England is an anomaly in not undertaking any of the three strategies to prevent transmission in schools, says Christina Pagel

The highly transmissible Delta variant of SARS-COV-2 is now dominant across Europe and North America. While vaccinations are protecting adults from severe disease quite effectively, children remain mostly unvaccinated. In England, the number of children admitted to hospital with covid-19 saw the highest rates of the entire pandemic at the end of July 2021 (an average of 53 admissions a day), just after the end of school term. 

The surge in cases and hospital admissions in children started after summer half term in early June, once Delta was dominant and after moving to step 3 of the roadmap. While ascertained cases and hospital admissions in children have fallen over the summer holidays, admissions of under 18s remain near January peak levels (about 40 admissions a day in August so far). Current overall case rates in England are five times higher than they were in early June (25,000 vs 5,000) and are rising slowly. Children return to school in a few weeks. 

The recent ONS schools infection survey reported that case rates in school children were lower in June 2021 than they were in November 2020. They concluded that schools in England were not “hubs of infection,” in part due to measures in place last summer such as frequent testing, isolation of contacts of new cases in schools, mask wearing (which continued in many schools even after 17 May 2021 when this was no longer mandatory), and low rates of covid in the community. 

Unfortunately, both November 2020 and June 2021 missed the peaks of infections in school age children which were in December 2020 and July 2021 respectively. The main ONS infection survey concurs that prevalence in school age children was lower in late June 2021 (<1%) compared to November 2020 (1%-2%), but reported similar rates in late July 2021 (2%-3.5%) as in mid December 2020 (2%-3%). This is also consistent with peak hospital admissions in children (to date) occurring last month. 

Schools don’t have to be worse than any other crowded indoor space to be a problem. The problem is simply that they are another crowded indoor space and one where children spend 35 hours a week. We know that Delta spreads easily in such indoor spaces, particular if they are poorly ventilated. That is compounded by the fact that children are now the population group with the least immunity to covid because they remain largely unvaccinated. Children in the US returned to school in early August in the context of already high community rates in many states and the number of children in hospital with covid there are now higher than they have ever been. 

If we want to avoid more hospital admissions in children this autumn in England then we need to get cases in children low, and keep them low, as they return to school. There are three ways this can be achieved, and these work most effectively when used together. 

Vaccines

Vaccines for 12-17 year olds have been approved in many countries, including the UK, but there is no licenced vaccine for under 12s. Most high income countries are now offering the vaccine to all children 12-17 year olds, including the US, Germany, France, Italy, Spain, Canada, China, Japan, Israel, Ireland, Mexico, Indonesia and Singapore. The UK is currently offering vaccines only to 16 and 17 year olds (as of this week) and to a small group of 12-15 years olds defined as clinically extremely vulnerable. Vaccines have been shown to be highly effective in adolescents in preventing both symptomatic infection and severe illness and would act to reduce transmission in secondary schools.

Public health protective measures

Countries have used a variety of different measures to reduce transmission within schools, but most include some or all of: social distancing (e.g. smaller class sizes, staggered breaks); ventilation (e.g. CO2 monitors, HEPA filters, window policies, outdoor learning); cleaning surfaces; mask wearing; keeping children within bubbles of regular contacts; frequent testing; and isolation of contacts of cases. 

Given the infectiousness of Delta, the European Centre for Disease Prevention and Control (ECDC) has updated its school guidance to recommend that a combination of interventions are employed within schools to keep transmission low and protect children this autumn. 

The US Center for Disease Control (CDC) also updated its guidance to recommend masking by all staff and students over the age of two, physical distancing, testing, isolation, and ventilation as a way to keep transmission down in schools alongside vaccinating adolescents. 

Community rates

As highlighted by the ONS Schools Infection survey, perhaps the biggest impact on cases in school age children are rates of general transmission in the community. When cases are high in general, it is much harder to keep cases down in school settings. 

England is an outlier in its attitude to infections in children

Most countries are using a combination of two or three of these approaches to allow children to go back to school more safely. For instance, countries such as Norway and Japan have combined low community transmission and preventative measures in schools. Others, with higher rates of community transmission, such as parts of the US, France and Spain, are combining vaccinating adolescents and public health measures. Closer to home, schools in Ireland and Scotland are receiving CO2 monitors to monitor whether windows need to be opened and masks are being maintained in secondary schools.

England is an anomaly in that we are undertaking none of the three strategies to prevent transmission in schools. 

While 16-17 year olds are now eligible for vaccination, most 12-15 years remain ineligible, despite two approved vaccines (Pfizer and Moderna) and a clear majority of parents saying they would vaccinate their children.

Almost all protective health measures have been removed for the next school term: there will be no national requirement for mask wearing; no roll out of CO2 monitors, or general support for ventilation; no social distancing; no bubbles; no requirement for under 18s to isolate if a household member has covid; and minimal contact tracing within schools if a child tests positive. 

Finally, community rates in England remain very high. With almost all public health measures removed and full capacity events such as football matches restarting, not only is the government not achieving low rates of transmission, it is not even trying to. 

Under current policies, this next term is very likely to bring renewed extremely high cases in children and a few thousand more children requiring hospital admission. Even the lowest current estimate of 2% for rates of long covid in children will see thousands more children end up with long term symptoms. For many of the rest, even a mild course of illness will result in a week or two of missed school—a significant disruption. Clinically extremely vulnerable children are left in a precarious situation with no protection from exposure to a disease that could be very serious for them. 

As Israel is considering delaying the start to the school year, the American Academy of Pediatrics is calling for vaccines to be extended to under 12’s and Canada warns of increased severity of Delta in children, England is increasingly alone in its stance which effectively suggests that infections in children are nothing to worry about. I believe we need to join our international colleagues, take infections in children seriously, and urge the government to follow international best practice as laid out by the CDC and ECDC to make schools as safe an environment as possible.

Christina Pagel, director, Clinical Operational Research Unit, University College London, UK and a member of Independent SAGE. Twitter @chrischirp

Competing interests: none declared.