The final term of the year begins today, with children in Tāmaki Makaurau resuming remote learning. Paediatrician Dr Jin Russell outlines a gold standard plan for safely reopening.
In Auckland, a date for reopening schools is expected to be announced soon. Everyone wants reopening schools to be as safe as possible, both for students and for staff. We need a public-facing gold-standard, evidence-based plan for reopening schools in Auckland. The good news is that the government is not too far from being able to achieve this.
One of the successes of New Zealand’s elimination strategy has been that schools have mostly stayed open. In an elimination state, children do well because they experience little harms from the pandemic. But in a suppression strategy, such as we now appear to have in Auckland, doing our best for children involves protecting them from both the direct harms of Covid-19 – being infected with the virus – and the indirect harms of Covid-19: prolonged school closures, isolation, financial stress, and sick family members and friends.
Firstly, it’s important to summarise how Covid-19 infection affects children. Without good information, many families may be so anxious that they may wish to keep their children home indefinitely leading to absenteeism and educational harm. That’s not a good outcome either.
How children are affected by Covid
The majority of children who are infected with Covid-19 experience a mild or asymptomatic illness, and severe illness is rare. During the New South Wales winter delta outbreak, 2,864 children were infected, and of these 1.5% were hospitalised. Paediatricians in Australia have reassured that the majority of these hospitalisations are minor events, often for rehydration, or a brief stay on the ward for oxygen. Of the 2,684 children, 0.2% needed intensive care, and these were all young people aged 15-18 years old who were, sadly, unvaccinated. Severe illness is rare among children.
While this is reassuring for some parents, we need to take a whole-of-population view – an epidemiological view. Children who have pre-existing conditions are at increased risk of more serious illness, and this can be thought of as similar to the risk posed by other respiratory viruses such as RSV and influenza. We would also expect hospitalisations to be inequitably distributed, such that children in more disadvantaged neighbourhoods do worse. So even with a low overall hospitalisation rate, if we allowed unfettered community transmission, we would expect a surge of paediatric hospitalisations, and this would put pressure on the health system (think of this year’s RSV surge) and would be unacceptably inequitable. We didn’t close ECEs during the RSV surge this year, and we don’t close schools every winter when the typical respiratory viruses go around. But, in general, parents and paediatricians are keen to see lower levels of all of these respiratory viruses in children.
There’s also the unknown of persisting symptoms after Covid-19 infection in children, commonly referred to as Long Covid. This phenomenon appears to be less frequent, and milder, and of shorter duration than in adults. However, while research is ongoing, it’s a good idea to protect children from being exposed to the virus in large numbers.
Prolonged school closures are harmful for children. Schools do far more than provide formal education. They are essential services for children’s wellbeing, learning, development, mental health and friendships.
This is why a gold-standard plan for reopening schools is needed. A gold standard plan is a win-win. Not only will it protect children, teachers, and their households from Covid-19, it will help to keep schools open. Without rock-solid mitigations in place, we risk outbreaks, rolling school closures, with knock-on effects on parents” confidence in sending their children to school.
In Australia, Victoria produced a plan for reopening schools which has been praised by paediatricians and experts. It involves three protections: Vaccination, Ventilation and Filtration, and “Vital CovidSAFE steps” such as hygiene, distancing and masking.
Why vaccination matters so much in schools
Like Victoria, it is mandatory for all New Zealand school staff who work with children and students to be fully vaccinated by January 1 2022. Because infected adults transmit delta more readily than children do within school settings, a highly vaccinated school workforce will make it harder for delta to spread within schools. In one New South Wales study of delta transmission within schools and ECEs, the proportion of infected children who transmitted the virus to a close contact within the school setting was only 1.6%. In the same study, 11.2% of infected adults transmitted to another adult within the educational setting, and 7% of infected adults transmitted to one child or more.
Infected children can transmit Covid-19 to their household bubbles, including more vulnerable adults. Older adolescents tend to transmit more like adults because of the biological continuum.
The answer to preventing this is, of course, vaccination. Reopening schools presents an opportunity to reach those unvaccinated families who have not yet been reached through the vaccine rollout. When schools are reopened, we should couple this with a push to vaccinate all eligible young people and unvaccinated family members on site. This will also protect teachers.
The role of ventilation and filtration
Ventilation and filtration are key components of the Victorian school reopening plan. These protections are so important because the delta variant spreads through airborne transmission. Microscopic virus-laden particles can float through the air over several metres and accumulate in poorly-ventilated spaces. Maximising natural ventilation through opening windows and doors, to bring as much outdoor air in as possible, is crucial.
But where Victoria has really gone above and beyond is in the provision of 51,000 air purifiers with high efficiency particulate air (HEPA) filters. These HEPA filters are capable of removing 99.9% of human-generated SARS-CoV-2 virus particles from the air. They are used more commonly in high risk settings such as medical wards and MIQ facilities and in schools overseas. There is some cost to purchasing these units, but this cost needs to be balanced against the social and economic impact of rolling school outbreaks and school closures. Victoria has made the calculation.
Not all New Zealand schools were built with ventilation in mind, and some classrooms will be harder to ventilate naturally than others. We don’t have a great track record on ventilation in schools. The Victorian plan includes ventilation audits and the use of CO2 monitors. Portable CO2 monitors are an inexpensive tool that can be used to identify which classrooms are harder to ventilate. Audits may inform room occupancy plans, and where to put air purifiers.
A government initiative that provides all schools with air purifiers and CO2 monitors for auditing would likely be very popular with schools and parents. If we leave the provision of such portable air cleaners to schools themselves, what do we expect to happen? Private and well-resourced schools will purchase these protections themselves, while less resourced schools, arguably at higher risk of outbreaks, will be left behind.
Getting more serious about ventilation and clean air is the way forwards now that delta has taken root. Not only does better ventilation and cleaner air protect children from Covid-19, air purifiers are also able to clean out Staphylococcus, Streptococcus, and other viruses from the air. They would also be helpful in the event of severe Australian or New Zealand bushfires.
In New Zealand, we are not far from being able to achieve a gold standard school reopening plan like Victoria. Schools are putting in an incredible effort to plan for this. Their efforts can be maximised by the government taking school reopening plans to the next level.
The government can front-foot clean air initiatives for schools, just as it has been bold on vaccine mandates. This would be a win-win for child health and education. A gold standard school reopening plan, that includes resources for cleaner air, and vaccination on-site, would give the public confidence that the government is committed to doing its very best for children’s health and to keeping schools open as much as possible in the pandemic.
Dr Jin Russell is a developmental paediatrician in Auckland, and a PhD student in life-course epidemiology at the University of Auckland. She is a former member of the NZ Policy and Advocacy Committee and College Council of The Royal Australasian College of Physicians.