The last time I shared an update from Dr. Dora Anne Mills was June 8, a little over a month ago. The number of confirmed cases of COVID-19 has increased since then, alarmingly so in the United States. We may have been able to keep the numbers relatively low in Maine, but we cannot be complacent.
- Number of confirmed cases of COVID-19 around the world: Was 7,097,017, and is at this moment 13,127,006
- Number of confirmed cases of COVID-19 in the United States: Was 1, 960,642, and is at this moment 3,364,704.
- Number of confirmed cases of COVID-19 in Maine: Was 2,305, and is at this moment 3,159
These numbers only tell part of the story. There are other important numbers: People who have died, people who have recovered, for instance. The sources I cited above should have those other numbers.
Since the beginning of the COVID-19 pandemic, Dr. Mills has been sharing information and updates on her Facebook page. She calls them Not-So-Brief COVID-19 Updates. Dr, Mills was the director of the Maine CDC and the State’s Health Officer for 14 years. She is currently the Chief Health Improvement Officer for MaineHealth. Because not everyone is on Facebook or has access to the information, with her permission, I have been sharing some of her updates on the Catching Health blog. This is her most recent:
Not-So-Brief COVID-19 Update, Monday, July 13, 2020
REOPENING K-12 SCHOOLS
So much of the pandemic discussion these days is centered on the trillion-dollar question: what about schools reopening this fall? This virus is extremely intelligent and insidious, and the issue of reopening during this pandemic is certainly a topic worthy of a book, yet book volumes have already been written about it. I’ll share a few brief perspectives on K-12 (non-boarding) school reopening, with a focus on the issues of the relationship to community transmission; application of known strategies; and the emerging evidence of COVID-19 among school-aged children.
My perspective is a public health one and as a pediatrician. To be more complete, the perspectives of educators, parents, students, and policymakers are needed. They are the experts on what is doable in the classroom and the resources needed or available.
First, reopening schools is heavily dependent on how much COVID-19 transmission there is in the state or community. While there are no clear criteria yet for the case incidence, test positivity rate, and/or hospitalization or death incidence needed for schools to reopen safely, experience in other countries indicates that school outbreaks are more likely to occur if there is significant community transmission.
For instance, reopening of schools in Norway, Japan, and Denmark (all reopened in April), where there was low community transmission, did not result in an increase in COVID-19 or school outbreaks.
However, community transmission at the time of school reopening was higher in Germany, South Korea, and Israel. In Germany, there was increased transmission among students, though not staff. South Korea reopened schools in late May, with distancing and masking required. However, due to increased community transmission, they have had some outbreaks in schools, and have had to close some down. Israel re-opened schools in early May, along with restaurants and most businesses. Because of crowded conditions, they cannot not maintain physical distancing in schools (though they require masking of those > 7 years old). They have experienced school outbreaks, and are relying on testing, isolation and quarantining, and closing schools with an outbreak. For the most part, schools in all three of these countries have remained open, despite outbreaks.
Interestingly, some countries that reopened schools early have stated that schools should be the first non-essential sector to open up since schools and daycares form a foundation for the rest of the economy. With schools closed, parents’ jobs in the rest of the workforce are jeopardized. Other countries, such as Taiwan and Sweden, never closed schools, since the evidence even in March, was that school-aged children are not at high-risk for severe disease and are not major transmitters of the infection. They also felt that schools are an essential service. It is an interesting question some countries pose – should schools be reopened before hair salons, indoor dining in restaurants, casinos, and bars?
Second, there are known effective strategies that should be considered in any sector, including schools. They include:
- FACE COVERINGS (masking)
- PHYSICAL DISTANCING (including keeping especially indoor spaces less crowded, maintaining some distance between students while sitting in a classroom, not allowing any large classes, closing gathering spaces such as staff break rooms, limiting the number of students in such areas as the library, gyms, and playgrounds to a cohort, having students eat lunch in their classroom, not allowing indoor group singing or exercise)
- BARRIERS (to keep people apart when distancing is not possible, e.g. plexiglass barriers between students when sitting at tables
- HAND HYGIENE (requiring all students and staff to wash or sanitize hands upon arrival, before eating, after eating and reapplying a mask, after touching frequently touched surfaces such as playground equipment, etc.)
