Landmark study of COVID-19 infection among K-12 students debunks early fears about transmission at schools

Debunking a fear that was widespread at the beginning of the COVID-19 pandemic, a novel CHOC- and UC Irvine-led study of SARS-CoV-2 infection rates among the K-12 population concludes that within-school transmission of the virus is limited.

The “Healthy School Restart Study,” one of the first to provide essential research on COVID-19 transmission in children and adolescents as schools started reopening last fall, also concludes that although the compliance rate to such mitigation guidelines as wearing face coverings and practicing social distancing at the four Orange County schools directly observed by investigators varied, it averaged about 90 percent.

The seminal research paper is under review and is expected to be published soon, says Dr. Dan Cooper, who treats kids with lung conditions at CHOC and who serves as director of UC Irvine’s Institute for Clinical & Translational Science. Dr. Cooper is a multiple principal investigator of the study along with Dr. Erlinda Ulloa, a CHOC infectious disease specialist and an assistant professor in the Department of Pediatrics at the UCI School of Medicine.

Dr. Dan Cooper, pediatric pulmonologist at CHOC

“The number one fear was that, just like influenza, children would be a reservoir for COVID-19 and would spread it to each other at schools and then spread it to adults,” Dr. Cooper says. “The data is showing us, fortunately, that that’s not the case. While such spread can occur, it is limited and when schools follow standard mitigation procedures, spread is minimal.”

The study, a joint effort of CHOC, UCI Health and the Orange County Health Care Agency, found that infection rates at schools reflected those of the community, and that neither remote learning nor highly mitigated onsite school attendance could eliminate SARS-CoV-2 infection.

“It would be disingenuous to say it’s 100-percent safe to return to schools – we’re still in a pandemic,” Dr. Cooper says. “It would be wrong to say there’s absolutely no risk in sending your child back to school, but it would also be wrong to say there’s no risk in not sending your child back to school.”

A total of320 students ages 7 to 17, as well as 99 school staff members, participated in the research project by agreeing to nasal swab and blood testing. Two of the schools in the study serve low-income Hispanic learners. One school serves a high proportion of kids with special needs, and the fourth school serves predominately white kids from upper- and middle-class families. The first three schools mainly provided remote instruction, while the fourth school predominantly provided onsite instruction.

“The four participating schools reflected the enormous diversity of income, community COVID-19 case rates, school type (private, charter, public), and learning status (remote vs. onsite) that face learners, school staff, and policy makers across the United States,” the paper states.

The study was done in two phases – in early fall, when there were lower levels of COVID-19 cases, and a second time during the late fall-winter surge, when there was a tenfold increase in COVID-19 cases. Trained observers studied kids four times a day – during classroom learning, at active recess, during PE, and during communal lunch.

During the first testing phase, no kids tested positive for COVID-19. During the second phase, 17 kids tested positive for the virus, along with six staff members.

School A, which primarily serves lower-income Hispanic students and had 97 percent of its students engaged in remote learning, had the highest infection rate, at 12.9 percent. School D, which serves upper- and middle-class students who primarily attended class in person, had the lowest infection rate, at 1.2 percent.

In the aggregate, there was no statistically significant difference in SARS-CoV-2 positive rates among remote or onsite learners, the study found.

In addition, the study found there was a significant relationship between SARS-CoV-2 positivity and presence of symptoms – data that supports the use of limited symptom screening as a mechanism to enhance healthy school reopening.

Investigators also tested for 21 other circulating respiratory pathogens and turned up no signs of the influenza virus – just the common-cold rhinovirus, which stays functional on surfaces such as desktops for much longer intervals than the coronavirus or influenza virus.

“The mitigation procedures and cleanliness procedures that had been put in place got rid of the flu,” Dr. Cooper notes.

He adds: “This study should make parents feel better and prompt them to ask the right questions to their school. Parents should ask, ‘What are your mitigation plans? How are you making sure people are paying attention to your plan? What happens to a child who reports symptoms during the day? Do you have a plan?’ That’s what I would want to know as a parent.”

Mitigation procedures should remain

With widespread implementation of pediatric COVID-19 vaccination still many months away, it’s likely that adherence to COVID-19 mitigation procedures, including physical distancing and face covering, will need to continue for the near future, the study concluded.

Dr. Cooper notes that some students, mostly from lower-income families, are going on a year without in-classroom learning – an unfortunate situation that comes with many disadvantages, such as more sedentary time at home on the computer and increased obesity and depression.

“We have to weigh the damage to kids of keeping schools closed,” he says. “Who is being impacted most? It’s the low-income kids.”

