The pressing challenge facing our national, state and local leaders of how to structure K-12 education during the SARS-CoV-2 pandemic has only intensified during the past few weeks. The decision ultimately rests with the leadership of the over 13,000 public school districts in the United States, as well as the leadership of the thousands of private K-12 institutions. The role of national and state leadership is to provide a workable framework for the safe operation of these schools based on data-driven, scientifically-based risk assessments.

K-12 Schools Are Community Backbones

Students and their parents want safe in-school instruction. Equally important, they want key services that are difficult to provide outside of the school setting. Schools support the needs of people: students, families, staff and community members. Over the years, our shared expectations for the role that schools play in our communities have exponentially expanded to help students succeed.

• Direct instruction enables teachers to better address different learning styles and respond to individual students appropriately.
• Schools provide a safe and secure environment where children have access to teachers, counselors and staff who can help with medical and mental health needs.
• Students have opportunities for face-to-face social interactions with peers, teachers and support staff.
• Schools provide food security in the form of breakfast and lunch.
• Schools provide physical education, music, fine arts, career and technical training that do not readily lend themselves to virtual learning.
• For many students whose parents didn't attend college, schools are where they learn about the paths to higher education.
• Schools are directly and indirectly a major economic engine in communities. Parents can work while knowing their children are safe.

When schools closed in March, this traditional system, built around person-to-person contact, suddenly had to depend on virtual connections. Schools were not prepared and many families did not have access to the necessary technology, but distance learning was seen as a temporary measure. Now that the new school year is upon us, families face uncertainty as SARS-CoV-2 spreads unabated in many parts of the country.

What We Know About Respiratory Pathogens in School Settings

There has been much discussion in the press and political circles about the mild nature of SARS-CoV-2 infection in children and adolescents, an observation supported by scientific data. The critical context that seems to be missing is that emerging data suggest that school age children readily spread SARS-CoV-2. We have already seen the closing of summer camps in the past few weeks due to SARS-CoV-2 spread. Centers for Disease Control and Prevention (CDC) data show the 5-17 year old age group has the highest SARS-CoV-2 test positivity rate of any age group. A new study from South Korea suggests that 10-19 year olds spread SARS-CoV-2 at rates similar to adults. A second recent study showed that children less than 5 years old had higher levels of SARS-CoV-2 in their respiratory tract than children 5-17 years olds, who had levels similar to those of adults. A recent outbreak of COVID-19 involving 18 high school football players who spread the virus to family members is an obvious cause for concern, as contact sports may soon begin in parts of the U.S. To limit the spread outside of school, we must prevent the spread inside of school.

Children frequently carry pathogens, often asymptomatically, in their respiratory tracts and easily pass these pathogens to their care providers, primarily parents and grandparents. The SARS-CoV-2 data are not surprising if we look at our experience with other respiratory pathogens in school settings. At the University of North Carolina (UNC), we studied the spread of viral and bacterial agents in children at a research day care/elementary school. The documented emergence and spread of multi-drug resistant Streptococcus pneumoniae within the day care center, and other studies like it, was influential in driving the development of a conjugated pneumococcal vaccine for use in children. This vaccine has been highly successful in driving down rates of serious pneumococcal infections in children, but has also had the unexpected benefit of reducing serious pneumococcal infections in adults as well.

The spread of influenza virus in the K-12 age group is also instructive:

• A study done at the UNC research day care/elementary school showed that asymptomatic influenza infection was common in children and that it could spread widely in a day care/school setting.
• The initial U.S. outbreak of pandemic influenza A H1N1 in 2009 occurred in a New York City high school following spring break trips to Mexico, and almost all of the infected students had mild or no symptoms.
• A large population-based study has shown that seasonal influenza may be driven by adolescents and then spread to adults. Further, modeling studies of pandemic influenza suggest that adolescents, through school classes, social interactions with friends and participation in sports have the potential to be "super-spreaders."

As school districts wrestle with how to conduct the school year in their district, we must also plan for the coming U.S. flu season, which typically begins in November, peaks in January and February, and ends in April. The Director of the CDC, Robert Redfield, has been warning since late April about the specter of a second wave of coronavirus during flu season. A potential driver of this second wave could be K-12 students bringing 1 or both viruses home to their care providers, who are more vulnerable to these pathogens.

What might be the consequences of the spread of these 2 viruses from K-12 students? During a typical flu season, many hospitals have 95-100% bed occupancy. In addition, emergency departments (ED) have a finite capacity of patients that they can care for during a 24-hour period. When that capacity is reached, the ED goes on what is called "ambulance diversion," requiring ambulances to take patients to the next, closest hospital. Ambulance diversion occurs most frequently when hospital beds are full as they frequently are during flu season because ED patients who require a hospital bed will be held there until an inpatient bed is available.

