Children in the Age of COVID-19: A Conversation with Professor Brooke Nichols

Interview by Sarosh Nagar

HHPR Editor Sarosh Nagar interviewed Brooke Nichols, Ph.D., MSc, an Assistant Professor of Global Health at the Boston University School of Public Health. She conducts research on epidemiological modeling and mitigation efforts for viruses like HIV and COVID-19. The interview focused on Professor Nichols' work regarding COVID-19 testing plans and school reopenings. Read more about Professor Nichols here: https://www.bu.edu/sph/profile/brooke-nichols/

Sarosh Nagar (SN): Welcome Professor Nichols! Thank you so much for giving me the chance to interview you. So, to start, what got you interested in studying infectious disease modeling and global health?

Prof. Brooke Nichols (BN): Oh, that's a great question! So, I think the first time was when I was in Namibia in 2008. I had gone there to do a research project because I was doing my master's in public health and epidemiology, and originally I intended on studying something "atypical," and at the time, HIV was the major focal point of much research, so I wanted to choose another topic. However, as I arrived, I saw the devastating impact that the HIV epidemic was having on the healthcare system in Namibia. At that moment, it became clear to me that it needed to be a top priority to deal with the HIV virus, so my interest in infectious diseases and global health was born, and now, I hold a Ph.D. in the subject, and all my work since then has been focused on it. It's fascinating to me because it doesn't matter who you are. You can always get infected.

SN: So, on this subject of infectious diseases, I want to pivot to the elephant in the room: COVID-19. As you know, the US is currently undergoing a 3rd coronavirus wave after suffering two major ones previously. How did this spike in cases occur despite our experiences with the past two waves? What factors are behind the renewed rise in cases?

BN: What's been interesting about the epidemic in America is that, due to the country's enormous size, each wave had a different epicenter, so the first wave was mostly concentrated in the Northeast, the second wave in the South, and so on. But, contrarily, some places have already had a first wave and are now experiencing a second wave. As a result, it's difficult to find common reasons for infection because the US is such a heterogeneous country.

However, we can note a couple of things that might be driving case growth. For example, in some places that are now having a second wave after previously having a first one, not enough people were infected to achieve herd immunity while people's behavior didn't change enough to stop the spread. Now, as the winter approaches and temperatures drop, many individuals are shifting to more indoor activities, like restaurant dining, despite the higher rate of indoor transmission, which may explain the increase in cases. In addition, we must also still think about superspreader events because new data suggests that they have a relatively large contribution to the overall epidemic, and I think that the impact of these factors is driving the third wave as a result.

SN: You’ve studied the specific strategies of COVID-19 testing across the world, so do you think the US should be altering its testing strategy to cope with this new spike?

BN: Yes, I do. I think the biggest problem with the current testing situation is that there is no clear national plan. There's nothing. Everything is done at a local level, maybe at a state level, and we need to focus on a higher level. We need national leadership, and we need a plan from the top-down that we can follow because when the virus spreads in Minnesota, it doesn't just stay in Minnesota, right? And once it moves to, say, Wisconsin, it doesn't stay here because people move, so we need to shift resources accordingly.

This point is especially true when resources are scarce. For example, we have COVID-19 antigen tests capable of rapidly delivering results, but there aren't enough of those available, so there needs to be an increase in production to make the epidemic disappear. But how do we allocate those resources to where it's most needed to prevent further spread? We likely need a method of coordination across the country, like a national command center, to organize this kind of work, and I think that such a plan would be quite successful.

SN: Building on your discussion of the different state responses to COVID-19, what are your thoughts on the various state reopening plans? Are some going better than others? Are they occurring too early?

BN: I don't have a lot of familiarity with specific state plans, but I know a lot about Massachusetts, so I can comment on that. In Massachusetts, there is the recognition that cases are increasing, and Governor Baker came out with new restrictions yesterday, but the problem in the state right now is that cases are increasing almost linearly, not exponentially, despite what the media says. Media sources say that cases are surging, but they are increasing steadily, and at some point, it will become exponential, but it's not happened yet, so it's the perfect time to implement something drastic. If we are going to do something, do it hard, do it now, and we could avoid another wave.

But even still, issues exist with these mitigation measures themselves. For example, the Massachusetts curfew asking people to be home by 10:00 pm is a bit flawed because coronavirus isn't going to stop spreading just because it's a certain time. Similarly, some of the other measures in place are strange, like the fact that we still have indoor dining, casinos and you can gather in groups of up to 25 outside, but kids still aren't in school.

SN: I want to expand on that very last point. You've been particularly outspoken on the debate about reopening schools here in Boston and across the country, so would you mind elaborating more on your view of this issue? Should schools reopen, and if so, in what jurisdictions? What should the conditions or criteria for these reopenings be?

