Opening schools safely is going to be a challenge. Clearly, there are regions in our country that are capable of putting forth a scientifically sound reason for reopening schools. In addition, many areas simply cannot open schools if science serves as the backdrop for their policies. But science has a hard time against politics and beliefs in our society. So where does that leave us? 

How do we return to school in the US? 

The return to school (RTS) debate is raging across our country.  Given the divisiveness that has arisen around lock-downs and masks, this is not a surprise.  

[Specific thresholds and important questions will be discussed below] 

The Trump administration ignited the national conversation with a policy statement that all schools open, full attendance, full stop.  They claimed that kids are less likely to get infected. They claimed that kids are less likely to get sick, and finally, they claimed that kids are less likely to spread SARS-CoV-2.  Within a week of his initial announcement, the administration has already started to walk back some of their RTS demands. 

Later last week, the CDC produced watered down return to school guidelines, and it is reported that White House staffers wrote portions of that document.  

Kids, Parents, Teachers, Custodians, Bus Drivers, and Administrative Officials are now anxious as they confront tough decisions about how the next few weeks are going to shape up as the return to school momentum builds.  

The National Association of Secondary School Principals surveyed school leaders about their confidence that they can open safely… only 35% reported that they were somewhat or extremely confident that they could do it.  Most cited the lack of resources as the reason for not being confident. [Michael Osterholm]

COVID19 and return to school… some background. 

Listening to various podcasts by epidemiologists have revealed interesting statistics and issues that need to be thought out in preparation for the coming school year.  

From Michael Osterholm:

  • roughly 33% of parents need/want kids in school full time so that they can work
  • approximately 33% of parents want their kids to be offered a hybrid or learn at home program.  
  • Roughly 33% of parents aren’t sure and have many questions to ask before they make a decision.  

The issues are far and wide-reaching.. and not simple to contend with. But this is a meaningful national conversation… that will ultimately lead to numerous different regional policies.  

  • A significant number of parents need their children in school so that they can work.  
  • a significant percentage of school teachers, bus drivers, custodians, admin staff, are over 45 years old
  • a considerable portion of teachers has a risk factor that puts them at risk of severe COVID19 illness.  
  • Many children are at risk by staying home.  Their security is at risk. Their health is at risk at home, and they rely on school for their meals.  
  • Very young children need to learn to socialize and interact with other children.  These are critical formative years.    
  • Many children live in multi-generational households.  Risk on. 
  • Older children may not thrive in a hybrid or homeschooling environment, but they will do far better than younger kids.  

We need to consider some broad assumptions that should be on the table for discussion:

  • It’s not written in the constitution that schools need to start in August.  
  • Funding has not been provided to schools as yet. 
  • COVID19 planning by many districts has just started. 
  • Many schools are too poor to implement changes necessary to make schools safe to attend. 
  • Attendance during a pandemic will NOT be a zero-risk proposition— ever.  


What does science say about children and COVID19? 

There are still many questions that remain.  It is certainly not as straightforward as the administration says it is.  But when you start seeing patterns, you can begin to make some useful assumptions.  

  1. Researchers in Berlin found that kids and adults carry similar viral loads, thus can spread the infection.
  2. In China… the researchers found kids were 1/3 as likely as adults to be infected but had 3x the chance of spreading infections when schools were open.
  3. In England… researchers found little if any difference in the prevalence of SARS-CoV-2 based on age. Children and adults seemed to have the same infection rate.
  4. A recent study out of South Korea showed that kids under 10 had a lower chance of transmitting the virus to adults, whereas children over 10 had the same chance of spreading the virus as adults do. More importantly, they found that households with children over 10 had the highest rates of spread among other members of the household.
  5. In Israel… after schools opened, the number of new cases in one region went from 50 per day to more than 1500 per day. That followed outbreaks at schools that infected at least 1335 teachers and 691 staff.
  6. An overnight camp in Missouri had to close after 82 children and staff became infected.
  7. A biostatistician out of the University of Florida’s College of Public Health says that preliminary data reveal that children do infect adults in the household… and may even be more infectious than adults.
  8. Based on the work by Derek Cummings at the Univ of Florida… we know that children are infected with their first coronavirus by age 3.. and get all four common coronaviruses by age 20. Every other coronavirus infects children and is spread by children… why should SARS-CoV-2 be any different?
Over 260 people were infected, of which 153 were students (attack rate: 13.2%), and 25 were staff (AR: 16.6%). This demonstrates the potential for infectiousness and mass transmission in the school setting.
The school in question reopened on May 18th after being closed for two months. Masks were mandated, but between 19-21 May, a heatwave occurred, and students were exempted from having to wear masks for these three days. Classrooms were crowded, and social distancing was not possible.
Over the following days, almost all students and staff were tested, and 153 of 1,161 students (13.2%) and 25 of 151 staff (16.6%) tested positive. Furthermore,  87 cases were detected among the contacts of staff and students who were SARS-CoV-2 positive. 
Following school reopening, new C19 cases surged in the school district.
Prior to school reopening, positive cases in persons aged 10-19 years accounted for 19.8% of COVID19 cases in Jerusalem. After reopening schools, cases in this age group accounted for 40.9% of the total.
The authors of the paper below made several recommendations: 
  • small class sizes,
  • minimizing student mixing,
  • use of face masks,
  • not attending school if any sign of illness,
  • outdoor classes,
  • and avoiding the three Cs:
    1. closed spaces with poor ventilation,
    2. crowded places,
    3. and close contact.