Further pressure is likely to occur in a state such as North Carolina, where more than 200,000 people have lost employer-provided health insurance during the pandemic thus far. Because this state, along with the hard-hit states of Florida, South Carolina, Texas and Georgia, has not adopted Medicaid expansion, these individuals will have no real health care alternative other than the ED, putting further pressure on those medical services. The specter of hospitals exceeding capacity for weeks and being unable to provide other critical medical services is a scenario for which planning must be done now.

Opening Schools Safely

To open schools for in-person instruction, we must acknowledge that the world has changed. The pandemic is still with us. Reopening schools must be done safely, based on data-driven, scientifically-based risk assessments of disease activity within the school's region. Some schools may be able to open without restriction. Many will need to offer a modified opening, blending modifications to the school day, direct instruction and remote learning in order to provide as much normalcy as possible. Other schools, where disease rates are high, will need to rely on online instruction for now.

For those schools providing in-school instruction, there are national and state guidelines available to help mitigate health risks. Additionally, many locations have gone beyond the guidelines and issued mandates that schools must comply with, including requirements to wear masks, provide for social distancing and limit the size of gatherings.

Let's look at 2 of the key questions all plans must address:

1. How do we provide for social distancing requirements and reduce group sizes to no more than 50 (for example)?

• School buildings are designed to serve as many students as possible. Classroom size, cafeteria size, hallway size and bus schedules are all built for capacity, not social distancing. To provide a safe environment, we must reduce the number of students in the building.
• Schools will likely need to adopt a modified schedule. For example, half of the students could attend every other day. Breakfast and lunch should be grab-and-go with meals eaten in classrooms or taken home. Students not in attendance should engage in remote learning. A shortened school day will facilitate teacher communication with remote learning students. Students who have IEPs, 504 plans or who receive specialized support will continue with daily attendance as required.
• Approximately 26 million K-12 students ride school buses. Transportation routes will need to be reconfigured and additional routes added to keep the numbers of riders fewer than 50.

2. How can we properly meet health and safety requirements? This is critical for students, staff and anyone who visits the school building. With proper precautions, schools can reduce the risk of infection. To do less could contribute to further SARS-CoV-2 spread. Minimum considerations include the following:

• Schools will need to implement a screening and reporting system to track symptomatic individuals.
• Students and staff must be required to wear face masks while indoors and on buses.
• Social distancing must be extended to all gathering areas, including measures to limit congestion at entrances before and after school, and to limit the use of shared work areas for both students and teachers.
• Student lockers must be eliminated to reduce an area of crowding.
• Additional hand washing stations and opportunities must be provided, along with sanitizing stations and appropriate personal protective equipment (PPE) where needed.
• A daily, school-wide cleaning and disinfecting program must be implemented for facilities and vehicles.
• And, while all the health and safety precautions are put in place to mitigate the risk of infection, accommodations must still be available for high-risk students and staff who cannot risk any exposure.

The reopening plan must be communicated as soon as possible to the students, parents, staff and community.

• There will be feedback. Listen to it and utilize that feedback to improve the plan.
• There will be unique situations that require accommodation outside of the plan. Provide those accommodations.
• There will be new expectations of staff. Provide the training necessary.
• There will be a need for building modifications, additional supplies, additional technology and additional personnel to open schools safely. This preparation may require more time and more money than schools have available. Schools may eventually be reimbursed through the $16 billion dollars allocated by the Federal CARES Act for SARS-CoV-2 related expenses. But local money must be spent now and the time for preparation is running out.

Given the central role school plays in our communities, in-person instruction needs to be the goal. Because children and adolescents can transmit both SARS-CoV-2 and influenza, it is important that everything is done in schools to mitigate spread of both viruses. Failure to do so could lead to community-wide outbreaks and increased pressure on health care systems. For both of these respiratory viruses, simple public health measures are important, including social distancing, mask wearing and hand hygiene. In addition, all K-12 students should be offered the influenza vaccine in the school setting. Testing for both SARS-CoV-2 and influenza should be available in all schools offering face-to-face instruction, through city, county or state health departments. Strict quarantine of sick and exposed individuals needs to follow CDC guidelines. Off-ramp criteria for shifting from in-school to online instruction need to be established and agreed to by school boards, administrators, teachers, staff and families in consultation with local or state public health experts.

It is important for parents to remember that we are in uncharted territory with this virus. Data should guide how schools approach instruction. In the coming months, our schools will need flexibility, creativity and cooperation to educate our children and keep our vulnerable populations safe.

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