Planning for School Re-Entry

“No more pencils no more books
No more teacher’s dirty looks yeah
Well we got no class
And we got no principals
And we got no innocence
We can’t even think of a word that rhymes
School’s out for summer
School’s out forever
My school’s been blown to pieces”

– Alice Cooper  from School’s Out (1972)

The number one question at well visits these last couple of weeks has been “What do you think is going to happen with the schools this fall.”  It is a question that weighs heavily on all our minds as we try to anticipate how we are going to manage our households come September.  Spoiler alert:  Hope you enjoy remote learning. Will try to navigate the concerns that face those making this decision in the fall and tease out where they are working with facts and where they are imposing philosophy.  @ the mother with the last name correlating to a city in northern Italy that Facebooked on this topic last night at 9pm….hope this addresses your query sufficiently.

While the primary purpose of schools is clearly to educate our children, there are many stakeholders involved when it comes to decisions of opening schools for on premise participation during a pandemic.  Among the stakeholders are the children, the teachers, the school’s support staff (administration, sanitation, transportation, etc), members of the supply chain that service school (suppliers of school lunches, makers of notebooks and binders, textbooks, etc), parents of students, extended families of students, and the employers of parents are among the many and just the handful that immediately came to mind while writing this.  The issue of opening schools is often easy when viewed through the lens of any single stakeholder.  Managing everyone’s interests is another ballgame altogether.

Viewing the topic solely from the perspective of the student stakeholder, this question yields a simple answer.  Open the schools.  The risk to a student’s individual health from getting COVID-19 in a school setting is minimal.  We have never closed schools for influenza, coxsackie virus, strep throat, or similar.  All of these illnesses are able to cause serious problems in children that can lead to hospitalization and even death.  While COVID-19 can cause serious problems for children as well, the frequency of such is not significantly different to change policy.  The harm to our children’s academic and social development along with their emotional status is almost guaranteed to be more by not going to school than attending.   Alas, it is not just about the children.

Current State of COVID-19 Pandemic

Currently, much of the country has been enjoying their reopening.  And by enjoying, many folks are simply returning to business as usual without thinking of consequences (see photo from this July 4th at Coney Island above).  As a result, and this one certainly could be published in the Journal of Common Sense Outcomes, the infection rate in this country is starting to escalate.  To be fair, part of this escalation is due to increased testing as has been pointed out not so eloquently by our commander in chief.  However, part of this escalation is due to actual spread of virus. This is beginning to become evident in the death rate in the United States which after months of decline, is again beginning to rise.

Looking at WHO data, you can see the spiking in cases starting towards the end of June.  Those are represented by the much taller sticks you see on the top graph in the figure below all the way to the right.  Much subtler, though concerning is that you may be seeing the warning shots for a much bigger spike in death rate is the slight elevation of the sticks all the way to the right of the graph on the bottom.  By definition there has to be a time lag from when cases increase and death rates increase (because you have to contract an illness, and it to run its course before the situation resolves for better or worse).

In a prior post we discussed R-values and their use as a measure for spread of an infectious disease.  Nutshell version – if the R-value is above 1, there is increasing spread in the community.  Below is a picture from the Covid-19 Projections Tracker website.   The model used on this site was developed by Youyang Gu and has garnered significant attention.

As you can see below, once states started to restrict activity, the R-values dropped precipitously (compare the lighter pink with the purple part of the bars).  Nearly all states managed to drop their R-value under 1 with the mitigation processes that were instituted.  The concerning part of the picture is the number of states in which you see the current R-value above one (the darker pink) part of the bars. The current R-value for New York as a whole is 0.98.  This number has been trending upwards from about 0.8 a few weeks ago.  Suffolk County is currently at 1.04.  This is not good, so brace yourselves.  Unless behavior changes, give it two weeks and they will start reporting “increased cases.”  Give it four weeks, including two of them discussing whether those increased cases are real, and you will see increased hospitalizations.  Give it a few more weeks and the death numbers will start to rise.  And that brings you to…..the start of the school year.

