COVID-19: The Dilemma of Reopening Schools (1 August 2020)

One of the most pressing COVID-19-related questions currently being debated on both the local and national level is whether schools should continue distance learning, resume in-person instruction, or adopt a hybrid curriculum consisting of both. Clearly, President Trump, as well as Education Secretary Betsy DeVos, believe that schools should reopen this fall, with the former suggesting financial incentives for schools that do reopen and threatening to withhold funding from schools that do not (1). However, there is no consensus on the way forward, and media opinion editorial pieces abound, arguing both for (e.g. The Wall Street Journal)(2) and against (e.g. USA Today)(3) reopening schools. In this post, I briefly discuss some of the concerns about resuming classroom instruction and review the limited experiences of those countries that have already done so.

Both proponents for and opponents of reopening agree that there are significant advantages to having children return to the classroom. Some of these have been explicated by The Centers for Disease Control and Prevention (CDC)(4). For example, the CDC contends that extended school closures are detrimental to learning, especially for students with physical or cognitive disabilities. By way of example, they cite a survey of 477 school districts by the University of Washington’s Center on Reinventing Public Education that found that only a third of school districts sufficiently expected schools to provide instruction, track student engagement, and monitor academic progress (with wealthier school districts being twice as likely than low-income districts to have such expectations)(5). Similarly, the CDC asserts that extended school closures are harmful to the development of children’s social and emotional skills, to include developing healthy peer relationships, something the CDC contends reinforces children’s feelings of “connectedness” and “sense of wellbeing”. Other arguments promulgated by the CDC for in-person instruction include student safety (A 2018 Department of Health and Human Services report found that teachers and other educational staff were responsible for more than one-fifth of all reported child abuse cases)(6), nutritional health (Nationwide more than 30 million children participate in the National School Lunch Program and nearly 15 million participate in the School Breakfast Program)(7,8), and physical activity. On this topic, the CDC clearly falls on the side of reopening schools, citing them as important for community infrastructure, developing social and emotional maturity, and providing critical services to include identifying and addressing neglect and abuse, fulfilling nutritional needs, and facilitating physical activity.

Similarly, in a position statement uploaded to its website, the American Academy of Pediatrics “strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school” (9). The AAP, like the CDC, cites the “well-documented” importance of in-person learning and claims that spring 2020 school closures had a negative impact on children. Like the CDC, the AAP points out the consequences of school closures, to include social isolation, interrupted social services such as meal programs, and physical inactivity.

Both the CDC and the AAP, as well as others who advocate resumption of in-person learning, are quick to point out that no plan will entirely eliminate the risk of COVID-19 transmission. Instead, they state that the implementation of multiple coordinated interventions can mitigate the risk — an approach that is compatible with the Orlandella and Reason “Swiss cheese model” of failure prevention (According to this model, in a complex system, hazards are prevented by a series of barriers. Like a slice of Swiss cheese, each barrier has intrinsic weaknesses or holes but when combined, the block of slices becomes impenetrable)(10). This risk reduction strategy emphasizes physical distancing, cleaning and disinfection, screening and testing, and the use of personal protective equipment (PPE). However, both the CDC and AAP cede that each of these measures has intrinsic challenges. For example, it may be difficult to enforce physical distancing on the school bus, on the playground, etc.; and the wearing of face coverings may be similarly difficult to enforce, especially with young or disabled children. Nonetheless, comprehensive recommendations can be found on both the CDC and AAP websites.

Any contemporary discussion about schools reopening is likely to include talk about the extent to which children play a role in the transmission of SARS-CoV-2, the virus that causes COVID-19. Epidemiological studies show that less than 2% of reported COVID-19 infections in China, Italy, and the United States have been in people younger than eighteen years of age. In one meta-analysis, researchers at the University of Edinburgh’s Usher Institute looked at sixteen unique studies of documented and probable cases of SARS-CoV-2 transmission by children, reports of COVID-19 outbreaks in schools, and population-based studies estimating the proportion of children infected (11). Based on these studies, the authors concluded that there is “limited evidence detailing transmission of SARS-CoV-2 from infected children” and “little data on the transmission of SARS-CoV-2 in schools”. They admit, however, that the evidence is limited and that the significance of prolonged fecal shedding of virus (which has been documented in children)(12) is as of now unknown. In their meta-analysis, the authors state that they intend to provide updates as new data becomes available. These updates will be posted on the Usher Institute’s website (13).

