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COVID-19 Update August 22, 2020: The AAP Update on Re-Opening Schools – with Important Changes

By Dr. Arthur Lavin

Glossary

  • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
  • Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
  • SARS-CoV-2– the specific name of the new coronavirus
  • COVID-19-the name of the illness that the new coronavirus is causing
  • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
  • Epidemic– a sudden burst of an illness that comes and goes over a limited time
  • Pandemic– an epidemic that bursts across the world not just one region
  • Spreadability– how contagious is the disease, how many people will end up infected
  • Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
    • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
    • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
  • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
  • Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
  • Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
  • Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
  • Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
  • Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
  • Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

 

Return to School

On August 19, 2020, the American Academy of Pediatrics (AAP) issued their new Interim Guidance on Re-Opening Schools this fall.  The Interim Guidance process is designed to allow the AAP to issue information on urgent matters in a timely manner, and requires a regular process of review and revision as new information is learned.

And so this revised Interim Guidance is issued as a normal part of the revision and update process, and is the first revision of the original statement from the AAP on re-opening schools that garnered an enormous amount of attention from parents, schools, and public health officials across the US.

Here is the revised statement: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/

Much of the revised statement is similar to the original, particularly in reference to specific safeguards to take once children as physically in the school.  These are the familiar steps involved in wearing masks, keeping distance, limiting contact amongst discrete groups in the school, testing, as well as age and staff specific guidance (e.g., pre-K, elementary, secondary, special education, staff), and specific areas (buses, playgrounds, meals and cafeterias), and many other specific areas of guidance.

The major difference in this revision is the emphasis on a point the AAP has always championed:

That the first priority must be to stop the spread of the SARS-CoV-2 virus.

From this flows the point also made in the revision that some communities will not have yet achieved this goal, and may be experiencing so much flow of the virus that schools cannot be opened safely.

The AAP also included advice that schools must approach the decision to open, the decisions of how to open with a lot of flexibility, and ability to layer various approaches to that no one, simple approach to opening is relied on, given how rapidly the flow of the virus changes in any community.

The AAP maintains its concern that learning in school, in-person is better than learning through on-line substitute teaching processes, and that not attending school can lead to a series of problems.  But the first priority is now clearly stated, that if the virus is too rampant, opening schools is even more dangerous than missing school.

The AAP has not set a level of viral activity above which the transmission risk is too high to open a school, but this week, America’s top infectious disease doctor, Dr. Tony Fauci, did.  He set the level at 10%, stating that if a community’s testing positive rate is 10% or more, then the risk of flares of COVID-19 by opening schools would simply be too high.

This does not mean if a community has a positive test rate of 9% or even 5% that it is safe to open.  Other information, such as the overall trend, the actual practice of testing in the community, and other considerations, must be taken into account to really guess intelligently, whether opening your school is safe.

Current Data in our Neighborhoods

As of this writing, our state of Ohio has seen a mild decrease in numbers of new cases, dropping below 1000 cases a day as of August 16.  https://www.nytimes.com/interactive/2020/us/ohio-coronavirus-cases.html    This is good news because rising to 1000 cases a day risked a rapidly rising caseload.  Doubling cases from 1 a day gets you to 1000 cases a day after 10 rounds of doubling, but the next 10 rounds gets you to a million cases a day!  Ohio hovered at about 1000 cases a day for more than a month, making us wonder, but as of right now, it seems that the danger of a rapid flare are decreasing, for now. Deaths in Ohio hover around 20-40 a day and that number has been steady for a number of weeks.

In Cuyahoga County the number of reported cases hovered around 300 or so a day from March 27 until June 19.  Then a big surge occurred with cases per day soaring from 237 on June 19 up to 919 on July 17.  Since July 17 the number of cases per day has dropped to its current level of around 600 as of August 21.  Significantly, the % of tests taken for COVID-19 are down to 4% this week.

If we consider Dr. Fauci’s threshold of concern at 10% tests positive, and Cuyahoga County is at 4% and dropping, we might be OK with very, very careful, widely spaced, masked, and pod-contained school re-openings.

The key point is that as long as the SARS-CoV-2 virus is circulating, the more time, the more people, gather indoors, the more likely explosive outbreaks will reignite the whole cycle.   For schools that re-open during times of active transmission, like now, the responsibility is urgent that some mechanism, or process, be in place to catch likely outbreaks very, very early, before the numbers really do explode.

Severity

A recent report on the worrisome Multisystem Inflammatory Syndrome in Children, MIS-C, sheds new light on this most feared manifestation of COVID-19 in children.

