COVID-19 and School Reopening 

As the COVID-19 pandemic continues to wreak havoc across our nation and the world, setting records for single highest daily cases in the U.S., the unintended consequences of the important public health measures that have been put into place to slow the spread of the virus are beginning to unfold. There are 138 countries worldwide who have closed schools, and >60% of children worldwide have had their education impacted. The consequences of this disruption in education are devastating.

Should schools reopen this Fall? For many of us who have been attempting to balance full time work and full-time childcare responsibilities in the middle of this pandemic, this is the million dollar question! As a mother of three kids (ages 4 months, 5 years, and 7 years) attempting to work full-time at home as a doctoral epidemiologist involved in COVID-19 research, and a faculty member/educator myself, with a spouse on the frontlines as an emergency medicine physician, I have been scouring the literature for months looking for data and evidence on this very topic to help inform my own level of risk tolerance for school reopening. I was at 200% capacity this Spring when only weeks into my maternity leave, schools closed, my spouse left our house due to concerns of COVID-19 exposure in the ER, and I was left to attempt to temporarily fill the role of teacher for virtual learning for my two older kids while getting pulled into COVID work. I recognize that I am privileged to have a job and a home and the resources to do what I could, and I was thankful that because I was on maternity leave I wasn’t teaching and having to move all of my coursework to an online learning environment in little to no time like my colleagues, but I struggled on an hourly basis to pull this off.

So, should schools open? I’m going to attempt to answer this critical question in this post.

Before I answer the question, I’ll point out that the answer to this question isn’t exactly straightforward, for the following reasons:

1) There is not going to be a zero-risk solution for opening schools.  COVID-19 is still an important threat to our health and well-being, and this is likely to be the case until we have achieved herd immunity through a vaccine (likely 1+ year away). It’s unfortunate that we are in this situation, and in the U.S., that a failure to respond to the COVID-19 threat in a timely and responsive manner was a missed opportunity. This situation is going to put each of us in the situation of calculating our own personal level of risk to make this decision, and we all may have different levels of risk tolerance. But it’s also important to consider that this risk is not going away any time soon. Not only do we need a vaccine, we need a safe and effective vaccine, AND we need uptake of that vaccine. This virus is here to stay, and I don’t think it’s feasible to close schools for 1+ years.

2) Whether we see face-to-face instruction, virtual learning, or a hybrid model, this will be a very different path forward. There is no going “back” to the way things were for awhile. 

3) The level of concern for COVID-19 varies by region and community, and thus the solutions will vary based on your own region. Do you live in a big city with an upward trend in COVID-19 cases?  If so, advice may look different than if you live in a rural area in the Northeast where there is a downward trend in cases and everyone in your community is wearing masks and listening to public health advice on physical distancing.  Does your community have access to testing? Is contact tracing happening in your region? In Georgia where I live, the threat of COVID-19 is even more pronounced as we have seen recent rises in cases in the last month. Our state was the first to reopen, and our Governor has shown no signs of introducing any new restrictions despite the increasing number of cases and record numbers of daily cases. In our area, my non-scientific assessment is that only about 50% of people are wearing masks in public.  In contrast, my colleagues in the harder hit NY area say that mask compliance is extremely high.  So the risk of COVID-19 spread in my community may be greater than in many other regions. 

4) My recommendations are primarily targeted to elementary and middle school, and to some degree high school. COVID-19 generally increases with age, and that the youngest (elementary kids) are the least at risk. These are also the kids who are least likely to succeed with a full-time virtual learning environment. The American Academy of Pediatrics guidance for school re-entry has specific recommendations by school level that should be considered. And college students will require an entirely different post, so not everything here applies to those learners.

5) It’s really important to note that new evidence and science comes out every day. Unfortunately (or maybe fortunately in some ways given a lot of the recent retractions of major scientific publications related to COVID-19), it takes a long time to conduct, analyze, and evaluate in a peer-reviewed setting high quality research on the questions we want and need answered immediately. I have multiple papers of my own research that have taken 6+ months in the peer-reviewed process alone. Keep in mind for a researcher to conduct this work it takes the following steps: applying for funding to conduct the research, planning and executing an appropriate study design for the research, doing the study, analyzing the results, writing up the results in a manuscript, submitting for publication to a peer-reviewed journal, responding to peer review critiques and revising any analyses or writing, and then publication to disseminate to the larger community. In my field of epidemiology, we know too that ONE single study is not the answer. It takes multiple study designs, in multiple populations, with various valid, evidence-based methodologies, to arrive at the truth. So with respect to COVID-19 and school openings, we have to acknowledge that we only know very little about COVID-19 right now and that there is likely to be new evidence and science that will emerge as we begin to open schools.  Some of the science is not as strong as it should be, and we have to do the best we can with what we have, knowing that recommendations will change over time.