Flordia Pediatric COVID statistics.. as of July 17, 2020. 

Below is data from the Department of Health in Florida.  23,170 children tested positive.  246 were hospitalized as of July 17th, and two died. Also, there were 14 cases of Kawasaki like disease, or multisystem inflammatory syndrome in children.  Children do get sick.  Data has hinted, as shown above, that they can spread the disease. Why wouldn’t they?  Keep in mind… schools aren’t even open yet.  

Florida Covid cases


Systemic risk.. opening schools during a pandemic, within in a hot zone. 

OK… so those of you saying that “only 246 needed hospitalization”.  Well.. what if you are in a hot zone that has no hospital beds available?  Go way back to March and my original article.  We still need to consider the systemic risk issue.  You need beds to put these children in, and you need hospital staff to be able to treat them.  There are hospitals in South Texas that now have set up a panel to determine which patients might be able to survive and which might not. Those deemed to be at high risk are being sent home… that is the picture of systemic failure.  

Your regional preparedness matters… a lot!

SARS-CoV-2 is in firm control in most parts of our country.  How your town, city, region, and states are able to respond to the crisis is of critical importance in determining whether or not you can even initiate a return to school process.  Your community needs to be able to rapidly identify and isolate cases if we are going to be able to slow the explosive growth that many regions are witnessing.  Many communities need to question whether or not they should shut down, not return to school.  

Other communities who are considering implementing a return to school program will need to provide clear and transparent answers to these questions: 

  1. What is the community’s positivity rate? 
  2. What is your test turn around time?  Beyond 48 hours is nearly useless. 
  3. Can your region isolate a positive case within 24-48 hours? 
  4. How long until you can isolate the contacts from the positive case and test them? 

Unless you have the testing, and tracing infrastructure in place you are probably not ready to implement a return to school program.  


How strong is the data that children do not catch/spread COVID19? 

This is one of the papers being quoted by the CDC and the administration who claim that children are at lower risk of catching the disease.  This was a mathematical modeling paper… and many real-life scenarios now show that this might not be what happens when the rubber meets the road.  In Florida, nearly 1/3 of children who have had a test have tested positive!  
There are many other terrible papers being used to further the argument that children don’t get or spread the disease. One compared Finland to Sweden. But what the authors failed to control for was the fact that Sweden wasn’t testing their children unless they presented to a hospital. Obviously, those numbers will skew to the low side.  
The bottom line is that a few large studies, including one by the NIH, are currently underway. We should have some preliminary data soon.  Children are getting the virus, and we need to know much more about transmissibility and their infectiousness… but kids are superspreaders of other coronaviruses, the flu, measles, etc… so it will be surprising if it turns out that they cannot spread COVID19 as well.   


What is the risk of long term damage in children due to COVID19? 

We don’t know the answer to that.  This is a novel virus. We have only been studying it for 6 months.  In Florida, the Palm Beach County Health Director has warned that they are seeing changes on chest Xrays that are consistent with lung damage, even in children who are not sick or hospitalized.  We do not know if that will translate into a chronic issue.  It is reported that nearly a third of adult COVID19 patients have had long term issues such as persistent cough, shortness of breath, and more.  

Recent reports show that more than 30% of people still have symptoms 3 weeks after their illness began.  Their symptoms vary from fatigue to cough, cardiac issues, and more.  

So, children do get sick. Some get very sick, a very small number die, and children might have long-term issues —that will take time to study.  


Can we return to school during a pandemic? 

Yes, there are regions in the country that are capable of having a scientifically sound discussion about returning to school.  Again, this will not, and cannot be a zero-risk issue.  More children have died from cancer, injuries, and car accidents than have died from COVID19.  We need to have this conversation.  Waiting for this to be a zero risk issue is genuinely a non-starter position.  

