The opening of schools in times of pandemic: the case of Andalusia

We will begin this post with a statement of principles that will soon be understood as to why it is necessary: in Science not everything goes. The term scientific evidence used to justify measures of various kinds hides a double meaning (due to the word evidence, since in Science nothing is evident) that can lead us to misunderstandings (see the interesting wikipedia entry). The proper term on which to base all decisions is scientific evidence. Scientific proof must be supported by experimental facts and its validity is determined by the scientific method. In short, this method means that the hypotheses we make about any phenomenon (whether in the natural, social, health, etc.) have to be verified, they have to be supported by experimental facts and these experiments have to be able to be corroborated by other scientists on an independent basis.

The number of statements (or hypotheses if you like) that are made without any scientific basis both in the media (not to mention the increasingly frequent hoaxes) and even in official documents is worrying to say the least. This inappropriate use (we assume it is not done deliberately) of Science leads to inconsistencies between official decrees published by different authorities: what does not apply to some cases cannot apply to others without a convincing explanation. This fact is particularly striking in the latest documents and orders published to deal with the health crisis caused by the coronavirus (COVID-19) following the state of emergency.

The results of some research are cited as a justification for the measures, but the results of others are ignored (carelessness or convenience?). This is just as if a scientist only used those experimental results that interested him to validate his theory and forgot about those that did not fit, or even invented the data for convenience. In Science, that would be a blatant case of fraud.

Analysis of the situation in Andalusia

We will now analyse the decree of 16 August 2020 which updates that of 19 June 2020. We will reproduce some relevant parts here (the full text can be downloaded here).

In point “1.1 Obligations of caution and protection” it is stated:

The public must take the necessary measures to avoid the generation of risks of spreading the COVID-19 disease, as well as exposure to such risks. This duty of caution and protection will also be required of the holders of any activity. Likewise, the health and safety measures established by the health authorities for the prevention of COVID-19 must be respected.

Without detriment to the above, it is recommended that citizens limit social gatherings outside the stable cohabitation group to a maximum of 10 people.

1.2. Interpersonal safety distance. The measure for maintaining the interpersonal safety distance established by Royal Decree-Law 21/2020, of 9 June, on urgent measures of prevention, containment and coordination to deal with the health crisis caused by the COVID-19, of at least 1.5 metres, must be followed, as well as the measures on the use of the mask established in the Order of 14 July 2020, on the use of the mask and other prevention measures in matters of public health to deal with the coronavirus (COVID-19) […]

Are these measures reasonable? What are they based on? The answer is that they are indeed reasonable. The reason is well known and is documented in a World Health Organization (WHO) document that explains the main routes of infection and ways to minimize them.

Thus, the most common way of spreading covid-19 is through Flügge droplets which are small droplets of saliva that we expel essentially when we cough or sneeze (also when we talk or sing) which travel a certain distance before falling to the ground. In addition to these flügge droplets, infection by aerosols (water droplets of microscopic size) cannot be ruled out, especially in closed, poorly ventilated environments, as it is known that the droplets can remain suspended for several hours. It is also known that the virus remains active for hours and days on different surfaces. The way it enters our body is through the mucous membranes, particularly the mouth, nose and eyes. Hence the importance of maintaining adequate hygiene (especially of the hands), a safe distance and avoiding crowds of people, especially in indoor areas, to mention some of the most common measures. The mask is also important as it retains a large part of the drops that we expel when breathing, coughing or sneezing.

To know the state of the pandemic it is enough to take a simple look at the official data. A worldwide reference is the Johns Hopkins University database from which we have taken the following graph showing the evolution of the number of daily cases in Spain up to 11 September 2020:

From mid-May to the beginning of July, there are hardly any daily cases, which is to be expected after a hard period of confinement. However, from 15 July (red arrow) there is a rather pronounced upward trend. This growth is much better shown in the following graph of the cumulative counts. The left arrow (blue) indicates 1 June, the middle arrow (red) indicates 15 July and the right arrow (yellow) indicates 15 August.