Where are we with potential cures or vaccines?

There are a lot of scientists working on both potential cures and vaccines.  There are positive studies to report on both topics.  At this current time though, it is safe to say that either being available during 2020 other than for experimental use is extremely unlikely.

On the vaccine front, there are some companies starting to report positive results in human trials.    The trials are reporting results where blood samples of test subjects receiving the vaccine demonstrated the presence of antibodies to COVID-19.  While this is a necessary step and encouraging, I cannot emphasize enough that this is not sufficient to denote the vaccine would work as it pertains to the real issue that is preventing disease.  The next steps take a bit more time to complete and they will address whether the vaccine is preventing disease as well as looking for more uncommon but serious side effects. Among those side effects includes whether the vaccine can increase disease in certain populations such as children who were given a vaccine for dengue fever.

Progress is being made towards treating COVID-19 as well.  A study published in the journal Cell this week (and thanks to my uncle and mentor, Simon Halegoua  for sharing this one) identified a potent neutralizing (blocking) antibody to COVID-19.  Such antibodies could be used to prevent disease in known exposure situations and/or treat those with active disease as is currently done for Hepatitis B, Rabies, and Varicella to name a few.   Human trials have already begun to assess whether the antibody identified is effective and safe to prevent or treat COVID-19.  The technique the scientists used to accomplish such has the potential to be used for other infectious disease as well.  (click here for a preview of the study, or here for the full study)

In summary, there are reasons to be encouraged by the progress scientists are making with respect to managing this pandemic, but actual large-scale deployment of the products of their labor are still many months away at best.  Therefore, for now, our main tools to combat this pandemic continue to be social distancing, masks, and handwashing.

What to do with Schools?

The AAP recently released some guidance for school re-entry.  The purpose of the guidance is to advocate for children (since they generally don’t get to do so themselves) and their education and address many of the concerns that affect all stakeholders. The guidance stressed flexibility and need to modify any game plan based on changes in the overall environment surrounding COVID-19.

The AAP guidance starts with the principle that all planning should start with the goal of students being physically present in school.  It recognizes that schools provide far more to students than just academics – they are necessary for a wide range of other concerns including to develop social and emotional skills, provide safety and nutrition, and provide numerous therapies.

While far from a blueprint on how to effectively open schools, the guidance works through many topics pertaining to how to facilitate re-entry to schools in the safest manner possible.  Included among the topics are social distancing measures (classes, busses, hallways, cafeterias), use of masks, cleaning/disinfection, testing/screening, and use of personal protective equipment (PPE).  Significant discussion towards preparing for increased behavioral and mental health needs was also included with the re-entry guidance.

From the student perspective, the AAP guidance is pretty much spot on.  It provided the voice that gets little, if any representation at the table in a rational manner.  As mentioned previously, students are not the only stakeholder in this matter, and we need to address that a bit before delving into actual recommendations for re-entry to school.

Teachers are clearly among the more critical stakeholders as they need to be present in school to educate.  The average age of a public-school teacher in New York is 42.5 years.  The percentage of teachers older than 50 years of age is 29.8%.  This latter category in particular is at significant risk for poor outcomes should they contract COVID.   Any recommendation for re-entry must be sensitive to this concern.

The other main group of critical stakeholders for school re-entry are the families of students.  One concern for families is the ability to maintain their own employment if able to work either at their typical place or remotely.  When children are not in school, this may be an issue if expected to also be providing the educational support needed for remote learning.  When children are in school there are often extended family members involved with getting children ready for school or after school.  These are often grandparents who are at higher risk for COVID-19 disease complications.

We are not going to run through scenarios for every stakeholder, but the message is the same – sending children to school will increase the chance of serious illness for those around them.  Not sending them to school introduces the students to the risks associated with poor education, poor social skills, and poor emotional health.

