there will be transmission but that was happening anyway, and we can't blame it on schools reopening. It's not that everybody's just locked up at home; they're all going out. Children have already got infected, even though they didn't go to school. So it is more likely that children will be infected by adults, rather than children infecting adults because that's how they have been infected so far.

What we are actually talking about is not a complete opening of schools, but a graded opening, where children will have a few hours of school per week, where they will follow Covid-appropriate behaviour. We are making sure that the teachers and the frontline staff who are going to take care of these children will be vaccinated, so all those precautions will be in place. So this is a fear which we have to overcome.

Also, the onus of sending their child to school will be on parents, and online learning will still be available. So if people are very worried about sending their children to school, they can opt for continuing with online education, but at least a start should be made. Then I feel more and more people will get the confidence to send their children to school.

Dr Lahariya, how would you rank the risk levels of scenarios where parents and adult family members are fully vaccinated, partly vaccinated or unvaccinated?

CL: I think this is an important concern for all families and parents, but what we need to remember is that sending children to school does not alter or increase the risk of infection for family members or the child. As we heard from Dr Singhal, children were already getting infected when they were locked inside the house. Right now, in rural areas, children are playing with each other. Even in urban settings, in slums, lanes, colonies, children are playing with each other. Some are attending tuitions. So their exposure is really high and sending them to school does not alter that risk. There is evidence that the risk of child-to-child, child-to-teacher and teacher-to-child transmission is really low.

The only scenario where I would say that the risk increases, is if none of the family members or the child are venturing out, and then the child is sent to school. But if your child is already going out to the market, if any adult family member is going to the workplace and back, then the child going to school does not alter the level of risk.

In a majority of nuclear families in urban settings, if both parents are vaccinated, then there is almost no additional risk. The assumption is that if a healthy adult is already going out, then a child going to school does not alter the risk. But for somebody who is really sick, or not vaccinated, there might be some risk. If we analyse each scenario, we would find that there could be around 50% to 70% of families where all adults are vaccinated or otherwise at low risk, who can easily send their children to school. That leaves around 20% to 30%--maybe 40% on the higher side--of families which might need to take some additional measures such as getting vaccinated, in order to send their children to school. I agree that there would be 5% to 7% of families where there would be high risk, for instance if they cannot be vaccinated due to some personal reasons.

But we should open schools for two sets of population. One is the lower-income group and lower middle-income group who have no other option for their child to learn, besides school. For them, schools should be open. The rest have a choice. I know schools will not be full tomorrow onward and it will take many months before people will send children to school. There could be a few parents who may take another year. But for the majority who want this, schools should be open.

Dr Singhal, do you think parents are being selfish by not sending their children to school?

TS: I feel that parents are very worried about the child and not so worried about themselves. If you ask parents why they don't want to send their child to school, the reply is always that 'we don't want the child to be infected', and not because 'our child will get infected and pass the infection to us'. That may be a concern of policymakers and others, but it is not a concern for parents; because parents feel that they have been vaccinated, but the children haven't yet been vaccinated, that is why they are worried. Ever since that information came about that the third wave will be bad for children, that has actually caused a lot of damage also, because people believe that children have been at home, now they will go out, they'll get infected. So that is why they are not sending the child to school, because the health of their child is the highest priority.

Are you seeing any evidence right now of a potential third wave that might be affecting children?

TS: Not yet. Also, we may take a decision to reopen schools and we may find the Covid-19 cases increasing and schools may close again. We don't know how long this whole cycle is going to last. But we should take the opportunity of the time when cases are low and community transmission is less, to send children to school. At least they will have a month of physical contact and learning, because nobody knows which way this epidemic is going to progress. The third wave may hit and schools could close again, but at least we've made a beginning.

What do you tell parents who ask about the hierarchy of risks involved in sending a child to school?

TS: We tell them that Covid-19 is a mild infection in children, it is just like the flu so they needn't worry so much. But the hazards of not sending their child to school are greater, and they are already seeing those problems in their children. Children have gotten fed up and now don't want to sit in front of the computer and learn online, they say. Earlier, their attention span was better but has now declined. Parents are realising this. We tell them 'you are vaccinated and the children will follow precautions', so they do agree with that. We keep telling them that children are at low risk and the danger of not sending them to school is higher than the danger of sending them. That's how we counsel them.

Dr Lahariya, vaccination has progressed to the point that more than 50% of the eligible population has had at least one jab of a Covid-19 vaccine. The fully vaccinated are much fewer. Looking at these vaccination numbers, how safe are we today in terms of a potential next wave getting triggered, in the context of reopening schools?