It should be kept in mind that in July a common action protocol was established throughout the country which allowed (in theory) the detection of almost all cases of covid-19 by means of PCR (something that did not occur at the beginning of the pandemic). The increase in the number of cases detected from 15 July onwards, almost a month after the end of the alarm state, is due to (see, for example, this entry by A. Durán)

1. A more effective detection protocol carried out by professional tracers and Primary Care (not in hospitals as was the case at the beginning of the pandemic), and

2. A significant increase in mobility, which necessarily implies a greater number of contacts between people.

What is clear from an analysis of the data is that the number of cases has not stopped increasing since 15 July. In fact, between 15 July and 7 September, more than 268 000 new cases were recorded.

We will now examine the data for Andalusia, and in particular for the province of Seville. In this case we are going to show in the graph the cases accumulated in the last 14 days which offer a much more precise panorama than the simple daily cases and is the one that has been used regularly for several weeks. The following graph shows the data accumulated over the last 14 days from 23 March (corresponding to day 1) to 31 August (day 162) (the numbers are taken from the official data published by the Junta de Andalucía and updated to 10 September):

Three clearly differing regions can be distinguished: from 1 to 60 (23 March to 21 May) which corresponds to the famous first wave, from 61 to 120 (22 May to 20 July) where there are hardly any cases in Seville and there is a slight rise in Andalusia, and finally from 121 to 162 (21 July to 31 August).

With these figures, a modification of the Order of 19 June 2020 was to be expected. On 10 August, the accumulated number of cases from the previous 14 days in the whole of Andalusia was 3279, while a week earlier, on 3 August, it was 1839. And that is because since 14 July it has been obligatory to wear the masks in all public spaces (even outdoors), regardless of whether or not the safety distance of 1.5 metres can be maintained (Order of 14 July 2020, updated on 1 September 2020).

Among the more restrictive measures in the new order of 16 august are the following:

1. Moving from meetings of 25 people outside the stable cohabitation group (although it has not been specified in the order itself what is meant by a stable cohabitation group it seems natural to think that it is the group sharing the same address) to 10.
2. The restaurant occupation is 75% but the number of people per table or group of tables is reduced from 25 to 10.

In spite of this, the number of cases continues to rise, reaching 10182 cases accumulated in 14 days on 31st August. What can be done? More restrictions? Selective admissions?

At this point a new variable appears: the return to school.

The return to school in Andalusia in 2020/2021 in the current situation of the pandemic

After a summer full of news about what the return to school would be like in each community and where, as a rule, what prevailed was improvisation, the time has come to make the corresponding decisions. In some communities there is talk of lowering the ratios of students, in others of making bubble groups. In Andalusia, after a period of silence which lasted until the publication of the Agreement of 28 August which we will discuss later, the concept of stable cohabitation groups in schools and colleges is taken as the basis for prevention measures. Now coexistence is not about those who live in the same house, but about students in the same grade. This is at least what happens in many schools in Seville. Thus, for example, there are schools with three lines (three groups in each grade) whose cohabitation groups are 75 students plus the teachers involved. No drop in the ratio: 25 children per class (and remember that we are talking about primary, in secondary it is even higher: 30). The safety distance is notably being skipped in most schools and colleges. For example, if we assume that we can have a useful area of 20 square metres, we can place 16 students while maintaining a distance of 1.5 metres. If we place all 25 students in the class they will be 1.2 metres apart. In any case, can those 25 children be on a bar terrace celebrating a birthday? According to the recommendations of the Order of 14 August, no, and even less so in a closed space. A study on the optimum distribution of pupils can be consulted in a previous entry.

Let’s talk about the Agreement of 28 August 2020, of the Governing Council, which provides for the measures of prevention, protection, surveillance and health promotion in cases of COVID-19 in non-university educational centres and services in Andalusia (published on 2 September).

It is worth quoting some sentences that illustrate what we mentioned at the beginning about the use of the scientific method. In the introduction to this agreement it is stated (in boldface some statements relevant to what follows, and the numbering of the paragraphs has been included so that they can be referred to later):

I- Educational institutions have a fundamental role in the development of children and society in general. The right to education and the right to child protection must be a priority in post-crisis recovery.

