Currently, 36 counties are on California’s watchlist of places where the coronavirus is trending too far in the wrong direction. Among other negative consequences of making the list, all public and private schools located in those counties are prohibited from holding in-person classes until their COVID-19 numbers have improved enough to meet established thresholds for 14 consecutive days. School districts subject to the restriction can request a waiver for elementary schools only.

KQED’s Brian Watt last Thursday spoke with Dr. Naomi Bardach, associate professor of pediatrics and health policy at UCSF, about the risk involved in bringing back classrooms for the upcoming school year, and the differences between how kids and adults both catch and spread the virus.

The following has been edited for length and clarity.

We know there is less risk for young kids when it comes to COVID-19. Is this true for both contracting and transmitting the coronavirus?

Naomi Bardach: Yes, and it’s pretty well-documented globally as well as locally. It doesn’t mean there’s zero risk for kids to either get it or transmit it, but they have a much, much lower rate, particularly in transmitting it, compared to adults and even high schoolers.

It’s important to make the distinction between elementary school kids and high school kids. It’s the elementary school age kids where we’re really seeing that difference.

What is it about younger kids that provides greater protection from the coronavirus?

There are a lot of different theories that have been floated. The best science we have right now to help explain it is a study that was done looking at what’s called the ACE2 receptors, which are how the coronavirus gets into the body. They’re  basically the doorway, and if you don’t have a doorway, you can’t get in.

The study, published in JAMA, looked at ACE2 gene expression in the nose. Meaning, do you or do you not make the ACE2 receptor in your nose. What they saw is that in the youngest age group, the 4- to 9-year-olds, there’s very little gene expression. There’s more gene expression in the middle school and high school age group. And then there’s even more in adults. So that kind of reflects the transmission patterns and how frequently kids are getting it in those different age groups.

Are there places in schools where the risk is higher?

The thing I’ve seen both in health care and also in an indoor camp setting where I’ve been doing some pilot testing is that our tendency as adults is to feel like when we are not working with children or not working with patients, we let our guard down. We’re in the break room and we’re eating food and we are sitting next to each other, not 6 feet away, and the mask comes off.

The other place that I would worry more about the transmission is with high school-aged kids. We know from the science and from epidemiology that they’re more likely to transmit at the student level. We need to think through hybrid curriculum and creative ways of making sure that they’re not passing things around.

What do communities need to consider when thinking about letting kids back in the schools?

There’s one really important thing to think about, which is that our mental model of kids being viral vectors, viral cesspools, needs to change.

We’re just very used to thinking about kids, especially young kids, as [sources of] infection.

But adults teaching young kids, and families with young kids at home, are not as likely to get the virus.  For high school-aged kids, it’s clear from the data and the epidemiology, as well as some of the basic science, they are the kids that you need to worry about more.

So our educational approaches are going to have to be different in the elementary schools versus the high schools. And as we think about teachers going back to school, it’s the adult-to-adult transmission that is the most important place to be focusing our efforts. That’s why in places with a high community prevalence, there’s a worry about opening schools. But [the lower transmission rate for children] also means that we have more control over viral transmission in a school setting than we thought when we imagined it was the children who are going to be transmitting the most.

What should families be thinking about when it comes to school this year?

There are risks at a societal level and there are risks at the individual level, and they’re both things that parents and families should be thinking about.

The risk to society and the effects we know come from schools being closed include poor educational outcomes for kids, which I think people really saw in the spring when schools were shut down, with very limited access to being able to learn.

That was exacerbating very clear existing disparities for kids who are poorer and have less access to the internet and devices at home.

Then there’s also very serious issues around mental health outcomes. So a lot more depression and anxiety in kids all across the socioeconomic spectrum — poor kids, rich kids, everybody struggling a lot. That’s important to be thinking about as we try to advocate for do we reopen or do we not reopen.

The other piece is the individual decision-making for parents. What is your school doing to help mitigate and decrease risk of transmission? There is also your own tolerance for risk to you and your family to consider.

Do you have any advice for parents to do better with distance learning?

That is such an important question, and it is extraordinarily hard to answer. As both a pediatrician and a mom, I struggle with it.

One important thing is acknowledging and recognizing the challenge for students of being distracted by screens.

If they’re on Zoom with their school, it’s very hard for them to resist going to other parts of their device, getting access to YouTube, to playing games, and to other things online. I haven’t seen a good technological solution to that yet. So, talk to them about the fact that distraction is hard and try to set it up so they have ways of limiting that.

The other thing is mental health. As this goes on for a long time, try to help students figure out how to have relationships, things like social distancing walks. Continuing their relationships is going to be extremely important. And being able to talk about their emotions.

Are there some overall messages for us to keep in mind as this pandemic evolves?

In some discussions, people set it up as a conflict between teachers and families, or teachers and pediatricians, with pediatricians and families wanting the kids to go back and the teachers saying no. I would say we need to support our teachers. They have to stay safe. We have to provide them with resources and testing capacity to be able to teach in a safe manner. We are all in it together. COVID is the enemy.

Also, we know a lot more than we did in March about how to mitigate risk. So we do know how to do it safely. We’ve seen other countries, reopen with relatively low community prevalence and they have zero infections, especially in their elementary schools, and they can control it in their high schools with hybrid curricula. So we know it can be done. We just need to commit to doing it as a society.

My last take is, right now, we’re in a surge. As we get to the next stage, we need to open schools before we open bars and restaurants.