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Editor's Comment
COVID-19

Safely Reopening Schools—Learning Amid a Pandemic

  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 3Editorial Intern, JAMA Health Forum

Seven states and the District of Columbia have ordered statewide closures to delay the return of in-person K-12 classes this fall because of coronavirus disease 2019 (COVID-19). Sadly, regions of the US that have historically started school earlier in the summer—and have spent less per pupil—are faced with the decision of whether to reopen for in-person classes against a background of alarming growth in new cases of COVID-19. Many are choosing to do so.

The American Academy of Pediatrics, the National Academies of Sciences, Engineering, and Medicine, the Centers for Disease Control and Prevention, and numerous articles recently published in JAMA Network journals have presented compelling motivations to resume in-person classes. For instance, with school closures comes the risk that children may experience worsened mental health1,2 as well as reduced access to nutritious foods and health services, lower academic gains, and less attention from protective services.3 These risks may be felt to a greater extent by underserved communities.4,5 At the same time, there are many unanswered questions about the viral load of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children, the extent to which children may contribute to community transmission, and mitigation policies that are most effective to prevent outbreaks in K-12 schools.

Two studies6,7 published in July in JAMA and JAMA Pediatrics have made important contributions yet confirm how difficult this decision-making will be for localities. A study by Auger et al6 elucidated the opportunity for reduced COVID-19 incidence and mortality with timely closure of schools. Notably, Auger et al found that school closures are most effective in preventing widespread community infection and mortality when cumulative incidence is low. It is not clear what this means against a background of higher incidence and in places where there are other nonpharmaceutical interventions, such as business closures and mask requirements.

A study by Heald-Sargent et al7 in JAMA Pediatrics added to our understanding of children’s potential role in the spread of SARS-CoV-2 by estimating the amount of viral nucleic acid among newborns to individuals aged 65 years. Although the authors were restricted to measuring viral nucleic acid and not infectious virus, their results suggest that young children can play a role in community-level disease transmission. Indeed, as 97 078 new pediatric cases of COVID-19 emerged in the last 2 weeks of July—a 40% increase in cases among children in conjunction with the return to school in many states—the implementation of public health interventions in K-12 schools is now more important than ever.

Given the limited resources of public schools, in the event of reopening, school districts should devote efforts to interventions that are well supported by public health officials and feasible to implement. First, mask requirements should be enforced for all staff and students for grade levels K-12 through new dress code policies. Second, districts should implement the practice of cohorting, a strategy for keeping small groups of students together, which in effect limits the exposure of students and staff to other contacts.8 Because school districts may not have the resources or budget to make extensive changes to their facilities, this practice coupled with modified scheduling could allow all students to have at least some in-person instruction each week while ensuring physical distancing. At a minimum, districts should prioritize offering in-person instruction to K-5 students, students with disabilities, students who might not be able to access remote instruction,3 and perhaps to students who were already having difficulty attaining proficiency at their grade level.

Third, school administrators should revise attendance policies that might encourage a sick student to attend school. Similarly, state per-pupil fiscal allotments for attendance should be modified to ensure that school districts will still receive funding for students who are unable to attend school in person. As the pandemic continues, staff should also be more diligent in recording attendance as an additional strategy for monitoring potential disease incidence and contacts between students.

Lastly, committees could be formed that include staff, administrators, and student leaders to implement new school climate initiatives that encourage widespread adherence to COVID-19 safety protocols among students, such as hand hygiene and mask wearing. These efforts will ensure that students are not prevented from complying out of fear they may be stigmatized by their peers.9

As K-12 schools that have already reopened navigate the repercussions of this decision, and while other districts continue to weigh their options, policy makers will need to facilitate engagement between stakeholders in education, medicine, public health, and social services. Furthermore, researchers should conduct studies to assist school administrators in decision-making, such as investigations of children’s potential to drive community-level transmission and randomized clinical trials to understand which mitigation strategies in schools are most effective for keeping disease incidence low.10 New knowledge must be conveyed in ways that can be useful by educators without medical or public health training, and proposed solutions must recognize limited district-level financial resources. Better yet, new funding should be made available to schools to help them reopen safely. Ideally, this funding would reflect the greater needs of students in under-resourced communities.3 Given that schools are lifelines for so many students, lives are at stake whether or not schools open for in-person learning during this pandemic.

References
1.
Golberstein  E, Wen  H, Miller  BF.  Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents.   JAMA Pediatr. Published online April 14, 2020. doi:10.1001/jamapediatrics.2020.1456PubMedGoogle Scholar
2.
Xie  X, Xue  Q, Zhou  Y,  et al.  Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China.   JAMA Pediatr. Published online April 24, 2020. doi:10.1001/jamapediatrics.2020.1619PubMedGoogle Scholar
3.
Sharfstein  JM, Morphew  CC.  The urgency and challenge of opening K-12 schools in the fall of 2020.   JAMA. 2020;324(2):133-134. doi:10.1001/jama.2020.10175PubMedGoogle ScholarCrossref
4.
Dooley  DG, Bandealy  A, Tschudy  MM.  Low-income children and coronavirus disease 2019 (COVID-19) in the US.   JAMA Pediatr. Published online May 13, 2020. doi:10.1001/jamapediatrics.2020.2065PubMedGoogle Scholar
5.
Martin  EG, Sorensen  LC.  Protecting the health of vulnerable children and adolescents during COVID-19–related K-12 school closures in the US.   JAMA Health Forum. 2020;1(6):e200724. doi:10.1001/JAMAHEALTHFORUM.2020.0724Google Scholar
6.
Auger  KA, Shah  SS, Richardson  T,  et al.  Association between statewide school closure and COVID-19 incidence and mortality in the US.   JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.14348PubMedGoogle Scholar
7.
Heald-Sargent  T, Muller  WJ, Zheng  X, Rippe  J, Patel  AB, Kociolet  LK.  Age-related differences in nasopharyngeal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) levels in patients with mild to moderate coronavirus disease 2019 (COVID-19).   JAMA Pediatr. Published online July 30, 2020. doi:10.1001/jamapediatrics.2020.3651PubMedGoogle Scholar
8.
Das  LT, Abramson  EL, Kaushal  R.  Reopening US schools in the era of COVID-19: practical guidance from other nations.   JAMA Health Forum. 2020;1(6):e200789. doi:10.1001/JAMAHEALTHFORUM.2020.0789Google Scholar
9.
Waasdorp  TE, Bradshaw  CP, Leaf  PJ.  The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial.   Arch Pediatr Adolesc Med. 2012;166(2):149-156. doi:10.1001/archpediatrics.2011.755PubMedGoogle ScholarCrossref
10.
Starr  P.  Using controlled trials to resolve key unknowns about policy during the COVID-19 pandemic.   JAMA. 2020;323(23):2369-2370. doi:10.1001/jama.2020.8573PubMedGoogle ScholarCrossref
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