#3: Back to School Special: COVID Edition

July 29, 2020 | By Justin Berk

How to talk about K-12 school re-openings with Dr. Joshua Sharfstein (@drjoshS)

Summary

The American Academy of Pediatrics (AAP) recommends that schools strive to reopen in the Fall, but there is hesitation from families and teachers alike. We speak with Dr. Sharfstein, a public health expert and pediatrician, regarding the importance of reopening schools for children, what criteria need to be met prior to opening, and how to keep children and teachers safe. Tune in to learn transmission amongst children, how other countries have reopened, why to cohort children, and how the primary care pediatrician can assist in the coming school year!

Credits

• Producers & Writers: Edward Corty, Nicholas Lee MD
• Infographic: Nicholas Lee MD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD, Edward Corty
• Editor: Justin Berk MD; Chris Chiu MD 
• Guest(s): Joshua Sharfstein MD

Sponsor: AAP Pediatrics On Call

If you provide medical care to children, Pediatrics On Call — the new podcast from the American Academy of Pediatrics — will help you do it better. Each week, hear the latest news and research on children’s health, on topics from obesity and mental health to keeping the kiddos safe when they’re stuck at home. Subscribe from your favorite podcast provider or find the latest episodes here.

Time Stamps

• Introduction 1:00
• How to answer “What do you think about school openings?” 11:30
• Risk Assessment of School Re-openings 14:40
• Evidence of Transmission among Children 17:10
• What Other Countries Have Done 19:40
• Community Threshold for Re-Opening and Using Protocols 20:30
• The Reasons to Cohort 22:45
• How to Address Scenarios 24:20
• Health Disparities and Return to School 27:00
• Existing Inequities and Children’s Sacrifice of Education 29:00
• “Opting Out” of School Return and Feeling Safe 31:30
• How Can Governments Help Support the Return 35:50
• Guidance to give as PCP 37:50
• School Alternatives / Innovations to Going Back 40:10
• The Difference Between Equity and Equality 42:50
• Testing in Schools 43:45
• Resources to Follow For More Information 46:00
• Take-Away Points 47:10
• Optimism 48:25
• Picks of the Week 53:50

Back to School Pearls

1. School reopening is important for the intellectual and social development of children along with keeping them safe.
2. Evidence suggests children under age 10 have low rates of COVID transmission.
3. Decreasing community spread may be the most important factor in ensuring it is safe to reopen schools.
4. Cohorting helps isolate outbreaks if they occur.
5. If at-risk students do not go back to school, we may further exacerbate health disparities.

Risk Assessment of School Reopening

There is no universally correct answer regarding reopening schools, and it will be an ongoing risk-benefit analysis. We can work to mitigate the risk of reopening schools, but we will never be able to eliminate risk completely. It is important to highlight the number of reasons why reopening schools is essential:

1. Intellectual development
2. Social development
3. Helping to feed children
4. Keeping children safe (one in five abuse reports come via schools)

Evidence of Transmission Among Children

In terms of studying the actual transmission amongst children, this has been difficult to achieve since most studies are performed in quasi-lockdown states. In his expert opinion, children < 10 have less likelihood of becoming infected, higher asymptomatic rate, and lower chance of transmission (Munro 2020). There is a lower chance of outbreak in this demographic, although it is not zero since there have been clearly documented daycare outbreaks. For older children, they are more likely to become infected but still likely to be asymptomatic (Gudbjartsson 2020), yet he seems to believe they are not as infectious when they are asymptomatic.

In terms of real-world evidence, countries like Germany, Norway, Denmark, and Israel are telling examples (Lee 2020). The first three were able to control community spread and reopen schools with conservative strategies, such as spreading out classrooms and spending more time outdoors. These countries have not demonstrated outbreaks. In contrast, Israel initially took some of these conservative measures but then transitioned to a more traditional classroom set-up that resulted in some outbreaks.

Community Threshold and Reopening Strategies

In deciding to reopen, there will be a threshold question: “Is it OK to open schools?” This will be almost entirely dictated by community spread and whether COVID-19 outbreaks are well-controlled enough to begin sending children back to school (with the US Surgeon General suggesting 10%). Once the threshold question is answered, we will then face questions regarding how to safely reopen, remembering that other countries have succeeded with a conservative strategy.

