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Re-opening schools during the Covid-19 pandemicA poisoned chalice?Many European countries are relaxing the stringency of lockdown. In the UK, some schools are reopening for pupils in reception (kindergarten), year 1 and 6. Are we being sensible or simply ignoring what a young US epidemiologist has called “……the unforgiving math of epidemics for which I and my colleagues have dedicated our lives”1. Ro has decreased to below 1 (meaning that on average each infected person is passing the virus on to less than 1 other person) and if this ratio is maintained, our national epidemic should be petering out. That’s a big ‘if’. Meantime, the economic and societal impact of the virus has wrecked the economy and imposed unbearable hardships. These are not just short-term but will have an enduring impact, especially on the socially and economically deprived. Draconian social distancing is not sustainable even though the trajectory of the pandemic is such that it will be with us for many months, possibly years depending on when effective treatments and vaccines can be developed. So, although advice along the lines of ‘if you don’t want to be killed in a car crash, don’t use your car’ is manifestly true, it doesn’t pass the reality test of daily life.So, what does science have to offer as we try to make our way along the Covid-19 tightrope? The opening of schools is a good a litmus test; it captures the dilemma of balancing trade-offs. Young children (aged less than 15 years) are less susceptible to Covid-19 infection and suffer much milder illness than those who are older. The chances of severe disease requiring intensive care in youngsters is many thousand times less likely than in the elderly. It seems too, based on the latest data from Asian countries, that children are less likely to be a source of transmitting new infections, but this evidence is less secure. What is not disputed is the immense harm to mental health, societal adjustment and educational progress that closure of schools has brought about. If children were the sole consideration then, wearing my hat as a paediatrician, the decision would be a no brainer. After all, children make up around a quarter of our population but are 100% of our future. But of course, it’s not that simple.There are the major issues of transmission between school staff, working mainly in enclosed indoor spaces, exposed to lots of children who are talking, shouting and laughing (hopefully) - the kinds of vocal activities known to spread the virus efficiently. Social distancing is hardly practicable, although some constraints to limit intimate person to person contact within schools can be implemented. But, intermixing of school staff and pupils will risk spread of infection. It is therefore paramount that the status of everyone in the school is ascertained. Testing of pupils and school staff can identify those who are susceptible (S), infected (I) - even if they have no illness - or have evidence of past infection (R). Recall the SIR boxes that provide this essential profile, one that must of course be updated with frequent testing. Unfortunately, the building blocks of this required profiling are not yet in place and scientists are rightly worried. Before schools reopen, they are advising government to ensure that local authorities are guaranteed availability of PPE, testing kits and the trained personnel to trace and track. Making available 200,000 tests per day (Boris Johnson’s pledge by June 1) is frankly irrelevant if schools are not able to implement the scientific advice that is being given to government ministers. After each day, school staff and pupils will return to their homes with the risk of infecting household contacts including many, such as grandparents, who are especially vulnerable. The only tool currently at our disposal, in the absence of effective treatments and vaccines, is testing and contact tracing. If infection occurs, close contacts2 will be asked to quarantine for 2 weeks. (In the next blog, I’ll explore the science behind the current dogmas on transmission). It is not hard to understand the public anxiety associated with this policy. Altruism will be severely tested because self-isolating offers no personal advantages to contacts. This is when behavioural scientists enter the domain of what is known as game theory. If each person chooses what seems best for them, the outcome could be a disastrous return to an increase in Ro and further epidemic waves. Experienced public health professionals point out that, unlike contacts of cases of TB, sexually transmitted diseases or life-threatening meningitis, Covid-19 contacts will not have the compensation of effective treatments. But for a fortnight those quarantined must accept the punitive downsides of not being able to work or carry out what may be essential tasks and will have to put up with yet more inconvenience after weeks of lockdown. A recent national UK survey indicated that around 50% of those requested to quarantine after being identified as contacts decided not to comply. It is a fragile situation. After all, Dominic Cummings (the current senior adviser to the UK government) is, by his own admission, a highly intelligent individual. We know what he decided to do. 1. Jonathan Smith. “I Promise, I Promise. You Can’t Cheat a Pandemic” April 3rd. 2020 <>cognoscenti>2020/04/03>hold-the> (My thanks to Gus Maffry for drawing my attention to this commentary)2. Defined as those in contact with someone found to be infected with Covid-19 for 15 minutes if within 2 metres, or any length of time if closer than 1 metre. Copyright 31.05.20 Richard Moxon ................
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