Unfortunately, with this pandemic, there are no clear-cut answers to address the issue of schooling.  There will need to be some balance between the interests of our children and those around them as there is some conflict between their interests.  What I would like to see, and what I expect to see are not at first one and the same, though I do believe they will end up that way.

Despite what appears to be a situation in which there is increasing disease burden, I would like to see the schools open on time.  There are of course some caveats.  Way back in March when this situation was truly emerging in the public eye, much was discussed about “Bending the Curve.”  This concept is still applicable, and so far we have been successful here in New York.  The goal when this started was not to eradicate the virus.  The goal was and should continue to be to minimize spread and intervene in a manner sufficient to ensure that there are no unnecessary deaths due to lack of capacity to treat.

With the opening of schools, we must be prepared for some differences in the manner we approach education and the environment in which it is provided.  The list below is just a taste of the types of issues that must be addressed:

  • Establishing reasonable physical spacing requirements. This issue may require different approaches depending on the age of a child and what resources a given district has.  Consideration for having two shifts during the school day or utilizing additional spaces for classes may be needed.
  • Establishing proper safety protocols. All students and staff should be wearing masks at this time.  While this will certainly require prompting is some age groups, it needs to be done.  For the very young children, would strongly recommend that the staff that works with them are from the lowest risk categories (younger without existing medical problems).  You should not have a 65-year old diabetic teacher in a Kindergarten class at this time.
  • Establishment of proper sanitation protocols. Frequent hand washing and disinfection must be encouraged.  This will require making sure supplies are available.  This one sounds simple, but obtaining such supplies has not been.  Having proper PPE for health staff in the school is similarly essential.  Changing guidelines to permit previously not-permitted use of equipment due to shortage is not acceptable.  Our hospital staff would have universally been fired in the past for what they have been told to do regarding protective equipment.  This issue is perhaps the most shocking with respect to our nations inability to provide basic supplies.
  • Modifying some of the curriculum. Choir would not seem to be a wise choice for music class, though there are many instruments and music related topics that can be worked with.  They can bang on a drum all day.  Indoor sports during gym would similarly not be advised though certain outdoor activity could easily be accomplished.  We should be able to provide a complete education for our children with some simple modifications as above.
  • Screening for and addressing ill children during the school day. Temperature checks are one easy screen.  While historically not a fan of sending kids home for a mild cough, current times are different.  If a child appears ill, is coughing, blowing their nose, etc, they need to be sent home until well.  The corollary here is that parents need to be more responsible than historical precedent has shown.  That means not giving your child acetaminophen to reduce their fever and sending them to school or turning a blind eye to the fact they vomited three times overnight or complained for the last three days of a sore throat.

In addition, we as society need to be extra vigilant and protective of our higher risk individuals. There will be increases in disease burden as school starts, especially with the other relaxations in restrictions that have occurred.  In a world where the goal is to mitigate risk, not eliminate, there may be needs to recommend stay at home orders for high risk individuals while the remainder go about their business using aforementioned techniques to minimize chance of spread.  If disease burden again begins to threaten capacity to deal appropriately with our ill, consider sparing the schools initially and restricting other forms of business.   Temporary school closures if disease burden increases is always a potential mitigator of disease as well on a population level.

While I believe that at some point the above will be the way forward, I do not expect us to arrive there in September unless the current trendlines of disease burden in the country improve.  New York will not be able to remain isolated from the recent surges and some early indicators are showing that already to be the case.  In our current political environment, I do not anticipate a reversal on the protocols established for re-opening businesses.  Being that schools are in the last phase of reopening in New York, I expect that with increasing cases we will be stepping back a phase or two at some point in before the school year.  That means you may be able to get a haircut so you look good onscreen with your child while they learn in a Zoom classroom.

With a little luck, once the election season is over, if there is no clear indication of imminent vaccine or treatment availability, the path forward will be revisited to more aggressively deal with mitigation, not elimination and ensuring that our children are not left behind by closing schools for yet another year.