Lori Walsh:
Today, we welcome Sanford Health's Dr. Wendell Hoffman back to the program. We're going to talk about the emerging research about kids and teenagers and SARS-CoV-2 transmission. What does a safer classroom look like in the absence of a statewide mandate for school openings or classroom mitigation efforts? How can parents and teachers evaluate the science we currently have so they can make smart decisions about how to live out personal responsibility during the pandemic? This is all part of our weekly updates on COVID-19. We'll have some general information for the rest of you who don't have kids in school as well. Dr. Wendell Hoffman, thanks for being here.
Dr. Hoffman:
Thanks very much, Lori. Good to be with you.
Lori Walsh:
Many parents are almost on the verge of panic because the back-to-school date is coming quickly. I just want to turn it over to you for a minute and ask the first question which is, what kind of science is emerging about kids and teenagers and SARS-CoV-2 transmission? What do we know at this point? What do we not know?
Dr. Hoffman:
Great question. We probably could use a couple of hours to roll through this. But, what do we know? What we know, and this was early on in the pandemic data coming out of China, is that we knew early on from their experience that this virus was very mild in terms of its effect on children. That data continued to be the case going forward as we have been engulfed in our own epidemic pandemic here in the U.S.
Dr. Hoffman:
Kids and youth count for, in multiple studies, maybe 5% to 10% of the overall SARS-CoV-2 symptomatic infections. In South Dakota, I believe I calculated that about 12% of the total number of positive cases... remember, these are positive cases, so they do not count asymptomatic cases. And if it is true that the total number of infections may be, I don't know, 8 to 10 times the number of positives, then of course we have many more that we don't even know about. But the point being is that the children and youth count for a small percentage overall. There is some data particularly now, with the now famous South Korea study to suggest that children, particularly those under 10, maybe less susceptible to SARS-CoV-2 infection, and potentially less likely to transmit the virus to others.
Dr. Hoffman:
Also, there's I think strong evidence... I always have to qualify this, because I do depend heavily on my pediatric colleagues. And I don't pretend to be a pediatrician, nor have I ever played one on TV, but I have seen a lot of kids in my career. And I do have great admiration and also for the guidance, that my pediatric infectious disease colleagues have struggled with, and pediatricians in general have struggled with trying to put together these recommendations. That said, there's strong evidence that the majority of children and youth who become infected are either asymptomatic or only have mild symptoms such as cough, fever, and a sore throat.
Dr. Hoffman:
I think we have to put all of this into that background context and to say for instance, of the 1,136 hospitalizations in the 0 to 19 category in South Dakota, I believe there have only been 25 hospitalizations. That's a 2.2% hospitalization rate. It's very small. We have zero deaths in that group. And so, I think the emerging science says that the young children may be a little bit different as you get older. Apparently as you turn aged 10 and you move up into middle school and high school, you begin to look more like the adult patient in terms of the ability to transmit it to each other and to others, say, in the family. I think that's an accurate summary of the emerging science as we have it with regards to transmission and seriousness of disease.
Lori Walsh:
Can you speak a little more to whether or not kids can bring the virus home to their families if they're asymptomatic or if they're mildly symptomatic. What do we know about how likely they are to transmit it to adults?
Dr. Hoffman:
Yes. I mean, I think we can say that... and remember, we stopped the school closures right earlier on in the pandemic in the United States. So there's a lot we have to learn. However, the data worldwide suggests that kids are probably more likely to get it within their households than they are in non-households. But we really don't know because we've not entered our own experiment, if you will, in this country. We are comparing ourselves to other countries. And while that's very, very good, I think we have to say that we can expect that there will be more infections as the schools open up. I mean, all you need to do is look at the kids out at the camp in the Black Hills. When you get kids together, there's going to be transmission. That's why all these mitigating strategies are so important.
Dr. Hoffman:
I think we have to be honest and say we can expect probably that we may well have more cases. Now the average age of a teacher in South Dakota, I actually looked this up, was about... I think it was 42.7, 43-ish. If the average age is in that range, we have to say that the vast majority of teachers for instance, and probably parents, are going to be in that age group where if they do come down with COVID-19, they also are going to experience a relatively mild condition. I think the overall risk is we may have a lot of cases, but I think we need to focus on the seriousness. And therefore, hopefully, respect the virus but not fear it.
