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The notion is out there that public school students should not return to in-person learning until they’ve been vaccinated. That proposition worries me. Here are five reasons why schools can and should open at 100% capacity before a vaccine for those under age 16 is available.

For kids, the risk of missing school dwarfs the risk of Covid-19. Kids are less likely to acquire SARS-CoV-2, the virus that causes Covid-19, than adults. Several meta-analyses confirm that in contract tracing studies, kids are approximately half as likely to acquire the virus as other household contacts with the same exposure.

In addition, the risk of death or other bad outcomes is low for children. Between March and October of 2020, among those between the ages of five and 14, the risk of dying of Covid-19 in the United States was 1 in 1,000,000. To put that in perspective, in that same age group during non-Covid times, the risk of suicide is 10 times higher. For young adults ages 15 to 24, the risk of dying from Covid19 was 9.9 in 1,000,000, and they are also generally 10 times more likely to commit suicide.

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A study in Sweden, where 1.95 million kids younger than age 16 attended schools without masks between March 2020 and June 2020, 15 (or 1 in 130,000) developed severe Covid-19 and none died.

Contrast these outcomes with those of adults. For the sake of comparison, imagine 100,000 infected people at different ages, using data from a meta-analysis conducted by an international team: two of those age 10 might die compared to 1,400 adults aged 65 and 15,000 adults aged 85. In other words, the risk of an 85-year-old dying from Covid-19 is 7,500 times greater than that of a 10-year-old.

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Meanwhile, school closure is associated with considerable harms to children. Mental health problems are on the rise. Abuse has gone undetected, and children with disabilities are no longer benefitting from educational and other programs. With proper use of precautions, such as masks, the chance of spread is very low even without vaccines, as shown in a recent analysis by three Centers for Disease Control and Prevention researchers.

When I put it all together, it is clear to me: Adult interests have been prioritized over children’s well-being by closing schools. For kids to return to school, I support teachers being vaccinated (though this is not essential), the use of indoor masks, capping classroom size at 20, quarantining students if symptomatic cases occur, and distancing between classes. These were the precautions used in the CDC analysis.

Vaccine data will take a while. Current emergency use authorization for the Pfizer vaccine permits adults as young as 16 to receive the vaccine, and ongoing trials are recruiting kids as young as 12, which may yield results later this year. If these are successful, future trials will extend to 9-year-olds. Trials including even younger individuals may not yield results until 2022.

Kids can’t wait for the results of these trials before returning to their lives.

Do kids in school drive Covid-19 spread? In the CDC analysis, when precautions were used, 0 of 654 staff members acquired Covid-19 in school. One well-done study from Germany took advantage of the staggered summer break to explore the impact of school closure and reopening on Covid-19 cases, and found no association between closing or opening schools and overall cases. These data further erode the claim that kids need to be vaccinated to slow the spread of the virus.

An emergency use authorization may not be appropriate. The entire premise of an emergency use authorization is that, when faced with an emergent biological, chemical, radiological, or nuclear threat, the Food and Drug Admininstration can allow products to be used based on lower levels of evidence than traditional approvals. A key provision is that “there are no adequate, approved, and available alternatives.”

There’s no question that Covid-19 is an emergency for adults, a catastrophic disease that becomes more deadly with advancing age. But it isn’t that for children. For them it is a respiratory pathogen with a rate of harm that is comparable to other, annual respiratory pathogens like influenza.

I hold that an emergency use authorization is not appropriate for a SARS-CoV-2 vaccine for children, which should instead proceed via traditional FDA approval pathways.

Vaccinating kids to slow the spread of the pandemic cannot be justified if adults are choosing not to be vaccinated. The risk-benefit calculus suggests that adults will derive more benefit from the vaccine than children, because the virus is more lethal in adults. If parents are reluctant to send their kids to school before children are vaccinated, they should be educated in a way that puts those risks in perspective.

Although a formal approval process will further slow any pediatric vaccine, I believe this is justified to ensure a favorable risk-benefit profile. In the meantime, schools can reopen.

The vaccines’ harm-benefit profile may be suboptimal in kids. The last consideration I offer is that we do not know if a vaccine will have a favorable risk-benefit profile, gain FDA approval, and be palatable to parents. Consider what might happen to a million kids who receive a vaccine that works as well in kids as it does in adults with comparable side effects.

