6 August 2020
As schools welcomed only Grade 12 learners back this week, the Paediatrician Management Group (PMG) and the South African Paediatric Association (SAPA) together urge government to open schools to all learners and not to allow fear or politics to harm the children of South Africa.
Speaking out against government’s decision to close public schools again, local paediatricians say that the decision is not based on scientific evidence, and the benefits to children of attending school outweigh the risks to both children and the broader community.
With no clear evidence that closing schools significantly reduces community transmission or overall deaths, local paediatric doctors call for all grades to be allowed to return to school as soon as possible.
A COVID-19 modeling study done in the UK which was based on the previous H1N1 epidemic and the SARS outbreak, predicted that school closures alone would possibly prevent only 2-4% of deaths. This is much lower than the effect of other social distancing interventions.
“Those school communities which are at risk, either due to high local transmission rates or poor infrastructure, should be identified and supported immediately to mitigate their risks so that they can reopen as soon as possible. Where schools are unable to reopen, the Department of Basic Education (DBE) must still ensure that all learners continue to have adequate academic material via radio, television, cell phone applications and all other means necessary. Educators must be held accountable for providing ongoing academic support and material at all times,” the paediatricians said.
Children’s risk to acquire SARS-Cov2 infection is lower than adults
Spokesperson Dr Fiona Kritzinger, a paediatric pulmonologist at the Christiaan Barnard Memorial Hospital in Cape Town, said children aged 0-18 in South Africa account for only 5% of COVID-19 cases.
“Children and young people have a lower susceptibility to SARS-CoV-2, with 56% lower odds of being an infected contact.”
South African data on COVID-19 case distribution by age shows that children aged 5 to 9 years old have an incidence of 15 cases per 100 000 population; 10- to 14-year-olds have an incidence of 22 per 100 000 population, and 38 per 100 000 in children 15 to 19 years old. In comparison, the incidence in the 20- to 60-year-old groups varies between 94 and 228 per 100 000 population.
A recent media statement released by the Western Cape Education Department (WCED) confirmed that only 0.1% of all learners who had returned to school tested positive for SARS-CoV-2 and no deaths of learners were reported to the WCED.
Dr Kritzinger said that although this percentage is affected by the current Western Cape testing strategy, “it is nonetheless reassuring that the reopening of schools has not resulted in any significant outbreaks at a population level”.
Children’s risk to transmit SARS-CoV2 in a household is lower than adults
“Family cluster and household studies showed that children are rarely the index case and that children seldom cause outbreaks. It has been confirmed that children were only responsible for household transmission in 9.7% of households.
“In the Italian cohort of Garazzino, 67% (113/168) of children had at least one parent who tested positive for SARS-CoV-2 infection and in 78% of cases the symptoms in relatives preceded the symptoms in the child, confirming that children are rarely the index case in a household. “she said.
Children’s risk of contributing to school and community outbreaks is very low
Dr Kritzinger said evidence points towards very limited spread of COVID-19 between children. “There are no reported large outbreaks in schools in any country. This supports the argument that asymptomatic children attending schools are unlikely to be significant spreaders of the disease.”
The reopening of schools had, in addition, not resulted in any significant outbreaks at a population level, said Dr Kritzinger. “In the Western Cape more than half of the schools have not reported a single positive case despite very high community transmission in the province at the time of the reopening of schools. In the schools that have reported a case, 72% reported only 1 or 2 cases. As of 16 July 2020, there were only 333 (0.8%) active COVID-19 cases amongst WCED staff, indicating that teachers are not at greater risk than other essential workers. There have been no reported outbreaks in Western Cape schools and weekly new staff cases have been decreasing since the reopening of schools despite ongoing high community transmission rates.” 
Children’s risk for serious disease or death from COVID-19 is extremely low
Dr Kritzinger says studies from China, Italy, UK and USA all report very low numbers of critically ill children and deaths in children under 19 years of age, with children experiencing a much milder disease than adults and deaths extremely rare.,
“By 9 June 2020 only 2.6% of all COVID-19-related admissions in South Africa were for children 0-18 years and only 0.4% of all COVID-19 reported deaths were in children 0-18 years.
“SARS-CoV-2 has caused less childhood deaths compared to influenza since the onset of the pandemic. Research from seven high income countries on 42,846 confirmed paediatric COVID-19 cases showed 44 COVID-19 deaths versus 107 influenza paediatric deaths during the current pandemic.”
She said that South African children remained at greater risk of death due to injury or pneumonia in 2020, with paediatric mortality from unintentional injuries, pneumonia and COVID-19 infection at 0.77, 0.22 and 0.03 respectively, per 100 000 childhood population.11
“Reviewing StatsSA data from 2016, Prof Servaas van der Berg and Dr Nic Spaull estimated the regular mortality risk for ages 0-19 in South Africa as a 1-in-1000 chance, while the projected COVID-19 mortality risk in the same age group is 1-in-76 000 (0.001%).