II- One of the main measures taken to reduce the development of COVID-19 has been to avoid social interactions by restricting the mobility of citizens and closing down non-essential activities and educational establishments.

III- The justification for school closure was based on the effectiveness of this measure in the context of seasonal or pandemic influenza epidemics. However, this effect is not so clear in the case of SARS-CoV-2. Modelling studies indicate that school closures can be significantly effective for infection control only when outbreaks are due to viruses with low transmissibility and attack rates are higher in children than in the adult population. This applies to influenza viruses, but not to SARS-COV-2, which have different transmission dynamics and affect mainly adults and older people.

The main reason for considering that schools should be opened is explained in section 1.1 on the impact of school closures:

IV- International agencies such as UNESCO, UNICEF, the WHO and the UN have highlighted the impact that the school closures and confinement have had on education, on children and on society as a whole, and have highlighted the need to recover educational activity so that the inequality that already exists does not increase, also highlighting the role that schools play in transmitting to students and the rest of the educational community vital information on how to protect themselves and their families.

V- Although we do not yet have sufficient evidence to measure the effect of school closure on the risk of disease transmission, the adverse consequences it has on the safety, well-being and learning of children are well documented.

As mentioned in paragraph I, children have the right to education (which is of children not of their parents), this is not in doubt by anyone, but also to the protection of their health (Article 43 of the Spanish Constitution). We have no objection to the negative impact of school closure on the education of students discussed in paragraph IV, but it is striking that it is decided without scientific evidence (as mentioned in paragraph V) that the benefits of opening schools outweigh the risks of contagion and its consequences. There are no experimental studies that have measured the effect of opening (only theoretical models) since schools have been closed for the most part.

In addition, paragraph III of the introduction where the modelling studies are discussed is taken from the document Prevention, hygiene and health promotion measures against COVID-19 for educational centres in the 2020-2021 academic year prepared by the Departments of Health and of Education and Vocational Training of the central government (version of 22-06-2020).

In that paragraph of the Department’s document, to justify the opening of schools, reference is made to an opinion article from JAMA Pediatrics, the journal of the American Medical Association published on 13 May 2020. In fact, the above-mentioned paragraph III is only a translation into Spanish of an excerpt from the JAMA Pediatrics article (specifically from the fifth and sixth sentence of the second paragraph of the article). But what is not mentioned in the Department’s document (the Board’s document does not cite any scientific literature) is that another modelling is also mentioned in the JAMA Pediatrics article (in the context of Britain and the USA) which concludes that “school closure alone would prevent 2% to 4% of deaths, far less than other social distancing interventions” (see the last sentence of the second paragraph of the JAMA Pediatrics article).

In other words, the Department’s document (and therefore the Board’s) seeks to justify on the basis of models (in the context of Britain and the USA) that are not experimentally confirmed, and which do not constitute scientific evidence, that school closures have little impact on the transmission of the disease and it is very positive for children and society to keep them open, but at the same time they forget to comment on the results of another study where reference is made to a rather negative fact. The above is a typical example of the fraudulent use of information, as we are only left with the part that is in our interest and not the whole picture (only the pros, not the cons).

If the intention of including scientific literature in the Ministry’s document was to give it scientific rigour (something very desirable indeed) and thus convince public opinion of the importance of opening and keeping schools open, the way in which this has been done is rather unsatisfactory. There is no doubt about the need to open up schools, and not only for the right to education of all children (education that could also be provided online, at least to a part of them, given the exceptional conditions in which we find ourselves: a global pandemic) but also for the benefits it brings to the children themselves, to society, to the economy, among others –but opening cannot be at any price, and even less at the price of undermining the constitutional right of children and their families to protect their health and even their lives.

The scientific reality today is, as a number of expert publications show, that there is very little scientific data to show the real impact of the opening of schools and the role of children and adolescents in the transmission of the Covid-19.