In addition to Dr. Cooper and Dr. Ulloa, other CHOC and UCI personnel who participated in the “Healthy School Restart Study” included Jessica Ardo, Kirsten Casper, Andria Meyer, and Diana Stephens, clinical research coordinators; Dr. Charles Golden, vice president and executive medical director of the CHOC Primary Care Network; and Dr. Michael Weiss, vice president of population health at CHOC.

The authors of the research paper also acknowledged the “outstanding management” of the complex study by Phuong Dao, director of research operations; Brent Dethlefs, executive director of research; and other staff members of the CHOC Research Institute.

In another research paper, published in late February 2021 in the journal Pediatric Research, Dr. Cooper and Dr. Ulloa addressed the biologic, ethical, research and implementation challenges of SARS-CoV-2 vaccine testing and trials in the pediatric population.

Among others, the paper was co-authored by Dr. Coleen Cunningham, CHOC’s new senior vice president and pediatrician-in-chief, as well as chair of the UCI Department of Pediatrics, and Dr. Jasjit Singh, a CHOC infectious disease specialist.

Children under the age of 12, this paper notes, have yet to be enrolled in COVID-19 vaccine trials.

The paper states that enrolling children in medical research involves a balance between access to experimental but potentially life-saving therapeutics and protection from unsafe or ineffective therapeutics.

The paper notes that in the early stages of the pandemic, a national working group convened and published a commentary outlining the challenges ahead that would inevitably need to be addressed as schools reopened. That commentary, the paper says, included a message that resonates with the immediate challenge of pediatric SARS-CoV-2 vaccine testing and clinical trials:

“This could be accomplished by building public health-focused collaboratives capable of continuous learning and rapid cycles of implementation, as COVID-19 information evolves at breakneck speed. Otherwise, we risk further compounding the incalculable damage already incurred by COVID-19 among children across our country and the world.”

Read more about the Healthy School Restart Study.

In the spotlight: Dr. Coleen Cunningham

Dr. Coleen Cunningham’s family has long joked that she knew she wanted to be a pediatrician before she was born. By eighth grade, she was certain that she’d work in pediatrics – and she never looked back.

“Kids are just wonderful,” she says. “They’re always a pleasure to be around – how could you ever not want to help a child?”

Today, she serves as both senior vice president and pediatrician-in-chief at CHOC and chair for the UCI Department of Pediatrics. In this unique dual role, which she began in March, Dr. Cunningham acts as a senior clinical leader with oversight responsibility for CHOC’s vast pediatric medical and surgical services, academic advancement, research and teaching programs.

Dr. Coleen Cunningham, senior vice president and pediatrician-in-chief at CHOC and chair for the UCI Department of Pediatrics

“The big job here is integrating our two institutions, CHOC and UCI, and learning how we can align better,” says Dr. Cunningham.

In this role, she explains, she works as a liaison between physicians and administration, which allows her to communicate the patient care needs from the standpoint of a physician to administration, and vice versa. She will also be overseeing the medical education components, so that both entities can ensure they are recruiting and providing the best trainees, residents and fellows.

“As an insider at both CHOC and UCI, I understand what the issues are, but I’m also able to speak for both teams,” she says. “I can take a step back and advocate for the group as a whole. This is a new perspective, but it affords each institution the room to adjust and align.”

Most recently, Dr. Cunningham served as professor with tenure at Duke University in the Division of Pediatric Infectious Diseases and as chief of Global Health and vice chair for research in the Department of Pediatrics. She held secondary appointments in the Department of Pathology at Duke and the Duke Global Health Institute.

She earned her medical degree from the State University of New York Upstate Medical University in Syracuse, NY, where she also did her residency in pediatrics and a fellowship in pediatric infectious diseases. At SUNY, she served as an associate professor of pediatrics and started a pediatric HIV clinic.

Her work on HIV and AIDS in children has been recognized numerous times and is one of the stand-out moments of her career.

“When I started my job, I was telling mothers that their baby had HIV,” she says. “I would be crying alongside them, because at the time, there wasn’t much we could do. Today, when babies are diagnosed, they can be effectively treated – they can live to be 60 or 70, and we get to tell their parents that they’re going to lead a normal life. Seeing that evolve over the course of my career has been very rewarding.”

Dr. Cunningham has published more than 140 manuscripts and led many multicenter clinical trials aimed at the treatment and prevention of HIV infection in children. The progress that has been made in treating HIV, she says, reinforces the importance of integrating clinical care and research.

“Driving the best care for tomorrow requires integrating research and data analysis into our patient care environment, saying ‘Can I improve? Can I do it better?’” says Dr. Cunningham.

Her goal at CHOC, she says, is making research visible.

