Debates Around the Role of School Closures in the Coronavirus 2019 Pandemic—Reply

In Reply In the first weeks of the new coronavirus disease 2019 (COVID-19) pandemic, it was presumed that children could be, as previously shown for influenza, among the major causes of disease diffusion. This explains why to contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), schools were closed in in most countries. However, we highlighted that this decision could be debated.¹ Most of the studies used to support school closure, including those cited by Lin and Chen, could be criticized because they poorly considered the age-dependent effect in the transmission of SARS-CoV-2. Moreover, the effect of school closure was not adequately evaluated. Only supposed medical advantages were analyzed without considering that potential benefits could have been canceled by the onset of social, economic, and health inequities that follow school closure.

With the long-term persistence of the COVID-19 pandemic, more data on the role of children in COVID-19 diffusion have been collected. Most of them seem to reinforce the idea that children have a low effect on COVID-19 circulation and that school should remain open, although with the maintenance of all the hygiene and physical distance measures for respiratory infection prevention and a continuous monitoring of COVID-19 epidemiology. Analysis of age-dependent effects in the transmission of COVID-19 epidemics has shown that children have a susceptibility to infection that is about half of that of adults and they develop symptoms in about 20% of cases compared with 80% of adults.^2,3 Moreover, epidemiologic studies have shown that risk of diffusion of infection from child to child is low and even the transmission from a child to an adult is uncommon.⁴ Finally, it has been reported that in asymptomatic children, viral load is lower than in the symptomatic ones.⁵ Considering these findings, it could be concluded that if susceptibility is low, many children are asymptomatic with low viral load, and they do not have a relevant role in maintaining the COVID-19 pandemic. Although this does not mean that children cannot transmit, it seems to indicate that the risk to assure all the advantages of school attendance is acceptable. On the other hand, as reported by Cheng and Liu in their comment, school reopening in countries such as Denmark and Norway was not followed by a rebound effect. In both countries, few new cases of COVID-19 compared with the period of lockdown were reported.

The comment by Verd and López-García regarding the risk that antipyretics can favor respiratory virus shedding, contributing to the diffusion of SARS-CoV-2, deserves a separate answer. Although this note does not concern school attendance during the pandemic because febrile children are symptomatic and should not attend school, it seems important. It highlights that the use of drugs, especially in children, must follow experts’ suggestions because they can have subtle and potentially important negative effects at the population level.⁶ The abuse of antipyretics is common, especially in pediatrics, and the possible increase in viral shedding can make a mild form more serious with obvious negative consequences.

Corresponding Author: Susanna Esposito, MD, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy (susanna.esposito@unimi.it).

Published Online: August 31, 2020. doi:10.1001/jamapediatrics.2020.3552

Conflict of Interest Disclosures: None reported.