Lori Walsh:
Okay. You mentioned the camp in Keystone. Would you explain for listeners, the difference between... as we evaluate a news headline or a study, the difference between a case study, where we can look at choir in Washington or a camp somewhere versus the gold standard of research. How do we as parents scrolling through the news, remember what we're looking at when we look at a case study versus something that is more rigorously... and you might even want to touch a little bit on the ethic. We can't infect a bunch of kids with SARS-CoV-2 and then study what happens. There's limitations to the kind of science that we can get out of this as we're going through it.
Dr. Hoffman:
Yes. I mean, really any observational study, let's take the camp out in the Black Hills. Where you're going to have the Department of Health looking at the occurrence of cases and doing contact tracing, and then reporting out what they see. That in a sense, would be a case study. Really, a case study is any formal look at any kind of an outbreak. And we use observational studies all the time. They're very, very important. You're right. I mean, it is a different kind of science, if you will, but it is very important and it's what what epidemiology is is really all about.
Lori Walsh:
Yeah. Let's talk about mitigation strategies. You said they are so important. For many parents, if they decide we don't have someone at home, for example, who is highly at risk, so we're going to make a choice to send our kid to school and not do things remotely, for a variety of reasons. What does a safer experience look like? What are the mitigation strategies that really matter in a classroom environment?
Dr. Hoffman:
Here's where there's an old saying that says, "What we desperately want is knowledge, but what we desperately need is wisdom." We have limited knowledge in this country regarding kids and schools opening up. What we need is a lot of wisdom therefore, based upon limited knowledge. But that's been true of this pandemic overall.
Dr. Hoffman:
I would refer your listeners to a number of good documents that are out there for guidance for school reopening. The American Academy of Pediatrics, for instance. Particularly, I thought a good one was the Sick Kids Guidance for School Reopening coming out of Ontario, which is a marvelous document I think, that really summarizes a lot of the stuff within these different categories. What was the question again?
Lori Walsh:
Trying to think about what are the strategies, the mitigating strategies that matter. Yeah, what works.
Dr. Hoffman:
Yeah, okay. Yeah. I apologize. Yes.
Lori Walsh:
Yeah.
Dr. Hoffman:
Yes. I think we have to go back to the blocking and tackling that we've talked about before. I think the social distancing, which will be challenging in schools. The use of masks, which I think is... there's a lot of very solid evidence. Not direct evidence, but what we would call indirect evidence. You're not going to put 50 people in a room with masks and 50 people in a room without masks, and expose them all to SARS-CoV-2 and then say, "Okay, masks work or they don't." But if that's the kind of proof you're looking for, then we can never say that wearing seat belts and using airbags has ever been proven. We're not going to do that.
Dr. Hoffman:
It's all based upon, for instance, indirect evidence. And there's lots of it out there. The prior use of masks in healthcare in general. The nature of this virus which is quite contagious and which any cloth material is going to help some in containing those respiratory secretions. Number three, are the studies that showed different kinds of masks preventing transmission outward of our obvious respiratory secretions. And then lastly to get back to it, the observational studies that show that masks do decrease the incidence of this infection within healthcare organizations. Which I think is the main proof that masks work, is within healthcare systems themselves.
Dr. Hoffman:
The last two would be hand hygiene. Very important, particularly and probably with the younger children. Because they're always going to their nose, it's going to be tough for them to wear masks. They're touching each other and they're touching everything. The hand hygiene will be particularly important. And then lastly, the environmental cleaning. Although to be honest, I think the whole issue of fomite transmission. Virus laying on a hard surface that you then pick up secondarily, is probably... Well, I think it definitely is less important than the direct transmission between one person and another. Primarily large droplet, primarily over a three to six-foot distance.
