COVID-19 and The Conundrum About How to Return to School for Children with Epilepsy

The global pandemic of coronavirus disease 2019 (COVID‑19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) and was first identified in December 2019 in Wuhan, China. Limited data suggests children are low risk and get less severe COVID‑19 infection. As the outbreak of COVID‑19 continues to spread, children with special health care needs may be at increased risk for complications. The forced school closure early in the year may have allowed for social distancing and protected children at risk from exposure to the virus. As the schools prepare to open in person schooling, the parents and caregivers of children with epilepsy are faced with unchartered and challenging decisions about how their child will return to school. When deciding between in‑person and virtual learning, limited data is available for parents and health care providers to make this decision for children with epilepsy. Presence of other comorbidities may also alter the decision and needs for school. A Parent is their child’s best advocate, who knows them and their needs the best. Some of the important considerations that can help make the best‑informed decision for this special population are discussed in this communication.


Introduction
Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which initially occurred in Wuhan, China in late 2019. This virus has now become a pandemic rapidly spreading globally [1]. While children have been reported to be less affected by COVID-19 compared to adults, children with certain medical conditions may be at increased risk for severe illness [1]. Children who are medically complex, who have serious genetic, neurologic, metabolic disorders, and with congenital heart disease might be at increased risk for severe illness from COVID-19. One centers for disease control and prevention (CDC) report noted that the majority of hospitalized children with COVID-19 in the United States had one or more underlying medical conditions such as chronic lung disease, cardiovascular disease, and immunosuppression [2].
Epilepsy is a neurological disorder characterized by a spontaneous recurrence of unprovoked seizures. It is one of the most common chronic neurological conditions, with a reported prevalence rate of 0.7-1.0% with high incidences in elderly people and children [3]. With the limited data available, it is unknown if patients with epilepsy have a higher risk for infection or severe complications of COVID-19. Various medical associations and societies for patients with epilepsy suggest that the history of epilepsy in itself seems unlikely to be a risk factor for COVID-19 [4]. Epilepsy, most authors will argue, does not consist only of epileptic seizures, but also many systemic co-morbidities with a common origin [5]. The CDC has indicated that due to high rate of associated comorbidities may increase the risk for COVID-19 infection in patients with epilepsy [4]. Conversely, children with well-controlled epilepsy and no other comorbidities may remain asymptomatic or exhibit only mild symptoms of COVID-19 [6].
Early in the year, in response to the COVID-19 pandemic, hundreds of countries implemented school closures worldwide [7].
This kept vast majority of children, including those with complex medical conditions, at home and allowed to maintain social Current data from these also shows the rate of infection among younger school children, and from students to teachers, has been low, especially if proper precautions are followed. There have also been few reports of children being the primary source of COVID-19 transmission among family members [9][10][11]. This is consistent with data from both virus and antibody testing, suggesting that children are not the primary drivers of COVID-19 spread in schools or in the community [12][13][14]. The results are still not conclusive, but the available evidence points to the theory that in-person schooling is in the best interest of students, particularly in the context of appropriate mitigation measures being implemented. This low presumed risk for children is countered by the potential harm prolonged school closure may cause in the long term. It can lead to significant learning loss, particularly in students with heightened behavioral and special needs for whom in-person instruction is vital [15,16]. Of another particular concern is the disparities in educational outcomes caused by school closures for low-income and minority students and students with disabilities [16].
What does this mean for children with epilepsy and their families? Parents, caregivers, and guardians of children with epilepsy face new and challenging decisions about how their child will return to school this fall, such as deciding between inperson and virtual learning. As mentioned above, limited data about COVID-19 in children suggest that children are less likely to get COVID-19 than adults, and when they do get COVID-19, they generally have less serious illness than adults. However, it is clearly identified that children who are medically complex, who have neurologic, genetic, metabolic conditions, or who have congenital heart disease might be at increased risk for severe illness from COVID-19, compared to other children. Severe illness means that they may require hospitalization, intensive care, or a ventilator to help them breathe, or may even die [2]. Children with epilepsy qualify for more than one of the listed risk factors due to use of immunosuppressive medications, being non ambulatory, respiratory weakness/insufficiency, intellectual disability, and mental health/behavioral disorders. CDC has provided a 'Decision making' tool for parents to try to make a calculated decision about in person versus distance learning for their child [17]. The questions in these tools are designed to help you weigh the risks and benefits of available educational options before you make decisions. This tool is a general tool and may not completely apply to children who are higher risk due to epilepsy and its co-morbidities but give some idea of what broadly needs to be considered. increased risk for severe illness from COVID-19 due to age or underlying medical conditions? If the child with epilepsy is not high risk based on CDC criteria [18], make sure their caregivers/ family members are not at high risk due to an underlying comorbidity, If you do identify someone at home at risk it might be a consideration for avoiding in person school for the child to protect the other family members.

c)
What is the level of community spread in my local area?
A critical role for the safe and successful opening of schools is a low local infection rate in the community. According to the University of Nebraska Medical Center (UNMC) Public health department and biocontainment center, the 15 countries internationally were successful in reopening in person schools because they waited until transmission rates were less than 10 cases/million population/day [19]. The ability or timing to return to in person schooling will also factor in the local health authority's preparedness with testing, timely contact tracing and quarantine. The best protection for the children, teachers, and school staff from getting COVID-19 infection is reducing the rates of transmission in the community.