Everyone understands the urgency to open schools—recounting its benefits is superfluous—but we do worry about the risks involved. The middle path needs to be found—to maximise advantage and minimise risks. The stakeholders are children, parents, school authorities, and state education and health departments. All of them deserve information and guidance to objectively assess risks and adopt mitigation strategies.
Countries with high levels of two-dose vaccination cover (called full vaccination, for convenience) have started reopening educational institutions cautiously. The UK, the first country to roll out vaccines, has had no major problems with school reopening. The US, with uneven proportions of fully vaccinated adults in different states, recorded surges of infections on school reopening in Texas and Florida, states with a low vaccination cover.
In India, states have different levels of vaccination coverage. Sero-prevalence studies show wide variations of infection-induced immunity as well. Therefore, individual states should make their own district-wise decisions regarding school reopening depending on the ground realities. However, some broad principles can be enunciated. States with very high sero-prevalence and/or vaccination cover, say 60% or more districts with high population immunity, and those with an excellent track record of epidemic management, such as Kerala, Tamil Nadu and Maharashtra can boldly begin planning to reopen schools. Since the national average of full vaccination coverage is still less than 10% as of now (Kerala leads with 20%), it cannot be a deciding factor. The roadmap we describe can be adopted in any state/district, irrespective of immunity parameters, by following the design in letter and spirit.
All schools should not be opened in one go; that is common sense. Selected schools in districts with high immunity prevalence should be opened for testing the waters by monitoring the impact on the spread of the virus for two weeks, covering two incubation periods. Which ones should reopen first: high, middle or primary schools?
Children below 18 are currently ineligible for vaccination. The lowest risk of disease is in primary school ages of 5 to 10 years. Obviously, primary schools are the best to pilot test school reopening. What are the preconditions? Every state may choose to pilot test reopening a limited sample of schools in selected rural and urban areas, with close monitoring. The parameters of monitoring must be agreed upon first.
The plan and timelines should be made and discussed with all stakeholders brooking no delay—education and health authorities should work in concert for successful implementation. Any objections ought to be addressed and resolved with appropriate remedial measures. This preliminary process, to select the schools for pilot testing, need not take more than two weeks in any state.
All school staff—teachers, office staff, attenders and transport personnel involved in children’s travel—and all parents and household members 18 and above ought to be fully vaccinated. Such a protective mantle for children will minimise the risk of infection and further transmission to families to almost zero. For children using public/private transportation, locality-specific safety plans must be made.
Children must be taught about the routes of virus transmission along with the rationale behind and discipline of social vaccine—wearing masks (except for eating and drinking), physical distancing, cough and sneeze etiquette, and hand hygiene. Food consumption should be done outside the classroom, preferably in an open area or well-ventilated hall.
Thermal screening and symptom screening at school entry by dedicated staff is a must. Children with fever and/or respiratory symptoms should wait in a sick bay until taken home. The local healthcare facility should monitor such children and their families with standard protocols for coronavirus infection screening (RT-PCR or rapid antigen test) and home isolation. These steps should be accurately documented and periodically analysed.
Should asymptomatic children be screened for current coronavirus infection or past infection (by antibody test)? In pilot phase schools, it is an excellent idea to do either or both, but even where circumstances do not permit these, pilot reopening without screening may be permitted.
After two weeks of experience with such intense action protocol, if there is no worrisome evidence of viral spread, more primary schools could be opened following the same protocol, until all primary schools in all districts of the state are reopened over the span of four to six weeks.
Then, and only then, can reopening be expanded to middle schools with children of age 11 to 15 years with a similar protocol under the guidance of local healthcare personnel with strict maintenance of records. As school staff become confident, high schools covering 16- and 17-year-olds can be opened either simultaneously or with a gap of two more weeks after opening middle schools. Randomly selected middle and high schools, say 10%, can be monitored for at least four weeks before all stakeholders can relax and declare these plans safe and successful.
England’s Public Health Department measured the impact of reopening schools by way of new infections. They tested antibody prevalence in children in 141 opened primary and middle schools during May and June—one month apart. The proportion of primary school children with antibodies remained stable at about 0.27%. This instilled confidence that their decision to open primary/middle schools was reasonable and correct.
Children aged 10 and above have slightly higher risk of infection than primary school children. Therefore, in any state, a statistically selected random sample of children in middle and high schools ought to be monitored by antibody testing both before and one month after school reopening. If this or a similar sequential plan of action and roadmap is followed, we will know, with objective data and evidence, how safe school reopening is for both children and their adult household contacts.
Safe reopening of schools is feasible now. The virus has taught us that its behaviour cannot be predicted or taken lightly. In matters concerning children, safety should always come first.
Dr T Jacob John
Former professor of clinical virology, CMC, Vellore, and past president, Indian Academy of Pediatrics
Dr M S Seshadri
Professor of clinical endocrinology and medicine, CMC, Vellore, earlier, and currently, Medical Director, Thirumalai Mission Hospital, Ranipet
(tjacobjohn@yahoo.co.in, mandalam.seshadri@gmail.com)