Dr. Hoffman:
I think those are the principles. The school systems I think in their great wisdom, knowing children and their behavior, are going to apply these things in a very wise manner. And they're going to dive in, because we know... and the pediatricians are speaking loudly on this, that the adverse impacts of school closure on children and youth... and I'm quoting here from that sick kids document, "Significantly outweigh the current benefit of keeping schools closed in order to reduce the risk of COVID-19 in children, youth, school staff, and the community at large."
Dr. Hoffman:
I think the pediatricians are really speaking, PSID and general pediatrics are speaking with one voice that the harm here, what we could call the incalculable collateral damage, is very significant. And it's one of my personal frustrations with how a lot of the COVID-19 stuff has been promoted, is that we're talking about harm only related to the virus. We're not talking enough about the harm of what we have had to do in closing everything down. I think a little lesson from the medical side is we commonly say... quoting the famous Hippocrates as to diseases, "Make a habit of two things to help, or at least to do no harm." Well, in this case, you've got both short-term and long-term harm.
Dr. Hoffman:
I find it interesting that the segment of the population that appears to handle this the best, may be the very segment that is going to experience significant harm in the long-term. I think we have to make this calculation. I'm fully in support of schools opening up using these wisdom principles and relying on the great wisdom of our teachers, our administrators, our school staff, to allow kids not to experience the long-term harm that everybody is afraid of.
Lori Walsh:
Yeah. One last question, and it's about masks. If you live in a district and you're sending your child into a classroom where masks are optional, the teachers have done their best to either provide some kind of plexiglass barrier for desks or to separate those desks, but yet there's going to the bathroom and going to the lunchroom and things in the hallway. If it's a choice and you know that some of those kids are not going to wear their masks because they're choosing not to, do you send your kid to school in a mask? Does it really protect them? Does it just protect the other kids? How would you advise a parent to make that decision if it's up to each family?
Dr. Hoffman:
Well, of course, I'm a believer in the use of masks. But I think we have to also be honest that masks, I think, primarily have to do a source control. That means that the reason I wear a mask is to try to prevent you from getting infection from me as opposed to personal protective equipment, the famous PPE, where I'm trying to protect myself.
Dr. Hoffman:
The higher quality of the mask, the closer you're going to get to a PPE effect. The lower the quality of mask, you're going to be more into the source control effect. My advice would be that I would advise masks whenever possible. They're going to be more important in the older age child and in the adolescents, I think. Because again, with the current data, with the current evidence that suggests that younger children may not transmit this as readily. Also, it's just going to be very difficult for those younger school aged kids to wear masks. Although kids are very resilient, and we may be really surprised at how willing they are to wear face coverings as a way to prevent transmission.
Dr. Hoffman:
My advice would be unless there are contraindications, unless it's been with a discussion with their primary physician to say that yeah, this is probably not going to work with this particular child for a variety of reasons, underlying medical conditions and so forth and so on, they should try to wear a mask. And go with your local school rollout plan, and remember that this is just the beginning. We're just coming out of the gate here, and there will be lots of things that will be tweaked and changed. We'll learn a lot. We'll change on the go. What we start with, just like with the SARS pandemic overall, is not where we're going to end up. This is a completely different situation than it was two months ago because of what we've learned. We haven't even talked about testing within schools and what that's going to do, and how that's going to help us. I'm very hopeful.
Dr. Hoffman:
I'm very optimistic that we can keep kids, their parents, teachers, as safe as possible while also avoiding that long-term harm problem which I think everybody probably agrees with. If learning is at least 50% social, and I will... I'm not quoting a study there, but I think healthcare for instance, is at least 50% social science and 50% hard science. If learning is somewhat like that, then we have to get kids back together. But we have to do it in a responsible way and use these mitigating strategies that can be applied in many different ways. And we will learn from each other. One school district may learn from another school district. I think it's going to be a massive learning exercise. I'm actually quite optimistic and excited to see how we're going to live alongside this virus, because we have to. We can't go back.
Lori Walsh:
Yeah. Dr. Wendell Hoffman, thank you for the knowledge and the wisdom today. We really appreciate your time. Look forward to talking to you next time.
Dr. Hoffman:
Thanks, Lori.