As an example of the above, we highly recommend the reading of another excellent opinion article published in the Archives of Disease in Childhood, a journal of the Royal College of Paediatrics and Child Health entitled “Reopening Schools during the COVID-19 Pandemic: Governments must balance the uncertainty and risks of reopening schools with the clear damage associated with prolonged closure” published in August 2020, where the authors review what is known about COVID-19 and children. Facts such as, for example, how children are less likely than adults to be infected and that they are often asymptomatic, but how those who do get the disease may have the same viral load as an adult (and would therefore be equally contagious), but they also admit that there is a percentage of cases that suffer complications that even being low cannot be ignored. In it the authors explain that

The European Union recommends that relaxation of social distancing measures, such as the reopening of schools, should only occur after there is clear evidence that the spread has decreased over a significant period, there is sufficient capacity of the health system to cope with future peaks, and countries have sufficient controls and testing and capacity to rapidly detect and isolate infected individuals.

Are we really ready for the reopening of the schools under the current conditions, with a rate of infection that has been increasing in Seville and throughout Andalusia and which on 9 September was 318 and 477 per hundred thousand inhabitants respectively?

And why not do what is proposed in that same article?

Schools can be opened in a gradual process, by year groups (e.g. primary and secondary), urban, rural or regional, or for different groups of students. The phased approach allows the monitoring on new infections of the impact of reopening at the local level before more schools are opened. Schools should have enough time and resources to plan and implement changes in time and physical structure to allow for social distancing and support of vulnerable teachers and students.

Before concluding we would like to mention the results of a study published in the prestigious journal of the US Academy of Sciences (PNAS). The main result of this study is that infection via aerosols is dominant in the transmission of covid-19 virus. That in order to stop contagion it is not enough just to maintain safe distances. That the only effective way to stop the pandemic is the combination of safety distance plus mask use. These results are based on the analysis of actual pandemic data in China, New York and northern Italy. Their conclusions could not be clearer:

We conclude that the use of masks in public is the most effective means of preventing inter-human transmission, and this practice, together with extensive testing, quarantine and contact monitoring, presents the most likely control opportunity to stop the COVID-19 pandemic before the development of a vaccine.

Conclusions

If we want to have a minimum guarantee that the reopening of schools and colleges will not be a health and social disaster, the authorities concerned should be consistent and provide the means to do so. Means which will, among other things, enable fewer pupils to be in class and safety distances of at least 1.5 metres to be maintained. The simple fact that there are fewer people in a classroom significantly reduces the risk of contagion if there is one or more sick people in the classroom. One way of reducing the ratio is to offer online schooling for all those families who wish to do so and especially those where people at risk live with the students. This can be done in two phases, starting with those families who already have the means for online monitoring, but also providing these means to those who do not have them and wish this type of education. Tutored online teaching for those families who wish to do so in times of pandemic also avoids unnecessary travel and additional contacts.

If it cannot be ensured that the measures that are already compulsory in other areas will be complied with in schools, then families cannot be required to take their children there in the knowledge that they are at greater risk of contagion. As long as the pandemic is not under control –and the data indicate that it is not, but rather the opposite– that it continues to increase (and the time for colds and flu is not yet here) it is counterproductive to do what is being done in schools: opening up without respecting either safety distances or reducing classroom capacity.

In any case, a discussion forum should be opened with all those involved: families, teachers, health and education representatives, to find flexible and safe solutions, something that has not been done at the Andalusian level. The current situation and society require this.

There is nothing better to end on than remembering the words of A. Durán at the end of his entry Confinement has saved hundreds of thousands of lives

We are worried, much more so than on the first of March, even though we are probably better prepared to detect a resurgence and control it, but perhaps not so much, so we are beginning to think that there is no reason to give up on attending a live football match or a concert, a demonstration, my favourite beach or the town’s festival. And we must be careful, because this virus only needs another dose of the spirit of the first of March to enter again in an exponential rate.

Apart from the reasons mentioned in this entry we would also add the opening of the schools under the current conditions and ignoring many of the safety measures established in the orders issued by the Ministry of Health and Families of the Andalusian Government.

This entry was written in collaboration with Niurka R. Quintero, Professor of the Department of Applied Physics at the University of Seville.