What can we do in our communities to keep COVID-19 transmission rates low so that it is safe for our kids to attend school?
Infection with COVID-19 is dependent on several factors: exposure; the amount of time you are exposed (CDC experts estimate that you must be exposed, with close contact, for 10-15 minutes to get infected); and the number of people you are exposed to: the more people, the higher the risk of exposure.
That is why COVID-19 is a disease that loves crowded settings–especially indoor settings: restaurants, office buildings, churches–and yes, schools.
Schools meet all of the criteria for an environment that effectively fosters the successful spread of infection, which is why schools have suffered so many outbreaks–not to mention deaths. Hundreds of school teachers across the United States have been infected, in addition, no doubt, to parents and grandparents of those students, teachers, staff who may unwittingly have brought the virus home.
So there is excellent motivation to understand and mitigate those risk factors–because doing so may help protect you, your family, teachers and staff when your kids head back to school. But it takes a whole community effort to accomplish this: families, schools and our public health departments and state must work together to create an environment that will ensure low community spread.
What Families and Students can Do:
- Know the risks and avoid them — see the COVID-19 Action Coalition brochure with specific recommendations below. Infection risk is a function of time and likelihood of exposure. To limit the exposure part of the equation, your school should plan for how to keep your child’s cohort small. You can make sure your children maintain that cohort outside of school to eliminate interclass mixing. Also, you have control over your family’s risk factors outside of school: you can keep your circle small and avoid the following high risk exposures: weddings, funerals, sitting indoors at restaurants and bars, indoor sports arenas or indoor concerts–really, any kind of close contact with large numbers of people especially indoors.
- Don’t go to work sick; and don’t send your child to school sick. You and your family should screen for symptoms daily. Have a backup plan if you are sick or your child is sick. DO NOT give your child tylenol and send them to school sick, because if they have COVID, they may spread it to other students and teachers–and from there, to vulnerable staff, parents and grandparents. This requires advance planning: who will take care of your kids if they are sick and you have to work? Who will take care of you if you are sick? Have you planned for how you will limit contact between you and your kids in that event? (see this informational handout on treating COVID at home). Have you planned for who will take care of your kids if they have to quarantine for 14 days?
- Hand washing: So-called “fomite transmission” via hands isn’t as important a factor in catching this virus as was believed at the beginning of the epidemic, but it still plays a role; and importantly, kids have some control over this risk factor, which may make them feel empowered. So it’s a good thing to encourage. Soap will do. Put it in a little soap box that they can carry with them. Or make hand sanitizer and put it in a reusable dispenser that they can carry. It may be prudent to carry one’s own if allowed, and avoid the public soap/sanitizer dispenser if that dispenser isn’t automatic.
- Masks: CDC recommends a “cloth face covering.” Dr. Bill Burman of Denver Health discusses why and how here. But what kind? There is remarkably little guidance out there. Here is an excellent website written by Harvard medical students–they reference studies on which are the most effective materials, which ones to avoid, and how to make your own. The bottom line: a mask should have at least 2 layers of quilted cotton (tight weave) and some sort of filter (silk or synthetic); fit snugly to the head (a pipe-cleaner can be inserted in the top seam of the mask helps it fits snugly over the nose). If the mask doesn’t fit snugly, it is markedly less effective. If it isn’t made of the right materials, it is also less effective–in fact, fleece was found to transmit particles more effectively than no mask, according to one study. Bandanas leak more than other sorts of mask, but are better than nothing. And don’t forget that once you use a mask, it needs to be washed, if reusable: according to pandemic expert Peter Sandman, “All used facemasks should be considered dangerous objects. After all, if a mask has stopped some flu-containing droplets or aerosols (on the way in or on the way out), then for some period of time the mask itself can give someone the flu. So if you’re going to use facemasks, you need to change them often; you need to dispose of them properly or wash them carefully (if they’re reusable); and you need to wash your hands thoroughly after touching a used mask.” But no mask (even medical masks–the very uncomfortable N-95 or surgical masks) will protect completely against COVID. Masks must be used in conjunction with all the other recommendations (distancing, hand washing, avoiding crowded places and cohorting). Note: when I go temporarily into a high risk setting, like a medical office or hospital, I do wear a medical mask–but these may be difficult to find and the N-95 must be properly fitted to your face, or it is not helpful.
What Your School Can Do. The interventions your school can implement are more powerful than the things you can do. So it is worth encouraging your school– and your local and state government and health department–to step up to the challenge.
- Ventilation: Put a fan in the classroom, or equip it with an air purifier like a HEPA filter. This will help the air circulate–but you must still have access to fresh outside air. Make sure the windows can and will be opened in all classrooms that will be used. Dr. Ashish Jha, physician at the Harvard School of Public Health emphasized this intervention at a recent forum on COVID and schools: “Open a window,” he recommended. “If the classroom doesn’t have a window,” he added, ”open a window anyway.” In other words–make sure you are in a classroom with windows that open. Your school needs to make that a priority. There have been very few transmission events in outdoor settings, likely due to the dilutional effect of outdoor air, UV light, and distance that can be better accomplished outdoors. If you can’t be outside, bring outdoor air inside. Also: a bank of windows in a room with the doors closed won’t work either–there has to be cross ventilation, or the air won’t move–so classroom doors AND windows must be open. Some schools are setting up outdoor classrooms with tents–that is brilliant, if your school can swing it.
