Masks, no assembly and no choir: the science behind reopening schools safely

Whatever you do, don't do what we did: that is the message for the world from Israel on reopening schools.

It started well. At the end of May, a newly formed government emboldened by low, and falling, coronavirus numbers jumped in headfirst, welcoming back the entire student body.

Within days, infections were reported at a high school in Jerusalem. The outbreak spread. Hundreds of teachers, students and family members were infected, and thousands more quarantined in outbreaks across the country. Hundreds of schools were forced to shut, and a nursery school teacher died. The move has been in part blamed for the country's now rampant second wave of the virus.

So what can the rest of the world learn?

"They definitely should not do what we have done," Professor Eli Waxman, chair of the team advising Israel's national security council on its response to the virus, told the New York Times this week. "It was a major failure."

In fact, it was a whole sequence of failures, scientists said, from closing all the windows at school during a heatwave and putting on the air conditioning - giving the virus a chance to thrive - to failing to trace contacts, even down to which bus students came to school on.

But while Israel has become a cautionary tale, it is far from the whole story. In fact, a growing body of evidence suggests it is something of an outlier.

A number of other countries have also begun reopening their schools, and none - so far - have experienced a significant rise in cases as a result, according to a research paper put together by the Royal Society's Delve initiative, a group of scientists compiling data on Covid-19. 

Even in England, so far, there has not been a spike associated with the partial re-openings which began on June 1, which saw pupils in nurseries, reception, year one, year six, and then later, years 10 and 12 in small groups, return slowly to the classroom.

The UK government is running a study to test teachers and students across up to 100 schools to provide a more accurate picture, with the results available later this summer, just before all schools go back at the start of September.

Source: Royal Society's DELVE report, Balancing the risks of pupils returning to schools 

These early figures are significant, because they address one of the key concerns over schools - that children, who do not seem to be badly affected by the virus themselves, could be major transmitters to their wider community.

As parents and teachers know, that is how flu and colds have always behaved, and without evidence to the contrary at the beginning of the pandemic, that's how it was assumed the novel coronavirus would also spread.

But actually, this does not seem to be the case.

As well as being less likely to suffer seriously with the virus, children are also marginally less likely to be infected, and - emerging evidence suggests - significantly less likely to spread it. 

In schools specifically, the largest study so far from Australia found that 18 people with the virus (nine children and nine teachers) only infected two more people. The results from the research, a large-scale contact tracing study across 15 schools in New South Wales in March, seems to have been echoed in other early work, although the data is scarce as many schools are only just reopening.

Professor Devi Sridhar, who assessed the evidence for Delve, said it appeared likely that schools only have a limited role to play in transmission, particularly in countries where case numbers were already falling.

"The takeaway message is that if you have low prevalence, then schools don't seem to impact onwards transmission," she told the Telegraph.

As such, she said the key element in re-opening schools was actually nothing to do with schools at all.

"The safest way to open schools is to have no community transmission or extremely low," she said. "Schools operate within communities, and that's my headline: the safest way to protect schools is to make sure it never gets to school in the first place."

That aim is still some distance away in England, where 892 new coronavirus cases were reported on Wednesday. But in Scotland, where Professor Sridhar advises the government and where schools open next week, there were just 64. 

But pressure has increased on governments to prioritise schools. This week in the UK, the Children's Commissioner Anne Longfield said the government must put schools before pubs. 

"There needs to be a discussion about getting cases as low as possible for schools to re-open, and the trade-off that involves, and increasingly countries are going to struggle with this," said Professor Sridhar.

Another issue on opening up other parts of society at the same time as schools means it blurs the data if outbreaks do occur, making them harder to trace. Professor Sridhar, chair of global public health at the University of Edinburgh, suggests this was another issue in Israel, where shopping malls, restaurants and gyms all opened alongside schools, with the president urging people to "go and have a good time".

"Children have to be prioritised," said Professor Sridhar.

The Delve paper stresses this particularly, emphasising the now well-documented risks of keeping children out of school for long periods of time, including the loss of learning, rising inequality, and deteriorating mental health. There is also the pressure on parents taking on childcare while trying to work.

This week the UN called school closures for more than a billion children globally a "generational catastrophe".

The Delve paper concludes: "Our assessment of the evidence suggests that keeping schools open should be the default position given the substantial risks from closures."

However, scientists said it was wrong to use this as a stick to beat teachers with, who had reasonable concerns about their own safety.

"You can't force teachers back into the classroom because you are guilting them about the damage they are causing children," said Professor Sridhar. "Teachers mostly went into education because they deeply care about children, but they want to feel safe. So this [damage] cannot be used as an excuse for not making schools as safe as possible for teachers."

Delve and other scientific groups, including the World Health Organization, have drawn up guidelines on reopening schools, which include distancing, improved hygiene, and other elements like staggered break times, as well as having a robust plan in place for when cases are discovered, as well as strong contact tracing.

In fact, a paper in The Lancet this week warned that reopening schools could see a second wave of coronavirus in the UK if the country's so-far inadequate contact tracing system is not improved (with one caveat: it also assumed reopening schools would see parents return to work and socialising).

The UK, as well as most other countries, has its own variation on these rules, including staggered break times and keeping a lid on riskier activities, like singing or mass gatherings - so no choir or assembly for now.

However, scientists said that one simple measure that would help teachers in particular feel safer was being ignored domestically: face masks.

In countries which have reopened successfully, like Germany, masks have been part of the strategy, particularly for teachers and older children, who seem to transmit the virus more than younger kids. There are other elements of their strategies, like huge outdoor lessons and very regular testing, that could also be incorporated. But masks could make a huge difference, particularly with some adjustments made to ensure that deaf students, for example, were not excluded by the policy, such as by using transparent masks.

Dr Sanjay Patel,  a paediatric infectious diseases consultant at University Hospital Southampton, said he didn't know why Public Health England was still advising teachers not to wear masks.

"Through this whole pandemic, the world has done something, like face masks, and we won't do it until the evidence shows it is 100 per cent right. Then two months later, we do it," he said. "I think face masks would make teachers feel a lot more confident, and I think for me I would feel more confident for them too."

He said getting teachers to feel safe about reopening was a major part of succeeding, and stressed that he did not blame them for feeling concerned.

"If we don't win over teachers, we don't win over unions, and we don't win over headteachers, and we fail," he said. "And we cannot afford to fail - it's too important to fail. We cannot continue to mess up our children's education."

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