The data is clear… children benefit from being in school.  That being said, there is a tremendous amount of preparation and work that needs to go into the policies, guidelines, and implementation strategies in districts that plan on opening.  This is going to be a hyper-regional roll out.  What works for one district might not work for another.  Data should be the driving force in determining risk mitigation strategies and RTS policies.  As we have witnessed far too often, politically motivated decision making can have fatal consequences for people and poses a significant systemic risk to regional health care/educational systems.  

Return to schools in hot zones

If the positivity rate is below a certain threshold.. some states say 5%, then they believe that this is a manageable situation.  It cannot be stated clearly enough; in states where there is active community spread, high positivity rates, or hospitals that are full, then return to school cannot happen.  Planning should be put in place for a return to school in a few months when numbers start to improve.  Those regions, although unpalatable, and unlikely to happen, should be locked down again.  Masks alone will not get them to where they need to be.  Strict distancing for a few weeks will allow districts in hot zones to consider reopening later in the fall. Without strict distancing, opening schools in a hot zone is a recipe for a disaster.  

If schools open in a hot zone, infections will rise, schools will close again, then they’ll try to open again and so on.  Parents will lose faith, teachers, and staff will not want to return, and ultimately it will be a failed attempt to return, and the kids will not have learned anything. 

Return to school in regions with low positivity rates

Many countries have shown that schools can be reopened in regions without active, significant community spread.  Again, let’s start with the premise that most kids need to be in school.  Our own school district’s attempt at distance learning was a disaster, so if there is a safe (not zero risk) means to get the schools ready, get policies and procedures in place, then schools should open. The key issue is whether or not those schools can prepare in time. 

This is a process that should have started in April.  Not mid-July.  Schools need to upgrade ventilation systems, perhaps find vacant buildings they can convert to classrooms, put into place testing and tracing procedures, prepare for fewer kids per class, instruct their teachers and staff about the new guidelines, and put strict contingency plans in place should active community spread return to their region later this fall. 

The schools need capital to prepare… that capital has not been forthcoming.  The schools need immense sums of capital to improve their infrastructure and meet state, regional, and local guidelines for reopening.  This does put a September start at risk… but again, we do not need to feel forced into opening schools on time.  I would rather have everything in place than rush back, only to have to them close again. Schools will rapidly lose the confidence and support of their communities if they need to shut down again soon after reopening.   

If your schools are planning on reopening.. here are some considerations to discuss with the leadership in your region.  These are essential questions that need to be addressed before we allow our children to return to school this fall.  

What local COVID19 thresholds should be used to guide school reopening? 

Basics… if there is no local spread, eg. Maine, Montana then there is no reason you cannot open safely. 

In states such as Arizona, Florida, California, and Texas there is no way you can consider opening schools.  You wouldn’t hike in a forest that is currently burning. 

Thresholds to consider before reopening school in-person learning. As articulated by Dr. Osterholm of CIDRAP  

  1. less than 5 cases per 100,000 population
  2. decreasing case numbers for two weeks. 
  3. Hospital capacity to handle new cases is > 25%. 

COVID19 related questions for your school administration. 

Opening the schools is the “easy” part… keeping them open will be the challenge. You only get to do this right once. Your school’s administration will lose the confidence of the community if they do not respond to COVID19 cases appropriately— these cases will happen.

Is your local district considering reopening?  If so, and if they have online meetings to discuss this, consider asking about the following scenarios. 

1. What happens if a teacher is ill?  

  • Do they quarantine for 14 days? 
  • Does the school have a testing infrastructure in place? 
  • Can you expect to have that test back in 2 days? 
  • What will that teacher’s students do? 
  • Will they quarantine?
  • Will they be put into other classes? 

2. What if a child is sick?

  • Do they quarantine for 14 days? 
  • Can you test them? 
  • When will you know the results?
  • Do you need to quarantine their bus? The bus driver? Their teachers? Their classmates?  
  • Who do you test in response to this child being sick? Does your school have guidelines for this? 
  • What should the family do? 

These are just some of the challenges that schools will face as they operationalize their return to school guidelines. 

What are you willing to sacrifice for your children to be able to attend school? 

We as a country need to answer a very basic question… do you want to go to a bar, or do you want your kids in school… you can’t have both. 

Disclaimer:  this information is for your education and should not be considered medical advice regarding diagnosis or treatment recommendations. Some links on this page may be affiliate links. Read the full disclaimer.

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About the author:

Howard J. Luks, MD

Howard J. Luks, MD

A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr. Howard Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions will be. Ultimately your treatments and his recommendations will be based on proper communications, proper understanding, and shared decision-making principles – all geared to improve your quality of life.

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