Assume the same 95% relative risk reduction seen in studies of the Pfizer/BioNTech and Moderna vaccines in adults. The vaccine might save one life for every 1 million kids who get it.

At the same time, assume the vaccine has side effects comparable to adults for the second Moderna dose in adults. In that scenario, 45,000 kids will develop severe headaches requiring analgesics and interfering with daily living, 14,000 will have a fever higher than 104 degrees F for less than a day, and 880 will have this fever last for more than a day. This happens not because these side effects are common — they are rare — but because you have to vaccinate 1 million kids to save one life.

My point is that the vaccine side effects, which are absolutely justified in adults — full disclosure, I have been vaccinated — may be a tough sell to children and parents simply because the absolute benefit to kids is very small given the low absolute risk of developing severe Covid-19 or dying from it.

Closing thoughts

The Covid-19 pandemic has harmed children — not because they have fallen ill from the virus, for the most part, but by the choices societies have made to protect adults who are vastly more likely to suffer from the disease. In many places, kids have already lost a year of school, development, and life. A vaccine for kids will not happen in the short term, and emergency regulatory pathways for one or more of them may not be appropriate. The risk and benefit will need scrutiny.

We must not keep the lives of children on hold waiting for what might never come. As Vladimir Kogan and I argue elsewhere, schools should open now after the impacts to teachers, parents, society, and schools are taken into consideration.

Vinay Prasad is a hematologist-oncologist, associate professor of medicine at the University of California, San Francisco, and author of “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer” (Johns Hopkins University Press, April 2020).

  • Dr Prasad’s analysis that in-school student transmission is amazingly low when studied. In the last 12 months the CDC reports only 58 covid deaths in the entire US 5-14 year old population. This clearly shows that the disease is less dangerous than influenza in this population, would you keep your child out of school also for the flu.
    People should review a Wisconsin public school study from September to October published in MMWR that students were at greater risk of getting covid from at home spread than in-school spread. Also student to teacher spread was so small that there was debate whether it occurs at all or teacher cases came from community/home spread.
    The science is there to show that in school learning is safe by current public health standards.

  • Not only it is bad for the mental health of the children but the whole family especially a single parent trying the keep a job, further the challenge for all Americans to compete in a world economy where according to a recent PISA test of all high schools worldwide the US results are dismal , look it up on the internet

  • Looking at death rates in my urban California county, as reported, it is really pretty safe for everyone under 40 to get sick – I am sure it is unpleasant, but the chance of death is around 1 in 1,000 for those close to 40 – but we are told if you have not known risk factors it is more like 1 in 5,000 – so, keeping the over 40s on Zoom, but gertting the kids in school is not much risk -= as the author says, the suicide rate for these kids is far, far higher than the Covid death rate.

    In my view, (I am too old for it but have two school age kids) it is just as important to socialize for these kids – maybe out of doors – if you live in California the weather allows this most of the year.

    Keep the kids who live with sick or frail old folks at home until the old folks get vaccinated – NONE of this is brain surgery.

    But, one possible wrench in the works, could be the variants. As long as they are not dramatically worse than the first wave and have about the same response to vaccine or natural immunity – let’s go for it. IF the new variants totatly escape vaccine or naturaly immunity – put the brakes on maybe. But at this point, we have to grab schooling as we can- we may need to start schools with our fingers crossed – then call it off again – but that may help us all hang on.

  • I agree with your article. And I have a better idea: children should also move into their schools (eat, sleep, study, live there 24/7).

  • Québec City, Québec, Canada; up to last week, my mother’s care home had been totally virus-free. Then two residents were infected by an employee. He was infected by his child who caught it at school.

  • My daughter is 10. Does it make me feel better that she and another child might die out of 100,000 infected? No, it doesn’t! Statistics are small until they hit your family.

    Also–masks are required for safety in schools. What about lunchtime? The above piece leaves out this incredibly important piece of information.

    • Please note that nothing is zero risk. Merely that the risk of contracting and dying from covid for kids is extremely low. If you are that risk adverse your kid would never leave the safety of his bed-he might fall and get a concussion, brain bleed and DIE! Frankly a life so “protected” there is ZERO RISK wouldn’t be a “life” many would choose.