6) The health of teachers and school staff is paramount - Just like with healthcare providers and other essential workers (e.g., grocery workers, manufacturing and food processing workers, postal workers, etc), teachers are going to soon become frontline workers. Just like basic necessities of healthcare, education (at least public education) is also a public good. Healthcare workers were outraged for months at the expectation that they had to go to work and risk their lives with limited personal protective equipment (PPE). Movements like www.getusppe.org and hazard pay for front-line workers pushed for this important agenda. We need to do the same thing for teachers and staff that will be required to safely open our schools. Teachers should not be paying for their own PPE as many have paid for their own school supplies for years. This has to be a community effort to keep our teachers and staff safe, which will also help to keep our students and children safe.

So, back to the question - should schools reopen for face-to-face instruction this Fall?  YES.  I was 100% supportive of schools closing this Spring with the many unknowns of the virus and the role children played in its spread, and knowing that we needed time to understand the virus, set up important infrastructure like ensuring appropriate personal protective equipment for hospital staff, COVID-19 testing, contact tracing, and isolation, and flatten the curve to help prevent our healthcare system from overwhelm. But I would NOT advocate for schools to continue to remain closed.  Schools need to reopen for the reasons described below, but they need to do so safely, and consider all of the scientific evidence that we currently have to ensure that reopening as safe as possible while still remaining open for learners, and safe for teachers and staff.

Here are some of the main reasons justifying why I advocate for schools reopening in a face-to-face environment (with appropriate public health measures in place), and allowing for virtual learning for those who are high risk (and virtual teaching options for teachers who are high risk):

1. COVID-19 is less common in children.  Though population-based data are still relatively sparse, it appears that COVID-19 is much less common among children than adults. There are various references to support this, including this one and this based on data from China. There is an excellent systematic review of 45 different studies from several countries on the topic that shows that children represent <5% of cases. For those interested in more data on this, UpToDate is the clinical resource that physicians use in practice to make real-time decisions on patient care and is an excellent source on this, and they have amassed a number of reference related to this topic here.

2. Among those children that get COVID-19, the risk for poor health outcomes such as hospitalization and death are rare.   Yes, we have seen the super scary reports of the proinflammatory syndrome related to COVID-19 in some children, such as described in this recent JAMA article. While this is a very serious condition, it’s important to recognize that the absolute risks of this outcome and other poor outcomes are still very low.  We have seen this established in a number of research studies, including this one in Canada and the US, and this one in Italy. In the U.S.,  less than 1% of hospitalizations were among children. Symptoms are much less severe among children than adults, with 90% of cases having asymptomatic, mild, or moderate disease.

3. Transmission of COVID-19 in children appears to primarily be from adults passing the virus to children, rather than children passing the virus to adults.  So far, what we know about COVID-19 is that of the children who DO get sick from COVID-19, they typically get the virus from an adult member of their household, where they presumably have prolonged exposure to the virus. See evidence for this here, here, here, and here.  I hope there are more studies on this topic in future months, because we only have a few studies on this, and lack of studies/evidence here does not necessarily mean it’s NOT possible to see spread from children —> adults, and it would be surprising if this was not possible. Part of the reason why children are thought to play a much lower role in spreading COVID-19 to others is because the vast majority of children are asymptomatic. This is different than seasonal flu, where children play a much larger role in the spread of the virus. But again, and this point is critical, we really need more studies on this one to confirm that transmission truly is lower among children. It is entirely possible that all of the school closures stopped this as a tranmission route, and this will be a place where I’ll be watching the data closely in coming weeks.

