Return to School
As we near the end of summer and schools share their plans for reopening, there are many questions parents and caregivers have due to COVID-19’s impact on our communities. There are certainly no easy, one-size-fits-all answers to these questions. After all, we are facing an unprecedented situation.
Ultimately, the decision of whether to send a child back to school will be a personal one for each family, incorporating the overall physical and emotional health of the child, presence of high-risk underlying medical conditions in household members, the ability to learn virtually, the extent of community spread, the family structure and finances, and parent’s/child’s comfort level. The resources below are available to help families navigate their child’s return to school.
- American Academy of Pediatrics (AAP)
- Centers for Disease Control and Prevention (CDC)
In the News
- Summer camps bring ominous virus warning in test run for schools (Bloomberg|Quint)
- Back-to-school vaccines your kids need (WebMD)
- Pediatricians are optimistic that students will be able to wear masks during the school year: 'Kids are really good at it' (Yahoo! Life)
- Spread of COVID in kids still a big unknown as Texas schools plan August reopening (Houston Chronicle)
- What to consider before class begins if your child has chronic health problems (NBC 2 KPRC)
The following strategies serve as the guiding principles that might help reduce – but not eliminate – transmission in school:
- Staying home when sick: Staff and students should stay home if sick or if they have been exposed to someone with COVID-19.
- Practice physical distancing of 6 feet whenever possible.
- If possible, create smaller class sizes to enable physical distancing of desks by at least 3 to 6 feet.
- Face covering: A cloth face covering or mask is preferred. Children over 2 years of age and teachers and staff should wear a face covering, per recent AAP guidelines.
- Hand hygiene: Use soap and water for 20 seconds or alcohol based hand sanitizers containing minimum 60% alcohol to be placed throughout the school for easy access. (CDC resources: Hand Hygiene Recommendations, When and How to Wash Your Hands)
- Cohorting: Form groups of students to stay together throughout the school day to minimize exposure and disease spread. Attempts should be made to cohort staff, if possible. Move teachers instead of students to minimize exposures. Different strategies would be needed for elementary, middle and high school.
- Well-ventilated spaces: Outdoor spaces should be utilized as much as possible and is safe. Open doors and windows as much as possible and is safe.
1. What are the most common signs/symptoms of COVID-19 in children?
- Temperature 100.4 degrees Fahrenheit or higher when taken by mouth;
- Sore throat;
- New, uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline);
- Diarrhea, vomiting, or abdominal pain; or
- New onset of severe headache, especially with a fever.
2. What is meant by being in “close contact” with COVID-19?
- You were within 6 feet of someone who has COVID-19 for at least 15 minutes.
- You provided care at home to someone who is sick with COVID-19.
- You had direct physical contact with the person (touched, hugged, or kissed them).
- You shared eating or drinking utensils.
- They sneezed, coughed, or somehow got respiratory droplets on you.
3. Can children have COVID-19 without symptoms? Is there a difference between symptoms of COVID-19 in children and adults?
Currently, it appears that, in general, children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection. However, children and adolescents can get severe COVID-19 disease and require hospitalization, particularly if they have underlying risk factors including (but not limited to) underlying immunodeficiency condition, obesity, heart or lung disease.
4. Is it safe for students and teachers to return to school in person?
Both the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) have published guidance documents addressing safety measures that schools and parents can practice to reduce risk. These measures (reviewed in part below) do just that—reduce—but they cannot eliminate all risk of acquiring SARS-CoV-2. The risk of infection in school will likely mirror the risk in the community; the higher the community rate of transmission, the higher the risk in school.
Ultimately, the decision of whether to send a child back to school will be a personal one for each family, incorporating the overall physical and emotional health of the child, presence of high risk underlying medical conditions in the child or other family members, ability to learn virtually, extent of community spread, the family structure and finances and parental/child’s comfort level.
5. Are the numbers of children who have COVID-19 lower because they have not been in school?
We still do not know definitively how likely children are to acquire and spread COVID-19 compared with adults.
A recent study analyzed 59,073 contacts of 5,706 COVID-19 index patients (those first identified to clearly have the virus in a given group) in South Korea from Jan. 20, 2020 to March 27, 2020 when mitigation efforts including school closures and social distancing were in effect. This study showed that household contacts of 10-19-year-old index patients had as high, or higher, a rate of infection as household contacts of adults, whereas household contacts of children 0-9 years had a lower rate.
