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How Sweden wasted a ‘rare opportunity’ to study coronavirus in schools

How Sweden wasted a ‘rare opportunity’ to study coronavirus in schools
Science
Theres nearly universal agreement that widespread, long-lasting school closures harm children. Not only do children fall behind in learning, but isolation harms their mental health and leaves some vulnerable to abuse and neglect. But during this pandemic, does that harm outweigh the riskto children, school staff, families, and the community at largeof keeping schools open and giving the coronavirus more chances to spread?

The one country that could have definitively answered that question has apparently failed to collect any data. Bucking a global trend, Sweden has kept primary school schools through ninth grade open since COVID-19 emerged, without any major adjustments to class size, lunch policies, or recess rules. That made the country a perfect natural experiment about schools role in viral spread that many others could have learned from as they reopen schools or ponder when to do so . Yet Swedish officials have not tracked infections among school childreneven when large outbreaks led to the closure of individual schools or staff members died of the disease.

Its really frustrating that we havent been able to answer some relatively basic questions on transmission and the role of different interventions, says Carina King, an infectious disease epidemiologist at the Karolinska Institute (KI), Swedens flagship medical research center. King says she and several colleagues have developed a protocol to study school outbreaks, but the lack of funding, time, and previous experience of conducting this sort of research in Sweden has hampered our progress.

We are trying to mobilize, but realistically with the school year ending in a few weeks, it seems unlikely we will be able to get what we want up and running, says King, who adds that her queries to public health authorities about other efforts have come up empty. There is some data collection happening in children, but its not focused around schools or, as far as I know, will not answer questions around transmission.

Because children rarely suffer severe symptoms of COVID-19, pediatricians in several countries have called for schools to reopen. But a key question remains: Because people with mild symptoms can be extremely infectious and frequently spark large clusters of infections , could schools also be a source of COVID-19 outbreaks, possibly driven by children who feel fine but can pass the virus to each other, their teachers, and their families?

In Sweden, they have had a rare opportunityto understand [school] transmission chains better. But you cant find what you dont look for.

Health officials and researchers around the world are scrambling to answer that question. Key to that effort is tracing whether infected children spread the virus to people theyve been in contact with. Im concerned that there may be a rush to judgment that asymptomatic school children arent spreading COVID-19 to adults, says Anita Cicero, an expert in pandemic response policy at Johns Hopkins Universitys Bloomberg School of Public Health. In Sweden, they have had a rare opportunity to understand [school] transmission chains better. But you cant find what you dont look for. The U.S. and other countries with closed schools would certainly benefit from that research.

Emma Frans, a clinical epidemiologist at KI who also writes a regular newspaper column on science and health, says Swedens overall goal during the pandemic has not been to eliminate transmission completely, but to prevent the health system from becoming overburdened and to protect the elderly. (It has succeeded at the former but not the latter: Sweden has suffered very high mortality among nursing home residents.) Regarding schools, Frans says, Most people in Sweden are quite happy with [them] being open. She acknowledges the lack of data is a missed opportunity. With Swedens centralized health system and extensive records, it would have been possible to track cases fairly easily had there been more testing.

But KI pediatrician and clinical epidemiologist Jonas Ludvigsson, who has published two review articles about COVID-19 in children, thinks tracing infected peoples contacts is of little use at this point in the epidemic. The virus is so widespread in society that responsible people do not think it is a good idea to trace individuals. We only test symptomatic individuals. I agree with that, he wrote in response to

Science

asking whether researchers were tracking school outbreaks.

Ludvigsson added that Swedish privacy laws allow health care personnel and school officials to notify parents and school staff about an infection only if a persons life is at risk. Because severe complications from the new coronavirus , that does not apply to cases of COVID-19, he says. Consider if your own child had COVID-19, he wrote. None of the kids will want to play with a child who has COVID-19, even if most kids will have no symptoms or only some fever and a cough.

In a review paper published 19 May in

Acta Paediatrica

, Ludvigsson concluded that children are unlikely to be the main drivers of COVID-19 spread . He cited case studies from France and Australia but wrote that, So far there have been no reports of COVID-19 outbreaks in Swedish schools, citing personal communication from Anders Tegnell, Swedens state epidemiologist, on 12 May. This supports the argument that asymptomatic children attending schools are unlikely to spread the disease, Ludvigsson wrote.

However, a scan of Swedish newspapers makes clear that school outbreaks have occurred. In the town of Skellefte, at a school with about 500 students in preschool through ninth grade. The school closed for 2 weeks because so many staff were sick, but students were not tested for the virus. In Uppsala, staff protested when school officials, citing patient privacy rules , declined to notify families or staff that a teacher had tested positive. No contact tracing was done at the school. At , but those schools remained open and no one attempted to trace the spread of the disease there. When asked about these cases, Ludvigsson said he was unaware of them. He did not respond to a query about whether he would amend the review article to include them.

An indirect clue about schools role in spread might come from antibody studies. On 19 May, the Swedish Public Health Agency announced preliminary results from antibody surveys of 1100 people from nine regions. They reported that antibody prevalence in children and teenagers was 4.7%, compared with 6.7% in adults age 20 to 64 and 2.7% in 65- to 70-year-olds. The relatively high rate in children suggests there may have been significant spread in schools. The agency did not provide more specific data to distinguish between younger children and those in high schools and universities, which have switched to remote teaching.

The missed opportunity in Sweden is a wake-up call, King says: We need ready-to-implement protocols for basic epidemiology during these situations. Studies now underway in other European countries may soon provide more clues. And Cicero and colleagues issued a in the understanding of U.S. schools role in the pandemic. We need a national mandate to prioritize and quickly fund research to answer these scientific questions, they wrote. As schools reopen, [computer] models are not sufficient to determine the actual risk to school-aged children and the teachers and caregivers in their lives.
Read more on sciencemag.org
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