Some items seem well established:

  • This is a roar of inflammation across the body that usually rises up some weeks after the infection first occurs.  Most cases actually appear in states about a month after the state’s peak activity.
  • The pattern of inflammation seems to occur almost only in children, and as such is the only severe manifestation of COVID-19 that is more common in children than adults.
  • It is rare, happening in about one in 50,000 children.  More that the initial rate of 2-3 per million, but still quite rare.
  • It has some parallels with another poorly understood syndrome, Kawasaki’s syndrome, but is not the same.

The new study from the state of New York adds important information, including:

  • Symptoms
    • Almost every child had a rapid heart rate
    • 80% had stomach aches, vomiting or diarrhea
    • 60% had worrisome rashes
    • 56% had very red whites of their eyes with no mucus or discharge from the eye
  • Lab tests
    • Every child with MIS-C had an elevated marker of inflammation called C-reactive protein
    • 91% had an elevated D-dimer, another marker of inflammation
    • 71% had an elevated troponin, a marker of inflammation of the heart
  • Most of the children with MIS-C need to be admitted intensive care and about 3/4 of them required quite intensive support, but only a small minority actually die from this syndrome.
  • The heart is in danger with MIS-C, with one third of the children with this suffering inflammation of the heart severe enough to impact heart function.
  • As with almost every way to measure suffering from COVID-19, MIS-C is far more common in communities of color than in the white population.  In NYC, 76% (!) of cases occurred in communities of color (about half of this 75% was in black and half in Hispanic communities)
  • MIS-C is NOT Kawasaki’s syndrome
    • Kawasaki’s happens in a narrower age range, <5 years old and MISC median age is 8.5 years old.
    • Both cause harm to the heart
      • Kawasaki’s main harm is to cause weakening of the coronary arteries that lets them bulge, creating aneurysms.  This happens in MIS-C, but only in about 8-9% of cases
      • MIS-C mainly causes the heart muscle to weaken causing shock, this happens in about 50% of cases of MIS-C. Shock is seen only in 5% of Kawasaki’s cases
    • Many mysteries remain
      • Why do the children who get MIS-C get it, and others do not?
      • Are there long-term harms after recovering from MIS-C?
      • Are there more subtle MIS-C like harms that mild or asymptomatic infection with COVID-19 cause that we have no idea are happening?

Diagnosis

It remains the case that no reliable test for past infection with COVID-19 is available, the blood, or antibody test.

BOTTOM LINES

  1. The AAP has made clear a top priority it has held all along:  children, family, staff, and teachers all deserve to live in a nation that can stop, or substantially reduce, the spread of COVID-19.   With low or no spread, almost all activities are possible, with high spread, almost no activities are possible.
  2. Fauci has set the level of a community’s percent of positive SARS-CoV-2 virus tests at 10%.  At that level and above, opening schools is too risky, a recipe for big flares of the epidemic.
  3. Ohio and Cuyahoga, right now, are thankfully seeing declining presence of the virus.  Positive test rates are at 4% now.
  4. But that does NOT mean the virus is gone.  It is very thankfully not spreading as much, but I consider our neighborhoods very much like a dry forest with a campfire that is smoldering.  SO much better than a wildfire, but not too many steps away from one.
  5. Most public schools in Cuyahoga County have decided to not open for some weeks after their usual opening, to see which way the trends go.  Many private schools have decided to open with steps taken to hopefully prevent virus spread.
  6. So now the stage is set.  We are so fortunate to be seeing some waning in spread.  At the same time a fairly good number of students will be congregating in schools starting next week.  And colleges are opening now too.  We will see, will the remaining cases lead to sparks of new outbreaks in schools and colleges?  It is still very, very possible, let us hope not.
  7. MIS-C is easily the most disturbing phenomenon of COVID-19.   The ONLY good news on MIS-C as of today is that it is mercifully quite rare, and treatments for it do save so many lives.
  8. But, MIS-C is frightening for the combination of severity and lack of warning.  It does not tend to happen during the active, contagious period of COVID-19, only following recovery by some weeks, even if during the infection, the child has NO symptoms.
  9. One reassurance, even though all children with MIS-C have rapid heart rate, IT IS NOT TRUE THAT all children with rapid heart rate have MIS-C, almost none of them do in fact.   Children with MIS-C get very ill, so if your child does not look very ill, chances are overwhelming THEY DO NOT HAVE MIS-C.

As we approach opening schools and colleges, we hope all of us, and all our families remain well.  We hope the outbreaks that will follow will be swiftly contained, and that we all find a path to live in ways the keep this virus from spreading.

To your health,
Dr. Arthur Lavin

 

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