News August 11, 2020

Recommendations for Strict, But Costly Re-Opening of Schools

SHP's Jason Wang and School of Medicine student Henry Bair suggest schools should and can reopen safely if they follow a set of strict — though expensive — guidelines to avoid COVID-19 infections among students and teachers.
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Weary working parents aren’t the only ones eager for their children to return to school in a few weeks. Many teachers, staff and administrators also want those classroom doors to reopen. Most importantly, the kids are craving the clamor of school hallways and the banter of friendships.

The American Academy of Pediatrics recently highlighted the importance of students getting back to the classroom in their COVID-19 return-to-school guidance: “Schools are fundamental to child and adolescent development and well-being and provide our children and adolescents with academic instruction, social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity, among other benefits.”

But it must be done safely if the country is to defeat the coronavirus. Israel has set an example of what can go wrong if schools open up too quickly and without enough safety protocols. The country had the virus under control and reopened schools on May 17. Within days, infections skyrocketed among students who then took the virus home to their families.

While many schools intend to follow the AAP guidelines, Stanford Health Policy’s Jason Wang, MD, PhD, believes school districts can further protect the 55 million students who attend elementary, middle and high schools by following an additional set of strict measures.

And he believes it’s time for children in the United States to get back to school.

“Prolonged school closures can exacerbate socioeconomic disparities, causing negative education and health outcomes, and amplifying existing educational inequalities,” said Wang, a pediatrician and director of the Center for Policy, Outcomes and Prevention in the Stanford School of Medicine Department of Pediatrics. “School closure may also aggravate food insecurity, domestic violence, and mental health disorders. Many children from low-income households obtain food through the National School Lunch Program and estimates suggest that one-in-four children may face hunger this year due to COVID-19.”

But serious precautions must first be put into place, Wang said, starting with each school district establishing a COVID-19 task force composed of the superintendent, members of the school board, teachers, parents and health-care professionals to develop policies and procedures.

“To implement and evaluate specific measures, the task force should create an oversee a command center for the school district, composed of data analysts and health experts who can liaise with the local health department,” Wang writes in this JAMA Pediatrics viewpoint with co-author Henry Bair, a medical student at the Stanford University School of Medicine who is also working on an MBA at the university’s graduate school of business.

It is particularly important that there are subsidies from the states to help these districts if schools are to open safely.
Jason Wang
Associate Professor of Pediatrics

The district task force should:

  • Work with its local health department to provide educational materials and training for students, parents and school staff on the basics of COVID-19 prevention;
  • Train school staff to screen for COVID-19 symptoms and arm them with thermometers;
  • Build temporary modular buildings if schools cannot maintain 6 feet of physical distance among all students and teachers;
  • Expand the district’s fleet of school buses or develop different pickup schedules;
  • Increase budgets to increase disinfection efforts of all teaching spaces, common areas and high-touch surfaces such as doorknobs, computers and desks;
  • Place transparent plastic shields on the sides of student desks;
  • And provide protective equipment such as hand sanitizers, disposable surgical masks, reusable cloth masks or reusable face shields.

These are expensive solutions, Wang concedes. But as the Centers for Disease Control and Prevention noted in its July 24 telebriefing on new resources and tools to support opening schools: The 5.6 million parents who haven’t been able to work due to school closures have collectively lost an estimated $232 billion.

Stricter Measures Mean Bigger Budgets

Some lower-resources communities might find these potentially expensive guidelines difficult to adopt. Those transparent desk barriers, for example, range from $100 to $200 per desk; COVID-19 tests run between $50 to $200 per individual.

Wang said that’s why additional federal funding and state subsidies are crucial for the low-income communities already hit by the double-whammy of having more parents as essential workers and some of the highest hospitalization and fatality rates from the pandemic.

“Low-income communities are suffering most from shelter-in-place policies because parents who are essential workers are out of the home and not able to help with online learning,” Wang said. “And many children in these communities also live in crowded conditions that are not conducive to learning at home.”

Wang and Bair note the academy’s guidelines emphasize the importance of identifying symptoms and signs of COVID-19, but don’t go far enough in recommending operational approaches.

“To address this, we recommend that schools implement multilevel screening for students and staff,” they write. Each morning parents should report to the school or district any fever or COVID-19 symptoms to an online or an automated telephone-based program. Any students with symptoms should stay home.

Three-pronged testing approach

The academy’s guidance does not include how schools can approach testing for the virus, so the authors recommend a three-pronged approach in collaboration with local hospitals:

  1. All students with symptoms should be tested.
  2. Schools should devise a schedule to randomly select a proportion of students and staffers for COVID-19 testing to identify asymptomatic individuals. The researchers note that a pooled testing strategy can significantly reduce costs.
  3. Students from high-risk households in ZIP codes with socioeconomic challenges should be offered more frequent testing.

Even with all the precautions in place, COVID-19 outbreaks within schools are still likely, the authors said. So schools should prepare for temporary closures and be ready to transition back to full-time online education by investing in online education platforms and training.

“Schools will need to ensure equitable implementation of online education among students, especially those with limited knowledge of or access to technological resources and consider subsidizing educational technologies for these students,” the authors said.

Jason Wang

Associate Professor of Pediatrics
Looks at innovative consumer technology to improve health outcomes.
Dr. Jason Wang, associate professor of pediatrics at Stanford.

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