- COHORTING (keeping the same group of students and staff together all day every day they are in school, and scheduling separate times for each cohort for an area of the playground, gym, and library);• SCREENING (e.g. screening for symptoms upon arrival or through an app)
- TESTING, ISOLATION, QUARANTINE (testing and isolating those with symptoms, conducting contact tracing and quarantining for those who are exposed)
- ENVIRONMENTAL STRATEGIES (such as regular cleaning of frequently touched surfaces and increasing air ventilation and filtration when easily possible)
- KEEPING THE VIRUS OUT OF SCHOOLS by only allowing essential personnel into them.
How these strategies are applied varies a great deal across countries. You can think of each strategy as a layer of protection. The more layers you can build into the school setting, the more protected everyone is. However, some layers may be practical for some schools, some ages, and some cultures, and not for others. Some examples:
- In France, schools have reopened since mid-June, and for younger ones since May. They have applied masking and distancing differently, depending on the age. There are no physical distancing rules for kindergarten children within their class cohorts. In primary schools, a three-feet (one-meter) physical distancing rule is recommended. In middle schools, when the one-meter distancing is not possible, students are required to wear a mask. Masking is required for high school students. There is an emphasis on cohorting and environmental strategies, such as disinfecting surfaces and ventilation.
- In Denmark, schools were reopened for young students in mid-April, and for all ages by early May. There is no masking of students or teachers. However, there is a strong emphasis on maintaining small cohorts of about 12 students, with a cohort of students and teachers not having contact with other cohorts to the extent possible. For instance, a cohort may have its own scheduled time and space on the playground and for dismissal onto buses. Students’ desks are kept 6 feet apart. Single-topic teachers such as those teaching art or music, sometimes have their own multi-topic cohort, in order to maintain small class sizes. Gyms and other spaces are used for classrooms. Some schools have split days – the first half for the younger students, and the second half for the older students – in order to maintain small numbers of students and staff inside the school. Students and staff are asked to wash their hands hourly. Of note, New Zealand, Norway, Sweden, and Switzerland also do not require masking in schools, but also emphasize these other strategies.
- Germany reopened schools in early May with strict physical distancing of 6 feet and classrooms with no more than 10 students. As a result, the two cohorts of students share a classroom, with each cohort attending one-half day in-person, with online lessons the other half. A few schools are routinely testing students and staff every four days, and allowing those with a negative test to attend school without a face mask.
- Taiwan, Japan, and South Korea emphasize barriers (such as tabletop plexiglass partitions between students), face masks, temperature screening upon entry, and opened windows to improve ventilation.
Third, there is a growing body of evidence related to the impact and transmission of COVID-19 among school-aged children. As science provides us a clearer lens, this will need to further inform the reopening and continued opening of schools. So far, studies indicate that:
- Children may be less likely to infect others (and this may be especially true of younger children)
- Schools do not seem to play a major role in community transmission
- Rates of COVID-19 infection are lower for children than for adults
- If exposed, children may be less likely to become infected with COVID-19
I’ll try to post at a later time a review of some of the literature leading to these assertions.
Regardless of the emerging science, one thing is very clear. The level of activity of COVID-19 in Maine and New England, even in southern Maine, is lower than countries that have successfully reopened schools. However, that is not true for much of the rest of the country, especially in the South, West, and increasingly the Midwest.
The key to reopening schools is to maintain low levels of viral activity in our communities. Therefore, the key to reopening schools is in each of our hands. It is to maintain the three Ws:
- Wear a mask
- Wash our hands
- Watch our distance.
Enjoy this precious time of summer, but please be careful and vigilant. This virus is schooled in ways the world was not prepared for and we are still learning about. I believe K-12 schools can be reopened safely and have done so in many different countries, but it will take the efforts of all of us across our communities to make it happen.Dora Anne Mills, MD, MPH, FAAP
Listen to a podcast of this update
Dr. Mills’ daughter started a podcast where she has been reading her mother’s updates: Not-So-Brief COVID-19 Updates from Maine.
- Massachusetts School Reopening Guidance
- France School Reopening Guidance
- Ireland School Reopening Guidance
- Danish School Reopening Guidance
- Brookings Institute, Reopening the World: Reopening schools – Insights from Denmark and Finland
- School openings across globe suggest ways to keep coronavirus at bay, despite outbreaks (AAAS American Association for the Advancement of Science)
- Review of other countries’ school re-openings and requirements by the U. of Washington
- These 8 Basic Steps Will Let Us Reopen Schools