** Updated on 7/18/2020 to clarify that our position is that community outbreak control is a pre-req for safe school reopening plans. Schools can only reopen safely IF there is already good community control of the outbreak in place. **
A: If we want schools to reopen for in-person instruction, here is what is needed:
1. Community control of the outbreak
2. Extensive modifications to the way school normally operates to provide infection control in schools
School reopening is THE. QUESTION. at the moment.
How and when to reopen K12 schools is a tremendously complicated subject, and we are still working with very limited information in terms of disease transmission among kids. Yours truly, Those Nerdy Girls, have as many opinions on when and how school should reopen as we have degrees. Between us, we are also the mothers of 20 children ranging from ages 1 to 21. We offer this opinion both as parents and as professionals.
Here are the facts about COVID-19 and kids so far. COVID-19 *very* rarely kills children, and there are serious harms involved with keeping schools closed or going to partial schedules.
American Academy of Pediatrics (AAP), the American Federation of Teachers (AFT), the National Education Association (NEA), and the School Superintendents Association have recently stated that in person instruction offers the most equitable learning environment.
That’s because the problems with closing or reducing in-person schooling include lost educational opportunities (which are borne disproportionately by kids in low-income districts), kids’ health and safety, and social and emotional development. Schools also perform an important societal function to keep children safe and supervised during the day so that their parents can work. Some parents are being put in the position of deciding whether to pay the rent, leave young children home alone, or send children to unsafe places. This is an impossible choice that no parent should have to make.
Kids with special needs are at particular risk from disruptions to the school schedule. We worry a lot about children who need supportive services that are traditionally delivered in school. Some children are receiving speech therapy, occupational therapy, or behavioral support virtually, but these services are better delivered in person. Children with autism spectrum disorder who need support for social skills may have less potential to practice at home. Children with depression and anxiety may rely on the structure and activities of school for their mental health. Teens, in particular, need social interaction with their peers for social and emotional development.
And we worry the most about the kids who are in unsafe situations at home, who have no home, or who have nothing to eat at home.
Yes, the risks of school disruptions to these kids and families are real and unignorable.
On the other hand, we can’t ignore the risks of sending kids to school in terms of the spread of COVID-19. It is true that kids who get COVID-19 very rarely require hospitalization and even more rarely die of the infection. We knew that much early on.
But kids live with adults and are taught by adults, and adults are at risk. Public health authorities–including Dear Pandemic contributors–urged schools to close in the spring to slow the spread of the disease and protect the entire population, not just the children themselves. This was necessary because we didn’t know how much kids were involved in spreading the disease back in January, February, and March. And guess what? We still know very little about kids’ involvement in COVID-19 transmission.
Our sense from the scientific literature right now is that kids may be less likely to transmit SARS-CoV-2 to other people, with emphasis on “may be.” It is not at all clear how this translates into practical applications at K-12 schools. Studies are in progress that could reveal more about transmission dynamics and mitigation strategies in kids, including in the UK and other locations where schools have begun to reopen.
The argument we’ve heard a lot lately goes something like: ‘COVID-19 doesn’t kill children and therefore we should just get on with school as usual.’ This risks an awful lot by making decisions specific to one age group and ignoring the reality of intergenerational relationships. The threat of COVID-19 spreading within schools does not end when the bell rings and is not limited to the kids themselves. Kids take home the germs they pick up at school, and ignoring their potential to pass them along to their higher-risk parents, siblings, and grandparents is a misstep. It discounts the importance of intergenerational societies and the health of the adults in children’s lives.
We also cannot make decisions about schools reopening by considering only the risks of COVID-19 for children, because the staff of schools are composed entirely of adults. The lives of teachers who are high-risk are an equally important consideration, and so are the yet-unknowable long-term health impacts, disruption, and loss of work hours when teachers fall ill with COVID-19 and recover–sometimes after an illness lasting 6 weeks or more.
The 10 Nerdy Girls collaborated on this post, and the 10 of us (with our 10 different PhD’s and perspectives) can agree on this: it’s very hard to balance the real risks of school closures against infectious disease risks that we cannot yet quantify.
