Forget what you thought you knew about the spread of Covid-19. Contrary to every other wave of the pandemic so far, this one is spreading most rapidly among children. Like a perfect storm, the onslaught of the more transmissible delta variant coincided with the start of school, and now, rates of new Covid infections are rising faster among school-aged children than among adults.
“The delta variant just changes the nature of this [pandemic],” says Sara Goza, a pediatrician in Fayetteville who is immediate past president of the American Academy of Pediatrics. “The first week of August, we were seeing some sick children, but not too many. In the next two weeks, we went into surge mode. Almost everybody who came in was sick.”
Four metro Atlanta counties—Cherokee, Forsyth, Henry, and Paulding—started the school year as mask optional. (Henry has since switched to a mask mandate.) Their infection rates for school-age children (5-17) rose higher than the state average. Four core metro counties—Fulton, DeKalb, Gwinnett, and Clayton—have mask mandates. Their Covid rates for school-age children are 40 percent to 50 percent below than the state average. (Mask-optional Cobb and Fayette, which switched from mask optional to a mandate, have rates about 25 percent lower than the state.)
To public health expert Harry Heiman, the mask-or-no-mask scenarios set up an unnecessary “modern-day Hunger Games,” a clash that leaves some children more vulnerable to infection. “The data demonstrating that masks are effective at reducing transmission is unequivocal,” says Heiman, a clinical associate professor at the Georgia State University School of Public Health.
Why masking and regular testing is important
Georgia Tech industrial engineer Pinar Keskinocak specializes in modeling the spread of infectious diseases, and she and her team have been analyzing SARS-CoV-2 since the beginning of the pandemic. Their dashboard shows that case rates for children over the past two weeks have risen higher than the infection rates among adults.
The disparity is especially strong for teens, ages 14 to 17. In most of Georgia’s 159 counties, the rate of infection in that age group exceeds the infection rate for adults 23 to 64. Rates of teen infection are lowest in Fulton, DeKalb, and Gwinnett (all mask mandatory), but those rates are still double the rates for adults 23-64 in those counties.
“We really need to pay attention to what’s happening with these kids,” says Keskinocak, professor and director of the Center for Health and Humanitarian Systems at Georgia Tech. “We really need to ensure a safe school environment for these kids because that’s where they spend most of their time.”
That concern was underscored by predictive modeling Keskinocak and her team conducted with researchers from North Carolina State University. They created a simulation in which a hypothetical school had 500 children with two or three positive cases at the start of the semester. They used different scenarios of susceptibility, roughly corresponding to elementary grades (no children are eligible for the vaccine), middle school (some are vaccine-eligible) and high school (all students are vaccine eligible).
Even in the schools with the lowest protection from infection, the model assumes 30 percent of children had immunity from natural illness. Middle schools were set at 40 percent protected and high schools at 50 percent. Based on other studies, the model set the effective protection due to mask-wearing at 50 percent and testing/quarantining at another 22 percent.
Within three months, 75 percent of susceptible students at schools without masking and regular testing would become ill, according to the study, which has not yet been published in a peer-reviewed journal. “Face coverings make a huge difference,” Keskinocak says. “You could go from 70 percent to 90 percent of susceptible people being infected down to 25 percent.”
A choice between education and health?
Georgia’s schoolchildren are especially vulnerable to the swift-moving delta variant. “There’s a correlation between how much Covid is being captured in the surrounding community and what’s being brought into the schools,” says Heiman. “Out of 159 counties, we have 159 counties with severely high risk for Covid transmission.”
As of September 3, Georgia ranked 45th for vaccination (52 percent of the total population with at least one dose) and had the sixth-worst infection rate, according to a state profile published by the US Department of Health & Human Services. Only 40 percent of Georgia teens and pre-teens (12-17) are vaccinated.
Unvaccinated teens (ages 12-17) are 10 times more likely to be hospitalized with a severe case of Covid than vaccinated teens, according to a report from the Centers for Disease Control and Prevention. But Shannon Deisen of East Cobb still worries about her vaccinated high-schoolers, especially her son who has Down syndrome and other medical conditions, which puts him at greater risk of complications.
When Deisen signed her children up for in-person school in May, she thought the Cobb school district would require masks. Now she feels that parents are choosing between their children’s education or health. “If people say they value lives, it is the epitome of hypocrisy to not protect children by mandating masks,” she says.
The Cobb school board majority shut down an effort by one board member to put Covid protocols on the August 19 meeting agenda. It could only be added at the last minute in the case of an emergency, and chairman Randy Scamihorn stated, “This is not an emergency.”
Yet on September 7, the Cobb Board of Health held an emergency meeting to discuss the rising pediatric cases. The health board urged public and private schools to use CDC-approved protocols, including “universal mask use” and vaccination of “all eligible individuals.”
Superintendent Chris Ragsdale, a member of the health board, abstained from the vote. In the discussion, he asserted that Cobb schools have contained the spread through distancing, sanitizing, and other measures, and said, “There is [an educational] cost for having, specifically, elementary-aged children masked—mandated—during the entire day.”
“Cobb’s public health protocols are intended to balance the importance of in-person learning and the frequent changes associated with Covid-19,” a Cobb County Schools spokesperson said in an email. “We will continue to update our school protocols accordingly.”
Henry County took a different approach when faced with rising pediatric cases. The district is offering a $1,000 bonus to school employees who are fully vaccinated by the end of September. A week after school opened with a mask optional policy, the superintendent met with local hospital, health department, emergency management, and county officials and agreed to ramp up mitigation efforts.
Mask-wearing is now required and large gatherings have been curtailed, including restrictions on in-person public attendance at board meetings. (The district reduced seating capacity at indoor events.) Based on health data, “I will make decisions that are responsible for our young people [so] that the safest possible place for kids to be during school hours is in a Henry County school,” superintendent Mary Elizabeth Davis said at an August 9 board meeting.
Long-term effects unknown
Beyond the emotionally fraught conversations about masks in schools, metro Atlanta pediatricians are focused on treating and protecting children. They are caring for more patients who need hospital care or have lingering effects, says Melinda Willingham, a pediatrician with InTouch Pediatrics in Snellville.
One patient, a Black 7-year-old boy, had a fever for three days, a cough, and runny nose—and a positive Covid test. When he came for a well visit about a month after he recovered, she noticed that his heart sounded abnormal. Further testing showed he had a mild case of myocarditis, or inflammation of the heart. His heart has since returned to normal.
“[Pediatricians] are very concerned about long-term effects from Covid and what we will see in the next six months or a year,” she says.
Willingham has seen some children with a serious inflammatory condition triggered by Covid and others who had Covid along with another respiratory virus, such as respiratory syncytial virus, or RSV. She urges families to vaccinate all household members who are eligible (ages 12 and above) and tells her patients why it’s important to wear masks and practice social distancing in school.
Children and teens will need to stick to those precautions for the foreseeable future. “Covid is definitely increasing, and I do not see it decreasing anytime soon, unfortunately,” Willingham says.
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