This week I have received a number of questions about daycare and school reopening strategies. It will come as no surprise that there is essentially no guidance about such from the CDC. In fact, the CDC refers schools to their messaging for Healthcare Facilities and state that schools “may find it helpful to reference the Ten Ways Healthcare Systems Can Operate Effectively During the COVID-19 Pandemic.” Schools are most certainly not healthcare facilities.
So, once again, we are left to fend for ourselves in this pandemic. Looking to other countries for clues may be helpful but, remember, the United States is in the grips of an epidemic spread of COVID-19 at a level unlike any other county (save India and Brazil perhaps). So school reopening protocols and lessons from countries like South Korea, Germany and the UK may not be directly applicable. Even still, South Korea closed hundreds of schools in late May that had reopened days earlier — and postponed the opening of many others — after a spike in cases of coronavirus.
First, let’s cover some basic principles of any reopening strategy. On these I think we can all agree and they do not really need to be debated (modified from World Health Organization (WHO)
1. Sick students, teachers and other staff should not come to school.
2. Schools should enforce regular hand hygeine and encourage facemasks when feasible.
3. Schools should,at a minimum, ensure daily disinfection and cleaning of school surfaces.
4. Schools should promote social distancing by staggering the beginning and end of the school day, cancelling assemblies / sports / other events that create crowds, have faculty meetings remotely, keep children’s desks to be at least 1-2 meters apart, teach and model creating space and avoiding unnecessary touching.
5. Schools should increase classroom airflow and ventilation with open windows.
6. Schools should have a remote learning option established for those children at high risk or unable to return safely to school
But here’s where things will break down given that, as a nation, we have steadfastly refused to implement the three basic pillars of any coherent public health response. Test, Trace and Isolate. But these are impossible to do at school, you say. But actually they are not.
Test, Part 1: I can already here the outcry. How are we going to test all of the children that return to school? Don’t you realize that an infected person is contagious for at least a week? Don’t you realize that infected people can spread COVID-19 without displaying any symptoms (pre-symptomatic or asymptomatic)? And yes, I do realize those things. Any feasible approach to reopening schools will require students to be tested for COVID-19 every other day. Impossible, you say…
Test, Part 2: Possible, I say. Enter batch testing and intelligent planning. This idea is simple, and feasible. By combining a group of samples, say from all the students and the teacher in one classroom, you can increase testing capacity by 20-30 fold. If anyone in the group is positive, the entire sample will come back positive. Then you can go back and test each individual in that pool. In a low population prevalence situation (such as, thankfully, California) the overwhelming majority of samples will come back negative. Now granted, nasal and cheek swabs are an arduous way of testing but saliva seems to be a particularly good way to isolate the virus. Saliva based tests will most likely be widely available by Fall.
Test, Part 3: The other efficiency gain of batch testing is that it can be replicated across other activity ‘pods.’ Say a child is part of a sports team, music group or other extracurricular activity – batch testing can also occur there. In this way, an individual might be tested across multiple batches permitting traceable movement across these pods. This leads us to our next pillar…
Trace. Presumably the movement of children will be easier to track than those of adults since, with the exception of those in the upper grades of high school, they will not be traveling independently. Some may access school through public transportation but, again, with supervised and traceable movements, close contacts should be readily identified, tested and quarantined if needed. Leading us to our final pillar…
Isolate. This step should be obvious but will place a significant burden on parents and guardians who will now be charged with keeping a child with COVID-19 home for a minimum of two weeks. While symptoms may resolve more quickly in children as compared to adults, two weeks of isolation will be necessary. Schools should have a remote learning option already established as noted above. Therefore, children in isolation after a positive test should be able to access this learning option – thereby relieving some burden on caregivers. In my own (adult) practice I formally evaluate quarantine end by administering 2 COVID-19 tests separated by 24 hours. This, while burdensome, falls in line with the recommendations of the South Korea Centers for Disease Control and would prevent a student from returning to the classroom too early.
As school districts move forward with reopening plans, no doubt they will spend significant effort communicating those strategies with which we can all agree – staggered start times, social distancing, sanitation and handwashing. However, I have little confidence that they will take the time and effort needed to implement a coherent Test, Trace and Isolate strategy. In fairness, why would they given that as a country we have been unwilling to invest in such a strategy? But, without such, schools will reopen and soon close again as cases spike.