- Avoid crowding by keeping cohorts small. Have a plan for staggered recess times and staggered classes so cohorts can stay separate. In Germany, schools aren’t mandating that students keep socially distanced within their cohort; but they are keeping children in very small groups; and if anyone in that group gets sick, the whole group must quarantine. Reverting to the open classroom model is another possibility, where students remain together as a cohort/group, but study different subjects at their own pace–kind of like a Montessori class. This could be done at both the high school, middle and elementary school levels. The high school students could watch their lectures on video (asynchronously), and teachers in the different subjects could be available to them by email or phone. This way students could have a single “home room,” and be able to attend full time school because their cohorts are so small. I have attended forums with teachers who have many excellent ideas–including this one– on this topic. They should be listened to and included in this conversation.
- Plan for teacher absences. Will there be a proctor and will the teacher be able to teach from home if in quarantine? What if a teacher gets COVID and the school has scarce resources: for example, there are no other science teachers to cover–can the school pair with another public school, and coordinate instruction so that one school can “cover” for another? Could all lessons be pre-recorded, as in the ”Montessori” high school model above? This would work for high school and middle school, and perhaps for some elementary school teaching also.
What the State / Public Health Department can do:
- Mandate COVID-19 surveillance testing and testing of symptomatic children and adults at school. Experts say testing is key to safe school reopening in Massachusetts. As of today, the Commonwealth has planned to offer testing only AFTER an outbreak has been identified. That is not prudent and is poor public policy. Why? Acting retroactively is always worse than preventing infection proactively–the horse is already out of the barn, as they say. Maybe that is why outbreaks have been reported in daycare settings here in Massachusetts–because there was neither surveillance nor symptomatic testing. If the Commonwealth has mandated and arranged for free COVID testing at our state colleges–as is currently the case– then it should likewise be possible to offer the same protection to teachers, staff and students in our public school systems and daycare settings. Such interventions will protect our students, our teachers, and our economy.*
- Mandate paid sick leave for all adults with COVID-19, so that parents can stay home to take care of sick children (or themselves). This will go a long way towards ensuring that sick adults do not take the infection to work–and that sick children are not sent to school infected because their parents cannot afford to stay home to care for them. To quote Nobel Prize winning economist Richard Thaler: “If you want people to do something, make it easy.” That is what paid sick leave will do–make it easy for parents to do the right thing.
- A dedicated contact program effort for schools. This is a critically important undertaking–and should have a dedicated staff to keep track of surveillance and symptomatic testing as well as contact tracing; and the payoff would be tremendous, in terms of giving public health departments a chance to get the epidemic under control in Massachusetts, since the age group here with the highest case rates is now among persons younger than 50–parents and children, in other words.
- Reduce air pollution–air pollution is known to be associated with increased mortality due to COVID. Just because the federal government is easing up on air pollution regulations doesn’t mean the Massachusetts state government should. The governor of Massachusetts has been given exceptional powers to make policy during COVID. And even if, despite this public health emergency, he feels unable to regulate known polluters, he can undertake an aggressive public health informational campaign and publish the air pollution statistics near various known high emitters, along with the current mortality figures for those areas (for all diseases, for that matter), and give them ample publicity; public opinion would correct this problem in short order.
And that’s it! Easy.
The takeaway:
Opening schools safely, according to Dr. Bill Burman at the Denver Health, can be done safely thanks to a combination of approaches: “symptom screening of students and teachers, low-barrier access to testing, masking and other PPE, distancing, cohorting, teaching outside when possible.” But in the final analysis, he says, “Opening schools safely is the responsibility of the entire community, since it is community transmission rates that will drive cases within schools.” COVID-19 may be a disease that loves crowded settings; but these interventions will go a long way to mitigate the propensity of the virus to spread in schools and slowing spread in that setting may even function to significantly slow the epidemic in our country.
But limiting transmission in our own community is not enough: we must limit transmission in all communities. Why? Because teachers, staff and students in our schools come from many communities. So it is critical that our communities work together–individuals, schools, and public health departments–in a concerted effort to drive down rates everywhere. That is how we are going to start seeing the light at the end of the tunnel, and get our children back to school full time.
An excellent brochure from the COVID-19 Action Coalition, adapted from an article by Dr. Erin Bromage: Know the risks of COVID-19– and Avoid Them. Many thanks to COVID-19 Action Coalition intern and Wesleyan student, Lauren Greenberg for the graphic design / writing of this brochure.
*The COVID-19 Action Coalition is advocating that symptomatic and symptomatic testing for COVID in schools should form the cornerstone of effective policy to limit community spread of the virus here in Massachusetts. Why? Because current research indicates 70-90% of cases identified by testing are asymptomatic or presymptomatic and best practices suggest frequent testing is key to preventing outbreaks. Identifying the virus early allows for more rapid isolation and contact tracing, which then limits disease spread and prevents or reduces outbreaks.
This safeguard should be offered universally–in all public elementary, secondary, and pre-K schools– at no cost to the teacher, staff or student. Until we have a vaccine, COVID-19 testing of both asymptomatic and symptomatic persons will improve the safety of all those who return to school. Viral testing supplements standard public health measures such as PPE and social distancing, and is critically important. Everyone wants students and teachers to return to school safely. In the context of the current pandemic, the only way this can happen is through a universal, systematic testing program that will identify outbreaks followed by effective isolation and contact tracing protocols to follow up with those patients who test positive for COVID-19. In other countries, surveillance testing has revealed incipient outbreaks, allowing health officials there to successfully address the outbreak immediately. Lacking such a tool here in Massachusetts will potentially jeopardize the ability of schools to remain open and may ultimately require an even more aggressive rollback of reopening plans with resulting damage to the education of our students and to the wider economy.
Photo credit: photo by Note Thanun, Unsplash.com
