So many situations, so many values-Understanding the complicated situations against COVID-19 issues.

The global spread of COVID‐19 has placed a burden on vulnerable populations including the elderly, pregnant and nursing mothers, children, and the disabled.

One of the burdens to children caused by the emergence of SARS‐CoV‐2 is the limited access to health and medical services and school.

Yamamoto et al., report a 40.6% decrease in pediatric emergency healthcare utilization in 2020 compared with the same periods (1–39 calendar weeks) during 2017–2019. The authors argue, controversially, that school closure is a positive aspect of public health interventions and has contributed to a reduction in emergency department (ED) visits, which could lead to the reallocation of medical resources.

In this editorial, we review the burdens that COVID‐19 has placed on children and examine the meaning of the article by Yamamoto et al.

School closure

At the beginning of 2020, there was no clear information on the effectiveness of the then‐expected vaccines and the route of transmission of COVID‐19. As Yamamoto et al. pointed out, children were regarded as a potential source of COVID‐19 transmission because of their known susceptibility to various viral infections, including influenza. This resulted in the closure of schools. However, the data were not supportive of this policy because during the SARS and pandemic influenza epidemics and recent observational studies it was concluded that "children cannot be the primary vectors of COVID‐19 infection."

Despite this finding, the then Prime Minister of Japan made a "political decision" to close all primary, middle, and high schools from March 2020. The social impact of this decision was huge, with parents raising school‐age children unable to go to work. Medical institutions were burdened by the inability to ensure that staff of child‐bearing age could attend work. In addition, distance learning was promoted in Japan at around the same time as the school closures, many parents could not afford. This resulted in the emergence of disparities in education.

In A policy evaluation paper published on 27 October 2021 concluded that there was no evidence that school closures in Japan had contributed to the control of infection. School closures in the Philippines and Bangladesh are also examples of such non‐evidence‐based policy enforcement. In the Philippines, school closures of more than a year, partly due to the impact of the delta variant of COVID‐19, denied children the opportunity to learn. Such policies undermine the right to development and right to participation, as stated in the Convention on the Rights of the Child.

In 2021, as a result of the outbreak of the delta variant, mainly in Asia, Europe, and the United States, reports of infections in children due to household contact became more frequent. At the same time, international organizations began to discuss measures to ensure that children could attend school safely. For example, five UN agencies (UNESCO, UNICEF, the World Bank, the World Food Programme and the UN High Commissioner for Refugees) launched the Framework for Reopening Schools. It states that when deciding whether to reopen schools, authorities need to consider the benefits and risks of the whole range of educational, public health, and socio‐economic factors in the local context, using the best available evidence. It clearly states that the best interests of all children should be paramount.

There has also been debate about getting children back in school safely in some academic journals such as Nature Medicine and Science. An editorial in Nature Medicine argues that "it is time to consider that the impact of COVID‐19 on children goes far beyond the symptoms of the disease itself." The journal Science in its Perspective reviewed a range of evidence and concluded that "evidence‐based measures need to be evaluated and implemented to reduce the risk of infection in schools, with an emphasis on protecting students and staff as well as minimizing disruption to education and access to additional services. Both papers refer to the potential mental and health consequences of keeping children out of school, in addition to the loss of learning opportunities.

Health and medical services

Several articles deal with decreased use of medical facilities, particularly the ED. A German study reported that a reduction of 63.8% occurred in pediatric emergency healthcare utilization and a Canadian study encompassing 18 EDs reported 57% and 70% reduction in overall visits to children's and general hospitals EDs respectively. Both articles consider these reductions as concerning and recommend communication of communities that EDs are serving. Services for healthy children including well‐baby/child clinics and routine immunization are also matters of concern with regard to the COVID‐19 pandemic because their parents are hesitant to access health services for children due to possible SARS‐CoV‐2 infection. A study in Saudi Arabia dealing with routine immunizations found that the most common reason for delaying vaccinations was the fear of being infected by COVID‐19. The most preferred place for giving vaccinations was the child’s own home, thereby requiring a significant and sustainable increase of routine immunization services during pandemics. In Germany, it was reported that the number of weekly visits to well‐child clinics decreased by more than 35%. Although the reason for the decrease is not detailed, it is not difficult to assume that parents/guardians considered a well‐child clinic visit as unnecessary during the pandemic.

Burden Implied in this article

School closures are generally considered as having a negative effect on children, even though they are accepted as a positive policy in relation to public health interventions. The authors point out that EDs may fail some children with accidental injury. This is happening despite the fact that we are in the SDG era with “No‐one left behind” as our motto. As the authors state: “Public health interventions are not sufficient to reduce the incidence of accidental injuries substantially and medical resources need to be available continually for patients with these complaints even during a pandemic.”1

Even the most well‐structured public health interventions have their limitations when it comes to treating patients and thus ED physicians need to be alerted to this. Policy makers should be flexible in their approach to managing pandemics, keeping in mind that the interest of the children should be paramount.

Disclosure

The authors declare no conflict of interest.