BN: Schools should absolutely reopen. There's been a lot of evidence suggesting that especially younger children, such as those in elementary schools, do not contribute disproportionately to the community spread of the coronavirus, which is encouraging. So, if we're doing all that we're doing to reopen schools in the US, with plans that include social distancing, masks, handwashing, and moving people around, that will help reduce the likelihood of an outbreak. Now, can kids get infected? Yes. Can teachers get infected? Yes, but the data suggests that the kids do not seem to be particularly efficient at spreading in that environment.

Now, normally the governors and state officials can set reopening guidelines, and then the local school boards add more specificity to these plans. But say we set a certain positivity rate threshold, and we say that at this rate, schools must close, as many states have done. Now, we start to run into problems. Case positivity rate is always going to be higher in a city like Boston than it will be in a less populated place like Wellesley, which means that we're going to have children in Boston who have not been in school for eight months now, having received little to no education, aside from "remote learning," though from personal experience, I doubt the effectiveness of such efforts.

As a result, a disproportionate number of children from low-income families and families of color receive virtually no education compared to wealthier communities, which have the resources to enable distance learning and other alternative means. Therefore, there is a need to make schools reopen safely to avoid an increase in the divide between the haves and have nots in our society. It's important! It's also definitely not a short-term thing either – COVID will last a while, and children need education in that longer time frame lest we risk worse inequality.

SN: Given the negative impacts of school closings, why do you then suppose that restaurants, bars, and other institutions are able to reopen while schools or not?

BN: Well, I imagine the reason is not science. If we could have a do-over of the pandemic and ask ourselves what we prioritize in our society, and we choose to prioritize education and equality, schools will open first. But that is not what we prioritized, and so that's the last in our bucket. If everything else goes all right, we'll add schools, whereas in other countries they do schools first and then see if they can add anything else. It's like rationing how much transmission we allow in society, seeing how it stacks up in some places versus others and deciding which modes are acceptable and which are not.

SN: So now that you bring up other countries, how has the international approach to school reopening has been different?

BN: So, there's been massive lockdowns across Europe, but a lot of them have kept schools open. In France, for example, they had strict lockdowns due to a drastic increase in the number of cases, but their elementary schools are still open. In other European states, like Germany and the Netherlands, the same is true, even though everything else has stopped, and so we see that these countries have prioritized education as part of their reopenings.

SN: For these educational measures, however, is there is an age cutoff beyond which you think students should not necessarily return to school?

I think we should make better choices as a society to reduce the incidence of coronavirus through other measures to allow all schools to open. But it seems like kids under 10 tend to be less problematic, but once you get into middle and high school, that's when we do see a greater likelihood of increased transmission. However, even in these settings, those results don't mean that a successful reopening with a low number of cases cannot be done. It can be done if there are good measures in place to mitigate the virus broadly.

SN: To then encourage these safe school reopenings you talk about, what support do you think local, state, and federal policymakers could provide to help with this process?

BN: Funding. I support measures like ensuring that teachers should have widespread, regular access to testing, and possibly children should as well (though some disagree), and if there was adequate funding from the government, the burden of paying for tests would not be on individual teachers, but rather, likely on school districts who would cover it with the aforementioned federal and state aid. This approach would be useful because we know that frequent testing strategies can help prevent transmission. For example, if you look at Boston University, they have this regular testing strategy for students, faculty, and staff on campus, and there have been no outbreaks, so if we can test often, we can prevent outbreaks early.

Now other mechanisms, like agreements with labs and other testing agencies, will also be important for these strategies, but funding from governmental actors could likely enable more effective mitigation. For example, we could use the funding for testing in the places where the case positivity rate is higher, decreasing the likelihood of any kind of transmission events. For example, instead of testing every part of Massachusetts at equal rates, we could focus the higher levels of testing in the communities that have been marked as "red" or having higher community spread. In this way, we could mitigate the disease's spread in the most vulnerable communities and allow them to reopen safely.

SN: So, looking to the future, we've heard a lot about COVID-19 vaccines coming out within the next year, but for children, a vaccine might require longer trials, which could run for several years. Do you think these school reopening measures can be maintained until a vaccine for children is available?

BN: I think it depends on the vaccine strategy. A piece of research that I'm working on is vaccine prioritization strategies looking at not just age and your job but also looking at geographic and the underlying seroprevalence of different communities. These methods allow us to see the minimum percentage of your population that needs to be vaccinated to generate enough herd immunity.

So, as this research indicates, there are many biological components to a successful vaccination plan, in addition to societal ones. People need to be willing to take it, and we need to get it to the right people. It's not straightforward, but I think we will see more prevalent vaccination between April and October, and I think our guidelines in schools will end up changing over time as vaccines get rolled out. However, I think we don't know exactly how vaccination will be prioritized for children, so it will be an important question for future discussion.

SN: All right, that's all of my questions. Thank you so much for the insightful answers!