    • For age 10, the risk the article cited is 1 in a million, not 100,000. Unfortunately, there are many, many other horrific things that our children have a 1 in a million chance of experiencing. What is the cost to our kids of taking extreme action (like keeping them out of school) for something that has a minuscule chance of actually happening?

  • Thank you — this is an interesting and persuasive analysis. What do you think about the points made by other commenters concerning the new more contagious variants. The timing of the studies may matter a lot (during or between the two grand waves).

    I have a question about a report from the UK about substantially higher infection rates among teachers. Coverage of the report is here https://docs.google.com/document/d/17iJw1cCs8OKh46qAo8Bv52tvUKmNHKINl5FIOezyUuw/edit Is this a reliable report?

  • Why is this an “opinion” when it uses so much evidence? Much more evidence than we seen used in justifications for closing businesses and schools to begin with. The new variants are yet to be studied in kids and at this point there is not evidence to believe they will be any more affected.

    • The preliminary evidence, which is still mostly anecdotal, doesn’t look good. Infection rates of the British variant in children appear to be at least as high as in adults, if not higher. However, the risk of serious illness remains very low in children, even if not quite as low as with the original virus. The unanswered question is whether infected children will infect adults at the same rate as infected adults infect other adults. This was not the case for the original virus, but may be different for the British variant.

      One small anecdotal data point: in Israel, in November, before the arrival of the British variant, 377 babies under 2 years old tested positive (PCR), while in January, after the British variant accounted for 70-90% of infections, 5,780 babies under 2 tested positive. Of course this could be a coincidence, but I would hope that those making public policy wouldn’t rely on this possibility.

  • “For kids to return to school, I support teachers being vaccinated (though this is not essential), the use of indoor masks, capping classroom size at 20, quarantining students if symptomatic cases occur, and distancing between classes.”

    There is not a (public) school in my area that can have 100% (or even 90%) of kids in-person while also capping classroom sizes at 20 kids and distancing between classes. The schools currently average 65% on campus and some of them can’t accomplish this at the current attendance level.

  • This analysis is reasonable. However, it fails to take into account three factors that might undermine its conclusions:

    1. The British variant is substantially more contagious than the “original” virus, which will result in higher rates of infection in children than seen in the studies to date, and correspondingly higher rates of infection of adults by children. Unfortunately, the British variant will almost certainly be the main variant in circulation in the US and Europe within weeks or at most months.

    2. It’s too early to say, but preliminary observations may indicate that the British variant and South African/Brazilian variants are more dangerous for children than the “original” virus.

    3. It is impossible to assess the long-term consequences of even mild infection throughout children’s lives. For example, some preliminary research shows that the virus may reduce male fertility (obviously in young adults, not seniors). While we all hope that this virus will turn out to be no more dangerous for children than the common cold, we will not know this for many years.

    • Ding ding ding….Right on the money and not addressed in the above commentary. More and more schools ARE opening and we are going to learn whether this was a smart move or pure folly during the next 2-3 months…..

    • You must be a member of the teachers union – they have converted 12 months pay for 9 months work into 12 months pay for NO WORK. Perhaps they could take a lesson from the Catholic school system which has fully opened (where not restricted by woke politicians) and have encountered no problems (see yesterdays WSJ for the full data)

    • So yet AGAIN we must wait until there is NO RISK EVER before resuming LIVING? seriously? There actually is not hard evidence or even good evidence that the “variants” are more deadly or contagious other than super scary headlines. Remember last year at this time when it was thought the original variant was FAR deadlier than it is turning out to be? Remember too that there may be “discovery bias” in the new “variants”-just because it is “found” now doesn’t mean it isn’t everywhere already. Sewage study in several European countries show SARS-CoV2 around MONTHS before the “outbreak” in China. So maybe the variant we encountered last spring is already a mutation. Which means also-far more people may have immunity already (antibodies don’t tell jack after 1-3 months-your immune system is far more complex than a stupid simple antibody)

    • Monyka – I do not disagree with you, BUT the huge outbreak in Manaus is very scary, and the outbreak in a place comparable to the US, with same variants, – the UK – are both very alarming in my view. I think they should make tentative plans but be ready to change them. (reopening plans)

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