Expert opinion: It would be reasonable to work with mitigating structures and work-flows to reopening schools then have continuous reassessment to see what is still required as time goes on (especially if community spread drastically decreases).

For actual procedures for reopening, it will vary institution to institution and need to be consistently reevaluated. Ideas that may be helpful to those attempting to design these protocols:

• Develop a decision tree that can be refined through the school-systems experience
• School systems will have to decide what symptoms require a student stay home, go to the doctor, and under what conditions a whole “pod” (see next section) needs to stay home
• Invest in contact tracing and monitoring of pods to evaluate whether a “sick” student may have transmitted disease (or was it allergies, an upper respiratory infection)

Why Should We Cohort?

The idea of having students remain in the same “pod” (or group of students) in the same room throughout the day is to make contact tracing easier. If one student has a concern for illness, the school will then just have to discuss and monitor the other students in the pod rather than the entire school. This will allow for easier isolation of a sub-group of students to allow the school to still function even if there are intermittent bursts of illness.

Health Disparities and Reopening

If at-risk students do not go back to school, we will also exacerbate health disparities. These students oftentimes do not have internet access or the ability for parents to stay at home to assist them. Dr. Sharfstein recommends viewing it as that these children have already sacrificed so much for our society (and our questionable choices) that we should, as a country, prioritize getting them back to school to reduce any gap that may emerge in their development.

Opting Out of the Return

In the United States, we individually are risk-averse, but we are not particularly risk-averse as a society (which has increased our community spread). Dr. Sharfstein recommends that family and instructors should be able to opt-out of returning to school if it is above their risk tolerance. (He gives an example of a 70-year-old grandmother taking care of children who cannot afford to get sick; she should not be forced to send them to school if she is not comfortable with it.)

In terms of our school staff, people need to feel safe in their place of work (just like healthcare workers and personal protective equipment). Dr. Sharfstein notes that there may already be a credibility gap between some of these school systems and instructors, but there is an opportunity to overcome this by paying attention to the concerns and working toward rebuilding trust.

Expert Opinion: In order to further build trust, it would be reasonable to open a few schools in a system at a time to demonstrate that they can open and operate safely. This would pave the way for more openings.

How Governments Can Help

First and foremost, Dr. Sharfstein recommended that they need to allot money. Congress should allocate these since school reopening is a national priority, and there will need to be additional funds for schools to be as safe as possible. They will need more staff, funding to separate classrooms, transportation, laptops, and cleaning supplies.

Expert Opinion: It would also be beneficial if the federal government could develop national standards to provide the local governments with guidance. Otherwise, it is oftentimes the school systems who have to develop guidelines and protocols for reopening without any assistance.

How Can the PCP Help?

• Help at the interface of schools and healthcare
• Work to get children tested when they need to be tested or get them into clinic sooner
• Help interpret the evidence regarding transmission
• Educate the community about the value of going back to school

Testing

If symptomatic, it will be important to test quickly to be able to determine if there is an outbreak.

In terms of universal testing, it may not be beneficial. It will take a few days for tests to turn around, and in a low-risk population, the test will have a significant amount of false positives. This may mean that there end up being additional, unnecessary isolations without truly assisting in controlling the disease.

Resources

• AAP COVID-19 Planning Considerations: Guidance for School Re-entry
• Johns Hopkins school reopening tracker

Goal

Listeners will explain the risks and benefits to school reopening during the COVID-19 pandemic. In addition, they will understand the most important steps to reopening being safe and what physicians can do to aid in school reopening. 

Learning objectives

After listening to this episode listeners will…  

1. Recall the benefits of reopening schools.
2. Be familiar with the risks of reopening and how to mitigate them.
3. Recognize what students may be at an increased risk of suffering if schools do not reopen and how to advocate for them in the future.
4. Identify how pediatricians can help school systems remain functional during the COVID-19 pandemic.

Disclosures

Dr. Sharfstein reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.