CL: What we need to remember is that the risk is not zero. We also know that the virus is around us and it will stay with us. So, we have to make the necessary adjustments. But we cannot deny the present for an uncertain future. We really do not know whether there will be a third wave, or what its extent would be.

And we should not interpret too much from what is happening in Florida or any other setup. We need to remember that India faced the Delta variant wave much before any other country. Since then, India has been vaccinating its population. So the level of immunity which we have developed is very different from the rest of the world. [Countries where] people were first vaccinated and then the Delta variant [entered], are facing a very different scenario. So, we should not be concerned about that. We should be looking at holistic evidence, not just one evidence from one setting and then try to juxtapose it.

We know that there is some risk and we must do all the necessary things to minimise that risk at home, at schools and in the community. It has to be a dynamic process. If cases rise, governments, family members, all need to decide whether schools need to be closed.

We also sometimes kind of get swayed by some new information. For example, a [Covid-19] vaccine was licensed for [children and adolescents] aged 12 to 17 years. But we need to remember that mere licensing should not mean that children should be vaccinated. We know the risk of moderate to severe disease is low in children, and vaccines prevent moderate to severe disease. So, for a risk which is already low, the benefit of vaccination for children aged 12 to 17 reduces.

What is also happening in the current discourse, is that there are many misconceptions and myths going around. The best way to tackle this is to start a dialogue. Dr Singhal also highlighted that parents have a genuine concern. But through dialogue, some of the misconceptions are addressed so parents can make a better decision.

A major resistance to opening school was that many parents were under the impression that if schools were open, then they would have to mandatorily send their children. Now, with the clarification that it is going to be a voluntary process and it is likely to stay voluntary, the resistance has come down. But there are still some misconceptions.

People are waiting for vaccines. For example, some doctors are saying that in the next few months, a vaccine [for children] will be available and then children can go to school. In my opinion, that is completely wrong. Though one vaccine is licensed for [children and adolescents aged] 12 to 17 years, that vaccine manufacturer has a production capacity of around 10 million shots a month. Even if it's scaled up, by December they project around 40 to 50 million shots by the end of this year. Now, India has around 145 or 150 million children. Each child would require three shots of that vaccine, which essentially means 450 million shots will be required, while they will be producing 50 million shots, enough for just 17 million children. So vaccination is not a solution. If we keep waiting for that, another academic year will be lost.

We need to have a calm and composed assessment of the situation, assess how much risk we are willing to take. Opening schools has to be a dynamic process. If Covid-19 cases increase, of course the government needs to close schools. But we cannot be in a situation where only if there is a guarantee that nothing would happen will schools open. That would be a big mistake.

TS: Though we say that only 10% of our population is fully vaccinated, we must understand that if 70% of our population has already got infected with Covid-19, even one dose of the vaccine actually works like two doses. Because we know that previously infected people, if vaccinated, have much higher immunity which is equivalent to two doses in someone who was never infected with Covid-19. So the level of complete immunity in our population may be higher than the 10% that we are assuming.

We also have to consider the risks and benefits of vaccination in children. In adults, we are willing to take the risk of vaccination because of the benefit of protection against severe disease. But when we talk about vaccination of children, we have to be also sure that the vaccine is very safe, because they anyway get mildly ill. So if we want to protect them, we should have a very, very safe vaccine.

Dr Singhal, what is your advice to parents who want to send their children to school, on precautions that they should be adopting? Should they be doing frequent testing?

TS: First, adults should try and get themselves vaccinated at the earliest and they should make sure that the other people working in the house are also vaccinated. Second, children should be taught Covid-appropriate behaviour. If the parents identify that the child has a comorbidity which makes them at higher risk [of severe Covid-19 illness], those children should not be sent to school.

Parents also have to be very vigilant and very responsible. Sometimes, if the child wakes up with a little cold, cough and a little fever, they say it's okay to send the child to school. But now, in Covid-19 times, that would not be correct. If the child is unwell, then they have to make sure that the child doesn't go to school. Also, they have to teach their children to not eat or drink in school, and not take off their masks. Hopefully, school timings will be short enough so that children will not need to spend too many hours there and won't need to take off their masks.

Parents also have to be careful that if somebody in the family is sick, then they should make sure that unless it is confirmed whether that family member has Covid-19 or not, the child is not sent to school. All these precautions have to be in place.

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