4. School closures are thought to play a limited role in preventing COVID-19 spread.  Though admittedly, this is an area that also needs more research, in a recent systematic review, modeling suggests that school closures ALONE would prevent 2-4% of deaths, which is substantially less than other public health measures such as social/physical distancing and mask wearing. Rather than close schools outright, what makes more sense is to keep schools open but put into place known risk reduction measures such as physical distancing (when possible), mask wearing, and limiting large gatherings within schools to reduce the risks of COVID-19 spread.  More on this later.

5. There is a substantial impact on our children and communities when schools are closed.  There is a wealth of evidence around the value of in-person education for children, and even in the last few months of schools closed, there have already been reports of the negative impact on children’s health and well-being.  This is one of the major points that the American Academy of Pediatrics makes in its recommendations to re-open schools. The AAP states, “Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.”  We also know that COVID-19 is disproportionately impacting some communities and students, particularly those with lower socioeconomic status, children of essential workers, communities of color, and children with two working parents when those parents have limited flexibility in their own jobs to care for children at home or provide them with any educational instruction during virtual learning. Prior research has shown that holidays and summer breaks increase the widening gap in educational achievement among children in lower vs. higher poverty levels. Not all households have the luxury of participating in virtual learning, due to unstable Internet, food insecurity, housing insecurity, or working parents who cannot oversee education. This gap is likely to increase during the COVID-19 pandemic, as we have seen record numbers of unemployment and a rise in poverty. COVID-19 is highlighting and widening educational inequities that previously existed in our school system, and disproportionately impacting our Black, American Indian, and Hispanic/Latinx communities. It is essential that this is taken into consideration as schools create plans for returning. Pediatricians are seeing increased numbers of calls to child and sex abuse hotlines, and we know that this is just scratching the surface of the mental health of our children. How can full-time virtual learning support children with additional needs, such as those with individualized education programs and 504s? What about very young children whose attention span for virtual learning is < 1 hour (see picture of my 5 year old son above, after only one 30 minute zoom call!). Kids need structured environments to succeed, and they need their school as a support system.

6. We cannot fully return our economy to normal without reopening schools full time in a face-to-face environment.  The COVID-19 pandemic and school closures are disproportionately affecting women who are now working multiple full-time jobs as a homeschool teacher, an employee, and a household manager.  The burden of care typically falls on women, and it is likely we will see limits on the career advancement of women and more women who are unable to work outside of the home or complete the requirements of their job at home. Healthcare workers, who we need to help fight COVID-19, are also disproportionately affected.

I would advocate for a return to face-to-face instruction, for all learners who are not at high risk of COVID-19, with as many risk reduction strategies we can put in place as possible. What can schools do to maximize safety?  First, this shouldn’t just be a solution that school boards and teachers should face alone. We all have to work together to reduce the spread of COVID-19 in our community.  The best way to reduce the risk for our children in schools is to reduce the risk of community spread, which evidence so far suggests this is largely through adults. Practices such as physical distancing outside of school hours, wearing masks in public places, and hand hygiene practices among families are essential to maintaining the health of the children, staff, and teachers in our schools.

This is an excellent guide that was just recently released by the Harvard School of Public Health, which advocates for specific measures of risk reduction that schools can put in place.  My kids are in the Atlanta Public School system, which serves > 52,000 students across 91 diverse learning sites around our city.  I would expect that the solution for such a large district that serves schools such as Thomasville Heights Elementary where all 417 students are considered economically disadvantaged, and where many students need to see their school reopen on a full-time basis so the students are not left further behind. All of the solutions that we put in place have to consider equity — how will our school reopening address inequities? Are members of the most vulnerable populations at the table when deciding the solutions and measures to put into place for safe reopening?

Here are some specific suggestions from the Harvard School of Public Health guide that we should consider. I urge teachers, school administrators, and staff to read the full report:

1. Play outside as much as possible. Continue to offer recess, but stagger recess times and ensure oversight to limit high risk behaviors. Have kids sanitize before and after recess.  Hold PE classes outside if weather allows, consider more outdoor classroom time when weather is appropriate.

2. Stagger school arrival and departure times to encourage physical distancing.

3. When it’s not possible to distance by 6 feet between students, consider other methods of risk reduction such as face masks.  Throughout the day, build in time for “mask free” time for both teachers and learners.

