Among the many, many unknowns about the new coronavirus: What role do children play in transmission of the virus that causes Covid-19 disease?

It’s a question that public health experts would love an answer to. Knowing whether kids are innocent bystanders, getting infected if someone brings the virus into their households, or are in fact a population that is stealthily driving this epidemic, would give response planners critical ammunition to use in the battle against the virus.

What’s at stake are decisions about policies that can be hugely disruptive to families and workplaces. Should schools be closed to slow spread when the virus enters new terrain, forcing parents to scramble for child care alternatives or stay home? Should long-term care facilities discourage families from bringing young children to visit grandparents or other aging relatives?

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Though the evidence to date suggests this virus doesn’t inflict severe disease on children, there’s reason to think kids may be helping to amplify transmission. It’s a role they play to devastating effect during flu season, becoming ill and passing flu viruses on to their parents, grandparents, teachers, and caregivers.

While the new virus is from a different viral family, its behavior is more like influenza than its coronavirus cousins, SARS and MERS, making experts wonder if it is doing the same.

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“Flu is clearly driven in part by schools. And we don’t understand what goes on with coronaviruses and kids — especially this coronavirus,” said Marc Lipsitch, an infectious diseases epidemiologist at Harvard’s T.H. Chan School of Public Health.

School closures could become a reality if the U.S. sees sustained transmission of the virus, said Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases. She urged parents this week to do some homework on whether their children’s schools are considering closing if and when the virus starts circulating in their communities, and how those dismissals would be handled.

“All of these questions can help you be better prepared for what might happen,” said Messonnier, adding that she had contacted the superintendent of the local school district where her children go to school to ask about closures.

When news broke in early January that a new virus was spreading rapidly in — and later from — China, parents flooded social media platforms looking for guidance about how serious the threat was to children.

Initial predictions, which have been backed up by data from China, were reassuring. These viruses can be brutal on older adults — particularly the elderly. But for some as yet unexplained reason, children appear to be spared the worst of the disease.

“Coronaviruses in general have a striking age-related disease [pattern],” said Ralph Baric, a leading coronavirus expert at the University of North Carolina. “So the older you are, the more likely you’re going to get severe disease.”

The largest study of cases from China to date illustrates that point graphically. Published by the China CDC earlier this month, it describes more than 44,000 confirmed cases. There were few detected infections among children aged 9 and younger — only 416 or about 1% of the total cases. None of them died.

Even cases among children and teens aged 9 to 19 were rare; there were 549 cases in that group, representing 1.2% of the entire study group. There was a single death in that age group. By contrast, 20% of the roughly 1,400 people 80 and older who contracted the disease died.

It’s not clear whether the low detection rates among young children means those infections are indeed rare, or if they are mild enough that they tend to escape detection. Baric noted several case studies from China that showed a low number of children who, although they tested positive, didn’t have obvious disease. However, CT scans revealed changes in their lungs that are characteristic to this infection.

“It’s not that they’re not getting infection. They’re not getting disease. They’re not getting sick,” said Malik Peiris, a coronavirus expert at Hong Kong University.

Peiris and Baric both think children are probably playing a role in spreading the virus.

“If they are infected, there is no reason to believe that they will not transmit,” said Peiris.

“There’s no evidence for any of this, but given the available data, that is quite a plausible scenario that one needs to think about.”

School closures are one of the tools public health officials often reach for — or at least contemplate — when infectious diseases spread. More than 1,300 schools in 240 communities in the United States closed schools for a time in the early days of the 2009 influenza pandemic, caused by the H1N1 virus.

The CDC had initially recommended that schools close for seven days — it later expanded it to 14 days — if infections started cropping up among their students. Within a few weeks though, when it started to become apparent the virus caused mainly mild disease, the CDC dropped the school closure recommendation. Despite that, as the pandemic progressed, school closures continued to occur — to proactively stem the spread of disease, or because so many staff or students were sick that it didn’t make sense to keep the school open.

The evidence is mixed on how well school closures work to change the course of an outbreak, like delaying the onset or decreasing its peak. Either outcome would make it easier for the health system to handle.

“To some degree, the jury is out on this strategy overall,” said Jeff Duchin, a public health official in Seattle and King County and an infectious diseases professor at the University of Washington.

It also isn’t clear on how long school closures should last. By and large, most school closures are relatively short, stretching only a few days.

There are questions, too, about how practical it is to stop kids from gathering simply by shutting down schools. Some studies and polls have suggested that children often gather in other locations — like libraries and shopping malls — when schools are closed, potentially cutting into any impact a closure might have.

“How long can you keep schools closed and not expect children to gather elsewhere?” Duchin said.

In one poll of 523 parents whose children’s schools were closed during 2009 H1N1 outbreak, 90% said they agreed with the decision, many saying they believed closures were an effective way to reduce transmission of the flu.

But the closures can also take a significant toll, particularly among low-income families. In the same poll, nearly 20% said their child missed free or reduced-cost school meals. Another 20% said they had to miss work.

Only a small fraction of parents said the closures were a major problem, but the disruption remains a consideration for health and education officials as they weigh closures in future outbreaks.

“We would really worry about low-income families who have less financial resilience,” said Gillian SteelFisher, a health policy researcher at Harvard who conducted the poll and who studies the public response to health crises.

If the U.S. saw sustained transmission of the coronavirus, experts said it would be critical for schools to communicate clearly about the reason for the closures — and the need for kids to stay at home and not congregate in other places.

