**4. Back to school**

School re-opening is critical to support academic progress, mental health and access to essential services. Considerations of transmission and case severity in children may guide childcare and school policies. Many countries have reported that children under the age of ten have the lowest population based COVID infection rates [2]. Furthermore, while serious infections in children under the age of two are known to occur [2], studies have shown low infection in schools and low probability of transmission between children and teachers suggesting that safe school re-opening may be possible [60].

Despite uncertainties regarding the safety of returning to the classroom, some data collected suggests a partial or total return to face-to-face classes by taking measures to reduce community transmission may be possible. Schools in multiple countries have already reopened their classrooms with little published evidence that schools implementing COVID-19 control policies contribute significantly to COVID-19 transmission [61].

Some studies of COVID-19 transmission demonstrate that school-acquired infections are limited in comparison to community-acquired infections [62]. For example, a case–control study from Mississippi, USA carried out in children over 18 years of age described a total of 154 with SARS-CoV-2 infections and 243 without infection. In this group having attended social gatherings outside the home and

receiving visitors was associated with a greater risk of infection, while attending school in person was not associated with a greater risk [62].

Despite this promising data, there have been school-related outbreaks. For example, in Israel 2 weeks after the reopening of the schools in mid-May 2020 there was a large outbreak in a high school when 2 students attended school with mild symptoms. Students (n = 1,161) and the school staff (n = 151) were tested and infection was confirmed in students (n = 153) and staff (n = 25). However, some factors reported that may have contributed to this massive outbreak were full classrooms with insufficient physical distancing, the lack of mask use in some people and the continuous air conditioning that allowed recycle indoor air in closed classrooms. Therefore, perhaps implementation of these preventative measures may mitigate school transmission [61, 62].

Some measures implemented in schools and nurseries to mitigate the contagion are:


It is important to mention that athletic activities may increase the spread of SARS-CoV-2. For example, January 26 the CDC reported an outbreak associated with a wrestling tournament in a high school that occurred in December 2020 including 10 schools and 130 student-athletes, coaches and referees, of the students 38 (30%) contracted laboratory-confirmed SARS-CoV-2 infection [63]. Contact tracing identified 446 contacts of the positive cases that were considered to have had a high risk of transmission. One death of reported in one of the contacts of the students. However, limitations of the evaluation include that fewer than half of the participants were evaluated therefore some cases may have been unrecognized [64].

Simulation models have been used to determine how fast the virus spreads, how easily it is contained, effectiveness of containment strategies, social and economic impacts of closure, and the role of schools in transmission [63]. For example, some simulated transmission control strategies include placing siblings or children who

#### *COVID-19 Transmission in Children: Implications for Schools DOI: http://dx.doi.org/10.5772/intechopen.99418*

cohabit together in classrooms, assigning one group of children attends face-to-face one week while another group interacts online and then switching roles the following week, or school closure for 14 days if a symptomatic child attends school with those who are asymptomatic returning and symptomatic students staying at home. Another simulation evaluated the effect of child-educator ratios per classroom including 7: 3, 8: 2 and 15: 2. The most favorable transmission profile was shown with 7 students for every 3 educators and group assignment of siblings or students who cohabit together [65]. Whereas the worst transmission profile was shown with 15 students for 2 educators and the random assignment of students [64].

Virtual learning has been used to substitute for in-classroom experiences for many children globally. 143 countries had transitioned to online learning by August 2020, generating stress for both students and their families [66]. Virtual instruction has placed increased demands on family members in terms of time and other resources [67]. Fantini et al. suggests that we must take a deep look into the policies that have led to the necessary closure of the schools and the impacts they have [2]. The isolation school closures cause have great impacts on children, impacting not only their social life, but also their identity and personality development. Without proper social interaction, children may develop anger, guilt, and even depression in addition to anxiety and adjustment disorders. Another consideration is that in the setting of school closures students may spend a greater amount of time with their parents. While this phenomenon has certain benefits, without the support of schoolteachers, parents may become overwhelmed as the only caregivers, potentially exposing children to increased domestic violence, especially when parents have financial and mental health problems that may be exacerbated by the pandemic [2]. Virtual instruction also negatively impacts learning as children are taught best in hands-on learning, especially when learning to write [2]. Together, these factors illustrate some the hardships for children related to the pandemic and school closures.

For these reasons, it is important to implement in-person learning for children as part of early recovery. However, precautions should be effectively implemented and practiced, that may include social distancing, prevention of shared materials, ventilation of spaces, increased hand washing practices and sanitizing availability. Control measures include in-person learning could be started through alternating face-to-face and virtual learning scheduling to decrease density, the use of masks [2] and training of teachers in students in safety procedures [2].