4. Instead of having class bathroom breaks, allow learners to leave for bathroom breaks throughout the day so bathroom lines are not needed.

5. For bus ride to school, leave windows open for air circulation (when possible) and encourage mask wearing, even when physical distancing isn’t possible.

6. Reward good behavior for risk reduction measures like hand washing, mask wearing, and distancing. Do this for teachers, staff, and students to help change the culture and create a sense of shared responsibility.

7. Keep kids within their own classroom and own “pod” as much as possible and ensure classrooms do not mix. This is critical for when there may be a COVID-19 exposure so that the entire school does not need to shut down, but only one classroom for the 14 days.

8. Allow flexibility for both students and teachers to ensure safety. For those at high risk of COVID-19 , extra precautions are needed to ensure safety. Providing options for full time virtual learning, or full-time virtual teaching, are ideal and would give families the most flexibility.

9. Frequent communications will be needed with staff, students, and parents to keep them updated on what is working, what is not working, and remind them of the importance of keeping up important public health measures to keep our schools safe.

10. Removing disincentives for sick staff members and students to come to school. For staff, this might include paid sick leave. For parents/students, communities need to consider options for affordable emergency back-up care for students (if they are too young to stay alone) to ensure that parents who have no other option for childcare do not send their symptomatic child to school.

11. More extensive cleaning and sterilization procedures of classrooms, common surfaces, and any shared areas. 

12. Some communities do not yet have a robust contact tracing program facilitated by their local or state health department, and schools may need to play a role in contact tracing. Before schools reopen, it will be important that a plan is in place on what will happen if a COVID-19 exposure occurs (e.g., how will students/staff receive communications, who will report to public health, and how will contact tracing occur, etc).

There are many more ideas in the Harvard School of Public Health Guide, and the American Academy of Pediatrics has excellent suggestions by grade level and how to prioritize some strategies over others (e.g., “Desks should be placed 3 to 6 feet apart when feasible (if this reduces the amount of time children are present in school, harm may outweigh potential benefits).”  Also, it’s important we protect our teachers, who will become and are essential workers. As AAP says, “school health staff should be provided with appropriate medical PPE to use in health suites. This PPE should include N95 masks, surgical masks, gloves, disposable gowns, and face shields or other eye protection.” We need to make sure our teachers are safe, like our essential workers and healthcare workers.

Beyond this, it’s incredibly important for our local communities to have discussions about how we can ensure equity in our school reopenings. For example, we are likely to see wealthier schools raise extra funds through PTAs for additional cleaning supplies, masks, better air filtration systems, etc, but what about the schools whose communities cannot raise this money on their own?  Perhaps each school could consider a voluntary matching donation to a sister school in an area that also needs these resources.  School systems in cash-strapped districts may want to reserve some resources (e.g. buses) for the areas that have no other option for safe transportation to school. Each school system may want to create a volunteer COVID-19 parent/teacher advisory board that could help with local implementation of policies. We need to ensure adequate training of teachers and staff, who can communicate instructions to parents and students, before schools reopen. Some of my academic mama colleagues piloted this in a university setting, and we need to do this for each school. For large school districts, this may not be a “one size fits all” approach, and schools may need volunteers to help with local implementation. We also need as much advocacy for additional funding from local, state, and federal sources as well as private donations to ensure that schools can effectively implement the public health measures needed to keep our students, teachers, and staff safe.

Personally, though I will continue to watch for more data and science, given what I know right now I am planning to send my own children (rising kindergartner and 2nd grader) to school for face-to-face learning assuming many of these public health measures can be implemented. I will commit to ensuring they wear masks and understand the reasons why (to protect not only themselves but also others), and I will advocate for additional support for schools that do not have as much in the way of private donations to help ensure equity in education. I do think the decision to send kids back in a face-to-face learning environment is a personal decision, that has to be answered by weighing the risks and benefits of your own situation. Are you or one of your family members high risk? If so, virtual learning may be ideal. If you see someone who is high risk on a routine basis (e.g., grandparent), virtual learning may be best. Perhaps you love homeschooling, and can offer a safe, healthy environment for your child to learn - go for it and minimize your risk! But you can also keep your own kids home while advocating for (and donating $ to) improving the safety of schools in your communities for those who must send their children back.

What do you think? Will you send your kids back to school this Fall?