Yet the world keeps turning, and we’ll have to do something in the fall. We do not envy school administrators one bit right now.
It’s helpful to start by asking ourselves: what are we trying to achieve with a safe school reopening plan? In no particular order (because we don’t think you can prioritize these in any meaningful way), we want:
–> Safety for teachers, students, and their families from COVID-19
–> Safety for the entire community from an outbreak of COVID-19 that could start in school settings
–> Education for our children, and in particular, to avoid making the education gap wider than it already is
–> To avoid social harms to children
–> To avoid economic harms to families
To achieve these aims, we need to think about the big picture and measure how each reopening plan stacks up against these goals. Measuring exactly 6 feet in between desks will not protect us all by itself. Dear Pandemic co-founder Alison Buttenheim described a framework for thinking it all through in a recent op-ed.
Here, we are paraphrasing her with four important domains to consider:
1. Iron-clad outbreak control in communities.
Reopening school safely means community control measures outside of schools. We need robust, free, accessible testing; contact tracing; and to eliminate high-risk, low-priority activities in the community. It means considering the number of cases circulating in each community as a key factor in how much risk there might be in school settings.
2. Infection control in schools.
This means small groups of the same kids with the same teacher day after day. It means turning hygiene practices into easy, mindless habits. Harvard University put together this great resource for thinking through infection control strategies in schools.
Uncertainty is going to be with us for a while. Schools should be making contingency plans for what happens in the face of a local outbreak and setting metrics for when those plans are triggered. In fact, it’s all we can really do at this point. Opt-outs and special accommodations for particularly vulnerable staff and students will be necessary. Expect change as community levels of disease and resources ebb and flow. What’s likely to work in one community at one point in time is likely not to be the best path for a different community, or even the same community six months down the road, or even all the people within one community.
Building trust through open communication among all players is critical. School leaders should provide transparency, and parents and teachers should demand it. Teachers, parents, and students need to know about new routines, expectations for remote learning, and how closure decisions will be made. They need to know how exposures and cases in the school community will be tracked and reported, what will happen when exposures or cases happen, and how communication about COVID-19 will be handled. The best way to navigate uncertainty is with transparency, empathy, and open communication.
Of the many proposals on the table for HOW to restructure school to allow as many kids to have face-to-face learning as possible, the one that makes the most sense to us is a split by grade level: older kids attend school entirely virtually while younger kids attend entirely face-to-face. In-person instruction should happen in small, restricted cohorts which include teachers and staff. The National Academies of Sciences, Engineering and Medicine also supported the idea of having priority for in-person instruction for lower grade levels in a recent statement.
Older kids are more likely to be able to learn independently and can often be safely left at home when parents must work. We do recognize that this solution isn’t perfect. For one thing, it will not meet the social needs of older children. Helping older kids navigate the SMART strategies (Space, Masks, Air, Restrict your Circle, and Time) for harm reduction in their after-school hangouts could be one approach to that problem. For another, it will require a lot more staff in classrooms.
Which brings us to our last point: all this is going to cost schools a fortune, and it’s a fortune they do not have. The United States has long underinvested in schools, and this is going to be a very big lift that goes well above and beyond what already thin school budgets usually have to handle. We will need to both think creatively and invest real dollars if we expect it to work.
So, our advice is:
– Get control of the outbreak first.
– Set a date for school opening.
– Prioritize having kids in school in person to the greatest extent that is possible, starting with the youngest grade levels.
– Keep watching for evidence of how disease transmission in schools operates.
– Focus efforts on the measures necessary to limit transmission with schools open. This means both adjustments to schooling and community outbreak control with continued limits on low-priority, higher-risk activities.
– Support schools with the dollars they will need to manage education in a pandemic.
It’s going to be a bumpy ride, so buckle up.
The Dear Pandemic editorial team:
Sandra Albrecht PhD MPH
Shoshana Aronowitz, PhD, FNP-BC
Jennifer Beam Dowd PhD
Alison Buttenheim PhD MBA
Lauren Hale PhD MA
Malia Jones PhD MPH
Aparna Kumar PhD MPH CRNP
Lindsey Leininger PhD MA
Ashley Ritter PhD CRNP
Amanda Simanek PhD MPH