Dr. Tara O. Henderson, Dr. Monica Gandhi, Dr. Tracy Beth Hoeg, and Dr. Daniel Johnson
"The only thing we have to fear is...fear itself — nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance.” — Franklin Delano Roosevelt
The recent school reopening guidance released by the Centers for Disease Control and Prevention (CDC) is an example of fears influencing and resulting in misinterpretation of science and harmful policy. In the U.S. 50% of schools are closed and more only partially open. President Biden ran on a campaign indicating that science and data would guide his policy. As we approach the anniversary of the first COVID shut down, this approach is needed more than ever, especially when it comes to schools.
Like in so many states, California and Illinois schools are being hamstrung by the CDC guidance. The guidance does not take into account the data we have regarding little disease transmission in schools. Nor, although the guidance cites the work performed across Wisconsin districts performed by our group and published in the MMWR, does it take that data and new analyses from that dataset into account. Keeping schools closed or even partially closed, based on what we know now is unwarranted, is harming children, and has become a human rights issue.
The facts about COVID and school
Here are the facts:
First, children are not at significant risk of poor outcomes from COVID-19. As of March 3, 2021, 286 children have died from COVID in the U.S., compared to >500,000 adults. While the death of any child is devastating, this is similar to the number that dies from influenza each year. And COVID-19 deaths in children and adolescents are magnitudes smaller than deaths from suicide, some now driven by school closure. COVID-19 in children can cause potentially dangerous complications — e.g., Multi-Inflammatory Syndrome in Children (MIS-C) — but this is very rare and in nearly all cases, treatable.
Second, viral spread is minimal in schools with appropriate safety precautions, even in communities with a high disease prevalence (significantly higher than the current CDC red zone that the CDC suggests middle and high schools be all virtual and elementary schools hybrid). Dr. Hoeg led a study of over 5,530 grade K-12 students and 654 staff members in Wisconsin school districts in the fall of 2020. COVID-19 test positivity rates reached 41.6% in the community during the study. Notably, despite the majority of ventilation systems not being replaced, with only 92% of students wearing masks (no mask wearing during recess), and with variable distancing, there were only 7 students (5 children grade K-6, and 2 in grade 7-12) and 0 staff who contracted the virus in school. Similar experiences are published from North Carolina, South Carolina, Chicago, and other cities and countries.
Third, no science supports mandating 6 feet of distance with children wearing masks. A 6 foot distance between students creates space constraints for schools to open in entirety. There is data supporting at least 3 foot distancing. In Dr. Hoeg’s study, >90% of elementary school children were less than 6 feet apart in the classroom and while eating (~80% of grade 7-12 were 6 feet apart in classroom but less in hallways and while eating). Recently, the CDC cited data of clusters of COVID-19 cases in Georgia. In this study, students sat less than 3 feet apart (not just less than 6 feet), there were small group instruction sessions in which teachers sat next to students, and many did not wear masks or wore them inappropriately. States are getting the message and passing rules allowing for 3-6 feet of spacing in schools using masking, why hasn’t the CDC?
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Fourth, despite fear-mongering regarding variants in the U.S., we have not seen evidence that variants are spreading through in-person schools. France, Spain, Switzerland and Belgium have demonstrated that K-12 schools can remain fully open safely even as the UK variant becomes dominant. Moreover, masks and >3 feet distancing will protect against variants like it does against all forms of the virus. Therefore, at this time, variants are not reasons to keep schools closed.
Science shows we can open schools
Vaccination is on the way for teachers and staff. Vaccination is expected to work against the variants. There are two major arms of the immune system: antibodies and T-cells. Vaccines work in multiple ways, most transiently by inducing antibodies that usually provide more short-term protection or protection from mild illness. The COVID-19 vaccines also generate strong T-cell immunity directed against the virus. These T-cells work against multiple parts of the virus, including those that are conserved across variants. A recent paper shows the ability of COVID-19 specific T-cells to protect against multiple variants.
School closure comes with long-term individual and societal costs. Many children cannot effectively learn, group, engage, socialize, be active, eat healthy food or get support until schools physically reopen. Children with special needs and from disadvantaged backgrounds are, in general, paying the largest price. As most private and parochial school districts are open for in-person instruction, the divide between the haves and have nots is exponentially growing. We are observing a significant psychological epidemic in children with depression and anxiety due to the isolation associated with school closure, with suicidal behaviors. Subsequent lost wages for families translates into poverty, eviction and food insecurity. Recent research assessed there are greater risks to life expectancy with schools closed versus staying open.
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We must act for children, and we can do this while keeping staff and teachers safe. This can be accomplished with appropriate distancing (3-6 feet for students in schools), masking, hygiene, cohorting, and increasing ventilation when possible; all of which can be achieved readily and immediately in classrooms and schools. Teachers and staff will have increased safety when vaccinated and the Biden administration has prioritized this group. The best way to overcome fear is to follow the science, and the science shows we can safely open our schools now for full-time (non-hybrid) learning and keep them open.
Dr. Tara O. Henderson is a professor of Pediatrics and interim chief of Pediatric Hematology, Oncology and Stem Cell Transplantation at the University of Chicago Comer Children’s Hospital. She was a 2018 Presidential Leadership Scholar. Follow her on Twitter: @doctortara
Dr. Monica Gandhi is a professor of Medicine and associate division chief of the Division of HIV, Infectious Diseases and Global Medicine at University of California- San Francisco. She is the director of the UCSF Center for AIDS Research. Follow her on Twitter: @MonicaGandhi9
Dr. Tracy Beth Hoeg is a physical medicine and rehabilitation specialist and epidemiologist at University of California-Davis and Sports Medicine at Northern California Orthopaedic Associates. She is the senior author of the 2020 study of transmission of COVID-19 in the Woods County Wisconsin schools (Falk et al. MMWR Morb Mortal Wkly Rep 2021; 70: 136-140). Follow her on Twitter: @TracyBethHoeg
Dr. Daniel Johnson is a professor of Pediatrics, chief of Pediatric Infectious Diseases and Academic Pediatric at the University of Chicago Comer Children’s Hospital. He is a member of the Illinois Department of Public Health’s COVID School Workgroup and Co-Lead of the Illinois Chapter, American Academy of Pediatrics’ Task Force on Return to School.