Another recent study in JAMA by Auger et al. published July 29, 2020, showed that between March 9, 2020, and May 7, 2020, school closure was associated with a significant decline in both incidence of COVID-19 and mortality. However, a subsequent editorial by Donohue and Miller pointed out that, since school closures were implemented in addition to other measures such as physical distancing in the community, closure of nonessential businesses and stay-at-home orders, it was difficult to interpret the effect of each intervention separately. A conclusion of the editorial was, “Whether the estimated associations between school closures and COVID-19 outcomes derive from reducing contacts among children or among their parents and caregivers, who are also less mobile as a result, is not known.”
6. What is the likelihood of transmission of COVID-19 on a bus that is well-aerated vs. a bus that on some days may have the windows closed?
A well-aerated bus has less likelihood of promoting transmission of COVID-19 than a closed one. Consideration about safety or health risk (e.g. risk of falling, triggering asthma symptoms) should be taken into account while considering keeping bus windows open.
The AAP guidelines encourage the following about school buses:
- Reducing the number of students riding the bus (especially if parents are able to provide their own transportation)
- Cohorting the same students
- Physical distancing of 6 feet between students if feasible—tape marks showing where students can sit
- Symptom screening is ideal prior to boarding bus, but might not be feasible
- Face coverings for students
- Drivers should be a minimum of 6 feet from students; driver must wear face covering; consider physical barrier for driver (e.g. plexiglass)
- Adults who do not need to be on the bus should not be on the bus
- Have windows open if the weather allows
7. Are HEPA filters in classrooms effective?
There is no direct evidence that a HEPA filter by itself would be effective in classrooms and has not been recommended by the CDC. Physical distancing, face coverings, hand hygiene and cohorting are the key ways to reduce transmission. Doors and windows can be opened (if not with health or safety risks) for increased air circulation.
8. Does a daily screening survey need to be administered by a school nurse?
Temperature measurement and symptom screening of students, teachers and staff should occur daily. This screening does not necessarily need to be administered directly by a nurse. Screening may be done at home with screening results transmitted to school or performed on site prior to admission to the school. The Texas Education Agency recommends that teachers and staff selfscreen for symptoms and should take their own temperature every day before school.
Identifying COVID-19 and considerations
1. How can I help determine if a student has COVID-19 or another illness?
Unfortunately, other respiratory viruses can cause many of the same symptoms as COVID-19. It is also possible to have co-infection of another virus with COVID-19, meaning, one can have more than one infection at the same time.
In an area with high prevalence of COVID-19, if a child presents with the typical COVID-19 symptoms (fever, congestion, cough, alterations in taste or smell, diarrhea), the likelihood of having COVID-19 infection would be higher.
Parents should be instructed to keep children home if they develop any signs or symptoms of COVID-19 OR if the child has been in contact with a person with COVID-19.
2. Should asymptomatic students whose family members are COVID-19 positive stay home from school?
Yes; according to CDC guidelines, students with a positive household contact are considered exposed to COVID-19 and should quarantine at home for 14 days. School officials should communicate with the local department regarding testing of the asymptomatic contact and guidelines regarding ending of quarantine and return to school.
3. How long is a symptomatic person contagious? What about an asymptomatic person?
Studies have shown that the concentrations of SARS-CoV-2 RNA (a measure of the quantity of virus) in upper respiratory samples decline with days of illness. For patients who are asymptomatic or have mild to moderate illness, contagious viral particles generally decline after 10 days following symptom onset or 10 days after the positive test if the person remains asymptomatic. In patients with severe disease or in immunocompromised patients, contagious viral particles are not detected beyond a maximum of 20 days following symptom onset in available studies.
4. If a child tests positive for COVID-19 and continues to test positive even though their symptoms have subsided, are they still contagious?
No; they are not considered contagious. Recovered persons can continue to shed detectable SARS-CoV-2 RNA in upper respiratory specimens for up to 90 days after illness onset, but at concentrations significantly lower than during illness and contagion is unlikely beyond the 10 (mild, moderate) to 20 (severe illness) days of illness.
5. Can kids of all ages be tested for COVID-19?
Yes; infants, children and adolescents of any age can be tested for COVID-19.
1. What are the acceptable tests for COVID-19 available in the community?
- A nasopharyngeal (NP) specimen collected by a health care provider; or An oropharyngeal (OP) specimen collected by a health care provider; or
- A nasal mid-turbinate swab collected by a health care provider or by a supervised onsite self-collection (using a flocked tapered swab); or
- An anterior nares (nasal swab) specimen collected by a health care provider or by home or supervised onsite self-collection (using a flocked or spun polyester swab); or
- Nasopharyngeal wash/aspirate or nasal wash/aspirate (NW) specimen collected by a health care provider
However, there are studies demonstrating lower sensitivity of anterior nares swabs as compared to NP or OP samples.
Antibody tests do not detect current, active infection. A positive test likely indicates a past infection with SARS-CoV-2. However, it is unclear how often patients with previous COVID-19 infection make antibodies that can be detected with this test.