Nonetheless, some scientists such as Gary Wong, a researcher in pediatric respiratory medicine at the Chinese University of Hong Kong, argue that while these studies are intriguing, they are observational only, and do not prove that children are less likely to become infected with SARS-CoV-2 or to transmit the virus to others. They propose instead that the lower incidence in children may actually reflect either less exposure (because of school closures) or less testing (because children with COVID-19 tend to be mildly symptomatic or asymptomatic). Other respiratory viruses can transmit from adults to children and back, so “I don’t believe this virus is an exception”, says Wong (14). As a matter of fact, several studies have shown that children with symptomatic COVID-19 infection have viral titers comparable to that of infected adults, making them potentially as infectious (15).

Perhaps the best predictor of what we can anticipate happening once schools reopen is the experience of countries that have already begun reopening their own schools. In Finland, where schools closed in March and reopened in May, there was no change in the infection rate for children aged 1–19 years, and the infection rate for this demographic remained comparable to a similar cohort in Sweden, where the schools were never closed (16). Researchers also found that the incidence of COVID-19 among employees at day care centers and primary schools in Sweden was no higher than that for people working elsewhere. In contrast, Israel, a country which had been touted in March as having the world’s top COVID-19 safety rating by a consortium of commercial and nonprofit groups, saw a pronounced spike in the incidence of COVID-19 cases, prompting concern that they may have reopened their schools too soon (17). On 3 June, two weeks after Israel’s schools opened, more than 244 students and staff tested positive for COVID-19; and according to the education ministry, 2,026 students, teachers, and staff have contracted COVID-19, and 28,147 are in quarantine due to possible COVID-19 as of 14 July (18). However, this is muddied by the fact that Israel simultaneously loosened restrictions statewide, and it is not clear how much of this spike in COVID-19 cases can be attributed to transmission in schools. Nonetheless, some transmission is certainly occurring in Israel’s schools (47% of cases in June, by one estimate)(18), which have been described as unprepared for reopening. Like Israel, Hong Kong has been lauded for containing the spread of the SARS-CoV-2 virus, likely attributable to lessons learned from the 2003 SARS (i.e. SARS-CoV-1) outbreak there in 2003. The government has been fastidious in its approach to reopening schools, paying meticulous attention to screening, social distancing, and disinfection; and transmission within schools there is thought to be low. Nonetheless, Hong Kong is now experiencing its third COVID-19 wave, and schools are once again closing as a precautionary measure (19). Elsewhere, some other countries are confident that transmission among children, particularly younger children, is negligible, and they are determined to return them to school. Both Belgium and France, for example, briefly reopened schools in June before closing them again for the summer break. Both countries plan on having children return once classes resume in September (20). Similarly, Italy, which closed its schools in March, plans on resuming in-person classes in September. In a press conference on 26 June, Prime Minister Giuseppe Conte announced that one billion euros would be allocated in funding to make schools “more modern, safe, and inclusive (and to enable classes) to start again in September in complete safety” (21). As with many other countries, Italy’s plan includes spaced seating, smaller classes, and staggered arrival times for students; and as with some other plans that note the apparent difference between younger and older children in SARS-CoV-2 transmissibility, Italy’s will include a distance learning option for high schoolers.

Although the lessons to be gleaned from other countries that have reopened their schools may seem discouraging and sometimes contradictory, it is very preliminary and undoubtedly, the data will become more useful with time. Nonetheless, there are some commonalities among the approaches to the upcoming school year. First, they all plan on returning their children to the classroom. If distance learning is offered, it will only be an option for a subset of students (e.g. high schoolers), and not for all students. Second, many plans are mindful of the studies of SARS-CoV-2 transmission rates and distinguish between younger and older children. Third, pretty much all of the approaches include plans for screening, masking, distancing, and disinfection. Many plans (e.g. Hong Kong’s) also include a contingency for reverting to distance learning in the event of an outbreak within the school.

As for the trajectory in this country, there is a disconnect between what is being said by the president and his leading COVID-19 medical advisor, Anthony Fauci. Whereas the former clearly wants all schools to reopen in the fall, Dr. Fauci would leave school reopening decisions to local officials, who could base their decisions on such factors as the incidence of COVID-19 in their districts (22). In one recent interview, Dr. Fauci said that schools and communities should assess the local threat, develop plans, and “try to get our children back to school as best as (they) possibly can” (23). For now, it appears that decisions are indeed being made locally. For example, California Governor Gavin Newsom has already announced that most California school campuses will not reopen at the beginning of the school year, and that those campuses that do reopen will have mask requirements as well as COVID-19 testing and social distancing recommendations for students, teachers, and staff (24). I suspect that come fall, we will see wide variability between states and school districts with respect to reopening, with some schools resuming in-person instruction, others continuing distance learning, and some instituting a hybrid curriculum. Moreover, I think we can anticipate that plans will be adjusted, based on the local incidence of COVID-19 cases, with some schools closing due to outbreaks. In all cases, we invariably will see some combination of screening, distancing, disinfection, and/or masking.