  • We live in the UK and our 9 y/o son is off with a continuous cough. The UK government will no longer test if you don’t need hospitalisation, he is meant to isolate with us for 7 days. After seven days we get to ring a government phone number to discuss the illness. My daughter is still at school as they don’t allow siblings to stay off (this is the next stage of the delay phase). I’m a chronic pain patient 46 y/o on immunosuppressant drugs who is bed ridden most of the time and when my father returns from hospital (he currently has MRSA) he will be in the same household. He is 83 y/o with Parkinson’s and shadows on his lungs. I am very angry we are in this situation, we couldn’t take our children out of school as they would fall behind, we would be fined and social services would be involved for neglect. The government is literally leaving people to die, instead of providing a skeleton childcare service, and taking primary children out of school for 2 months to get past the peak of the illness. Meanwhile sports stars, ministers and other public figures are getting ill and we are exporting cases to other countries. The don’t test, don’t tell is more than just a US phenomenon I’m afraid.

    • If you are in the UK, the situation you describe is impossible. The UK has Single Payer Nationalized Healthcare, which is the one true solution to the problems of Capitalist Kulak Medicine.
      Really, we shouldn’t be too smug here in the USA. The younger set wants to trade our system for yours.

  • It’s impossible to know. In my town, all the schools are off for 3 weeks, and we haven’t had a confirmed case of covid-19 within the county yet, let alone in a school.

    However, you may still have assignments or online coursework to complete in the event that schools do close.

  • Also most kids don’t smoke. Standardise mortality and those classified as serious by smoking status and it’s pretty compelling.

  • Dr, Schmerling,

    You raise an excellent point. Why don’t we look at just the annual common flu which is certainly already endemic as an pandemic every year. It’s a fact isn’t it s fact that kids in the day care environment often and frequently come down with flu. My daughter used to work at day care part-time when she was in high school and she often lamented the fact that here were so many sick kids during the flu season and she simply could not understand the rationale, thinking, and lack of common sense of parents who simply, mindlessly and conveniently just send their kind to day café so that the parents can show up for work. Is it a fact or is it published in any scholarly medical journals that these day care workers and teachers suffer from annual flu more often than other teachers (e.g. middle school or high school)? I don’t think so.

  • Hi, thanks for the great article – 2 quick questions about the issue of kids’ role in spreading novel coronavirus: since symptomatic people are more likely to spread infection (if we agree that’s true) and kids tend to be less symptomatic even when infected, wouldn’t it make sense their role is not big in spreading infection? Also: if kids played a major role in spreading infection, wouldn’t we expect teachers and daycare workers to be hard hit (which seems not to be the case)? Do you think these 2 points argue that kids are probably not major players in spreading the novel coronavirus? Presumably, it can happen but perhaps the exception and not the rule? Please correct any assumptions here you believe are incorrect!

  • It seems that teachers are forgotten in this debate I am in a small room with 1st graders that are coughing and sneezing Healthcare workers are provided with googles gloves masks and other protections when dealing with patients that are coughing and sneezing. We have no protection and are in rooms with students for hours a day. I can’t tell you how many parents load their kids up with Tylenol and send their kids to school to hide fevers and other illnesses so that they won’t miss work. I am older and I feel like they have no regard for our safety and the safety of our families I’m afraid to see my elderly mother in case an asymptotic student passes this virus to me why doesn’t anyone think about our welfare?

    • I’m seeing that as a parent of a Kindergartener. I can’t stand when I see kids dropped to school while sick. It’s selfish. Not only does it put everyone else at risk but the sick child is miserable. Luckily my son’s teacher take great precautions with sanitation at school.
      Good luck 🤞

  • Couple points regarding children. First, if any child, parent, or staff member is exposed, the school will likely be closed for a time. Second, many of the staff members are older. A school might be a dangerous place for them. Third, we don’t know if children are spreaders. It’s an unacceptable risk to keep the schools open.

    • Hearing case reports of symptomatic children in Seattle. Attempts by parents to have them tested being rebuffed. Don’t test, don’t tell?

      Sarah Tuttle
      @niais
      · 4h
      So to summarize – my 6yo has symptoms consistent with COVID-19 (in children, per the literature) and talking to both the @WADeptHealth & @UWMedicine teledoctor: I should practice social distancing from my 6yo, & she can’t be tested for COVID-19 b/c no known contact w/ COVID-19

    • Adam,

      Kids won’t get too sick. Their robust immune system supposedly would take care of the virus in most cases. In fact I am not aware of any kids deaths in Wuhan, Japan, South Korea, or Italy. Supply for diagnostic kits are limited in numbers. Most should be reserved and saved for elderly with much higher chance of dying due to underlying medical conditions. So no need in most cases for kits for kids (pun intended)

  • I would like to ask about 4 in 1 pre-school vaccination or any other vaccinations. My little one is due to have one very soon. I am a bit worried that she will be weak afterwards,which could be I believe dangerous these days with the coronavirus around . Makes me think aswell..What if a child is carrying the coronavirus with no symptoms and gets vaccinated ?

    • One option is to call your doctor’s office and ask if you can delay the vaccines. My children both have birthdays, and therefore are due for their vaccines, during peak flu season. Since I don’t want to bring healthy children to a doctor’s waiting room during flu season, more than one pediatrician has told me it is ok for me to delay the vaccines a few months and get them in the summer.

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