“CHOC already provides exceptional, top-notch medical care to children,” says Dr. Cunningham. “And if people heard about some of the incredible things we’re doing here, they’d be amazed. We want to lead the nation in care, but we also need to make that care more visible and teach others how to follow suit.”

Her drive to teach extends beyond her role with CHOC and has long been one of her passions. A few years ago, she was recognized as a top mentor by Duke, and she continues to actively mentor several junior faculty at the university.

“I love watching my mentees come into their own, fly and go beyond what I can do – it’s like having more kids,” says the mother of five. “I get excited to watch them grow and move their career in the direction they want it to go.”

Dr. Cunningham’s ultimate goals at CHOC are to fully and successful integrate the health system and UCI; develop the physicians, including the physician-scientists at both institutions; and enhance CHOC’s national reputation.

Once she has accomplished that, she says, she has only two things she wants to focus on: her garden and her grandchildren.

CHOC welcomes Dr. Coleen Cunningham

CHOC is thrilled to welcome Dr. Coleen Cunningham, whose appointment as senior vice president and pediatrician-in-chief begins today.

Following a national search, the University of California, Irvine School of Medicine and CHOC Children’s jointly announced in October 2020 that Dr. Cunningham, a renowned professor of pediatrics and pathology from Duke University, had accepted a dual appointment position as both the chair for the UCI Department of Pediatrics and as senior vice president and pediatrician-in-chief for CHOC. 

In this unique, dual role, Dr. Cunningham is responsible for leading UCI’s Department of Pediatrics and its 16 divisions that span the spectrum of diseases and disorders.  She is charged with bringing real-world academics, scientists and clinicians together to collaborate and uncover new knowledge through research, and effectively apply that knowledge to advance children’s health.

Dr. Coleen Cunningham

As CHOC’s senior vice president and pediatrician-in-chief (PIC), Dr. Cunningham serves as a senior clinical leader with oversight responsibility for the healthcare system’s vast pediatric medical and surgical services, academic advancement, research and teaching programs, as well as become the key physician executive liaison between CHOC and UCI.

“Dr. Cunningham’s broad medical experience, advanced research expertise and extraordinary leadership capabilities in the field of children’s health will be transformative to Orange County and the communities that CHOC and UCI serve,” said CHOC’s President and CEO Kimberley Chavalas Cripe. “Combining the clinical, research and academic expertise of UCI and CHOC will not only advance the pediatric care of children in the region, but also advance the education and training of the next generation of pediatric experts through a fully integrated program that leverages a top tier children’s health system with a top tier academic health system.”

Balancing the tripartite mission of UCI School of Medicine – Discover. Teach. Heal. – Dr. Cunningham will drive research, educational and clinical excellence, while helping further CHOC’s mission to nurture, advance and protect the health and well-being of children. In her role, she will ensure full integration of research and academic priorities across the continuum of care at both CHOC and UCI’s pediatric programs.

“Dr. Cunningham is a nationally-recognized scholar and forward-thinking leader, with a distinguished record of achievement in research, education and clinical care,” said Michael J. Stamos, MD, dean of the UCI School of Medicine.  “We are confident in her ability to lead our organizations.  Hers is a great story of achievement and we are honored to have her join us.”

Dr. Cunningham joins UCI and CHOC from Duke University where she serves as professor with tenure in the Division of Pediatric Infectious Diseases and as chief of Global Health and vice chair for research in the Department of Pediatrics.  She was chief of Pediatric Infectious Diseases until 2015 when she stepped down to focus on vice-chair responsibilities. She holds secondary appointments in the Department of Pathology at Duke and the Duke Global Health Institute.

Dr. Cunningham earned her medical degree from the State University of New York Upstate Medical University in Syracuse, NY, where she also did her residency in pediatrics and a fellowship in pediatric infectious diseases.  At SUNY, she served as an associate professor of pediatrics and started a pediatric HIV clinic.

Her work on HIV and AIDS in children has been recognized numerous times, as has her work on H1N1 influenza. Most recently, Dr. Cunningham was awarded the Denny, Katz, Simon, Tingelstad Academic Service Award from the American Academy of Pediatrics.  She also recently received the Translational Research Mentoring Award from Duke University Medical Center and was selected for participation in the Executive Leadership in Academic Medicine (ELAM) program.

Dr. Cunningham has published more than 120 manuscripts and led many multicenter clinical trials aimed at the treatment and prevention of HIV infection in children.  She has obtained several competitive research funding awards and served on National Institutes of Health and other grant reviews.  She has also done extensive work as an educator, teaching students at all levels, from undergraduate to fellows, focusing on training Pediatric Infectious Diseases Physician Scientists.