“Even though there is scant data on the role of co-morbidities in children, the Department of Basic Education (DBE) has already made provision to allow high risk learners to stay at home. In addition, all school staff members with co-morbidities have also been allowed to stay at home without any loss of income. Therefore, those who have been and would be attending school are per definition, not high risk.”
The major harms of school closure
The paediatricians argue that with basic education being a basic human right in the country’s constitution, the majority of learners would have missed half of the school year by the end of August, depriving them of this right.
“Only about 20% of school children have access to online schooling according to the DBE and it is estimated that only 10% of households have internet access. This lack of access to education is disproportionally affecting vulnerable and disadvantaged children.
“The knowledge and skills gap between those with access and those without will only continue to increase and this loss of education will have long-term and far-reaching economic effects. The DBE has not implemented any meaningful strategies since March to mitigate any of these effects and a significant percentage of learners have not received any educational material since March 2020.”
Dr Kritzinger said the emotional and psychological effects on children during and after lockdown is immense. Recent international reviews show that lockdowns, school closures and natural disasters raise levels of substance abuse, depression, domestic violence and child abuse. A recent study in Hubei in China reported that 25% of 8- to 12-year-old children had developed depression during lockdown.
“In South Africa, many learners are already under immense emotional and psychological stress due to poverty, malnutrition, crowded living conditions, child abuse, gender-based violence and other violent crime. The OPTIMUS study in 2016 reported that 42% of 15- to 17-year-old children reported some form of maltreatment.”
In addition, school closures increase childcare obligations, especially of healthcare and other essential workers. It has been estimated that if mortality rates for COVID-19 increased from 2.00% to 2.35% as a result of healthcare worker shortages, school closures would result in more deaths than the lives gained due to slower COVID-19 spread.
“By reopening the economy while keeping schools closed, many parents/caregivers are forced to leave their children at home unattended. Less than one-third of children live in households where both parents are present, and almost 42% live in households where the mother is the only parent present (Statistics South Africa, 2019). It is estimated that more than 2 million children aged 0-15 years will be left at home unattended, increasing their risks for accidental injury, abuse, fear, anxiety and isolation.”
Dr Kritzinger said that as paediatricians, they view the benefits of attending school as outweighing the risks and that public schools should be allowed to reopen.
“It seems illogical to close all schools in all provinces and districts if community transmission rates vary so significantly. Allowing school communities to monitor and manage their risks based on local transmission would enable more schools to continue with their school activities and limit interruptions over the next 12 months.”
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6 Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARSCoV-2 infections. medRxiv preprint server 2020 doi: https://doi.org/10.1101/2020.03.26.20044826
7 Garazzino, S., et al., Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 2020. Euro Surveill, 2020. 25(18).
9 Garazzino, S., et al., Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 2020. Euro Surveill, 2020. 25(18).
10 Dong, Y. et al., Epidemiology of COVID-19 Among Children in China. Paediatrics, 2020. 145(6)
11 Bhopal, S., J. Bagaria, and R. Bhopal, Children’s mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers. Public Health, 2020. 185: p. 19-20
12 Counting the Cost: COVID-19 school closures in South Africa and its impact on children. https://www.scribd.com/document/465818665/Van-Der-Berg-Spaull-2020-Counting-the-Cost-COVID-19 Children-and-Schooling-15-June-2020#from_embed
13 Fegert J, Vitiello B, Plener P, Clemens V. (2020). F acing the challenges and burden of the Coronavirus2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and Adolescent Psychiatry and Mental Health. Retrieved from https://doi.org/10.1186/s13034-020-00329-
14 Xie, X, et al, Mental Health Status Among Children in Home Confinement During the Coronavirus Disease 2019 Outbreak in Hubei Province, China. JAMA Pediatr, 2020.
15 Artz, L; Burton, P; Ward, CL; Leoschut, L; Phyfer, J; Lloyd, S; Kassanjee, R; Le Mottee, C. (2016).Sexual victimisation of children in South Africa. Final Report of the Optimus Foundation Study: South Africa. Switzerland: Optimus Foundation
16 Bayham, J. and E.P. Fenichel, Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study. Lancet Public Health, 2020. 5(5): p. e271-e278
17 Counting the Cost: COVID-19 school closures in South Africa and its impact on children. https://www.scribd.com/document/465818665/Van-Der-Berg-Spaull-2020-Counting-the-Cost-COVID-19 Children-and-Schooling-15-June-2020#from_embed
Press release by Linda Christensen on 0846669972