Antigen POC/Rapid testing for COVID has a low sensitivity rate, meaning there is a high percentage of false negative results. Point of care PCR tests such as the Cepheid GeneXpert® Xpress are more sensitive than antigen tests and are less likely to give false negative results.
With any testing, negative result at one point in time does not mean that someone may not test positive at a subsequent date/time. Testing may be negative in a person with COVID-19 if the test is performed too early (during the incubation period), if the specimen is not collected correctly or if the test that is used is not very sensitive.
1. What is the difference in wearing a face mask and a face shield? Do you have a preference
A face mask covers just the mouth and nose while goggles or a face shield protect the eyes. We don’t know how often transmission of COVID-19 occurs through the eyes and other membranes, but we know that it occurs with other similar viruses. Eye protection is considered to be an essential part of PPE for COVID-19.
2. How often should a face mask be changed?
A face mask should always be changed after interacting with a person with symptoms compatible with COVID-19 or known to be COVID-positive. Without such exposures, it can be worn for several hours, but should always be changed if it becomes damp or soiled.
3. In a classroom setting, if students are 6 feet apart, can they remove their masks?
The combination of distancing and masking is more effective than either used alone. Droplets can be projected more than 6 feet by a forceful cough in older children or adults. Distancing by 6 feet or greater provides protection but that protection will be enhanced by also wearing a face mask.
Students with underlying health conditions
1. Should children with underlying health conditions return to school in person?
The decision for children with underlying health conditions to return to school in person depends on a variety of factors, including the overall physical and emotional health of the child, presence of high risk underlying medical conditions, ability to learn virtually (and access to virtual learning environment at home), extent of community spread, the family structure and finances, and parental/child’s comfort level. Consultation with a health care professional regarding the child’s specific underlying condition and risk/benefits of going to school should be sought.
2. Are there extra precautions required for students with inhalers with or without spacers? Can students use their own inhalers in the classroom?
Students can use their inhalers with or without a spacer at school and self-carry their inhalers. Attention should be paid to proper hand washing before and after use. As an extra precaution, they should use the inhaler outside of the classroom where other students are present. Asthma treatments using inhalers with spacers are preferred and recommended over nebulizer treatments whenever possible to decrease possible airborne spread.
3. Why is obesity such a big risk factor for COVID-19?
According to the American Heart Association, there are multiple pathways by which obesity and excess ectopic fat increase the risk of COVID-19 complications. Obesity in general reduces cardiovascular fitness, increases the risk of blood clots, reduces respiratory reserve, impairs many metabolic responses and can cause impaired immunity. The impaired immunity can reduce the body’s ability to fight COVID-19, and can also help cause an immune response that actually makes the effects of the COVID-19 infection worse.
4. Should students with asthma wear a mask?
Yes; students with asthma should be able to wear a mask.
1. What is MIS-C?
Multisystem inflammatory syndrome in children (MIS-C) is an inflammatory condition that has been seen in children infected with COVID-19, when different organ systems (heart, kidneys, brain, skin, eyes, and gastrointestinal tract) become inflamed. The exact cause of MIS-C has not been determined. Children who have been diagnosed with MIS-C either have been diagnosed of having the virus or exposed to someone with the virus. The onset of MIS-C can be several weeks after the initial COVID-19 infection, and that initial infection can cause typical symptoms or be asymptomatic. Children with MIS-C often present with some combination of fever, chills, fatigue, vomiting, diarrhea, abdominal pain, red eyes and rash. Any child who experiences these symptoms after having been diagnosed with COVID-19 should be brought to medical attention immediately.
2. What is “well-ventilated” and good “air circulation” mean?
The term “ventilation” refers to the amount and direction of airflow – or “air circulation” within a room or space. This can actually be measured in closed rooms and spaces by facilities personnel. Inside of a building, the ventilation is determined simply by the amount of air that is pumped into and leaves the room; the more air that moves, the better the ventilation. Normally, this is determined by the settings for fans, air conditioners and heating of a room. However, ventilation often can be increased by the opening of doors and windows, especially if they are positioned across from each other to create directional airflow.
3. What is benchmark for high or low community transmission?
Unfortunately, this question has not yet been answered in the context of determining the level of community transmission at which it is safe to reopen in-person school. Countries in Europe and Asia that have successfully reopened schools with little increase in infection rates had previously established COVID-19 case rates in the community of less than 5 per 100,000 persons, a rate that is much lower than the current (as of Aug. 1, 2020) rate in many parts of the U.S. and most of Texas. This question will be answered as schools reopen in various parts of the USA and community and school rates of infection are subsequently measured.