As with my prior COVID-19-themed posts, my intention here is not to politicize, sensationalize, or trivialize the pandemic, but only to provide information and thoughtful commentary.

Until my next update — regards.

Michael Zapor, MD, PhD, CTropMed, FACP, FIDSA

(1 August 2020)

To read this and my other COVID-19-themed posts on Medium.com, please see: https://medium.com/@michaelzapor

References

1. https://www.politico.com/news/2020/07/08/trump-schools-reopening-federal-funding-352311 (Accessed 28 July 2020)

2. https://www.wsj.com/articles/the-case-for-reopening-schools-11594681985 (Accessed 28 July 2020)

3. https://www.usatoday.com/story/opinion/voices/2020/07/13/reopen-schools-coronavirus-online-learning-classrooms-column/5427438002/ (Accessed 28 July 2020)

4. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html (Accessed 28 July 2020)

5. https://www.crpe.org/publications/too-many-schools-leave-learning-chance-during-pandemic (Accessed 28 July 2020)

6. https://www.acf.hhs.gov/sites/default/files/cb/cm2018.pdf (Accessed 28 July 2020)

7. https://www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/national-school-lunch-program/ (Accessed 28 July 2020)

8. https://www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/school-breakfast-program/ (Accessed 28 July 2020)

9. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/ (Accessed 28 July 2020)

10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/#:~:text=According%20to%20this%20metaphor%2C%20in,the%20similarity%20with%20Swiss%20cheese.&text=When%20by%20chance%20all%20holes,and%20causes%20harm%20(Figure%20%E2%80%8B (Accessed 29 July 2020)

11. Li X, Xu W, Dozier M, et al. The role of children in transmission of SARS-CoV-2: A rapid review. J Glob Health. 2020;10(1):011101. doi:10.7189/jogh.10.011101

12. Xing YH, Ni W, Wu Q, et al. Prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019. J Microbiol Immunol Infect. 2020;53(3):473–480. doi:10.1016/j.jmii.2020.03.021

13. https://www.ed.ac.uk/usher/uncover/completed-uncover-reviews (Accessed 29 July 2020)

14. https://www.nature.com/articles/d41586-020-01354-0 (Accessed 29 July 2020)

15. https://www.medrxiv.org/content/10.1101/2020.06.08.20125484v1 (Accessed 29 July 2020)

16. https://www.folkhalsomyndigheten.se/contentassets/c1b78bffbfde4a7899eb0d8ffdb57b09/covid-19-school-aged-children.pdf (Accessed 29 July 2020)

17. https://www.wsj.com/articles/israelis-fear-schools-reopened-too-soon-as-covid-19-cases-climb-11594760001 (Accessed 29 July 2020)

18. https://www.thedailybeast.com/israeli-data-show-school-openings-were-a-disaster-that-wiped-out-lockdown-gains (Accessed 29 July 2020)

19. https://www.npr.org/sections/goatsandsoda/2020/07/10/889376184/photos-how-hong-kong-reopened-schools-and-why-it-closed-them-again (Accessed 29 July 2020)

20. https://www.washingtonpost.com/world/europe/schools-reopening-coronavirus/2020/07/10/865fb3e6-c122-11ea-8908-68a2b9eae9e0_story.html (Accessed 29 July 2020)

21. https://tg24.sky.it/politica/2020/06/26/scuola-conferenza-conte-azzolina-boccia (Accessed 30 July 2020)

22. https://www.reuters.com/article/us-health-coronavirus-fauci/fauci-would-leave-school-reopening-decisions-to-local-officials-idUSKCN24F2RD (Accessed 30 July 2020)

23. https://www.pbs.org/newshour/health/watch-full-interview-with-fauci-on-reopening-schools-coronavirus-vaccine-and-white-house-tension (Accessed 30 July 2020)

24. https://edsource.org/2020/governors-order-means-most-california-school-campuses-wont-reopen-at-the-beginning-of-school-year/636590 (Accessed 30 July 2020)