New CDC Guidelines Highlight School Reopenings in Europe, Asia

US Centers for Disease Control and Prevention (CDC) guidelines released yesterday leave many decisions to state and local authorities. The guidelines do, however, lay out CDC’s framework for understanding a variety of nuances involved in deciding how to reopen schools.

CDC authors covered a wide range of benefits and risks involved in reopening schools, drawing largely on international experience. The guidance applies broadly to K-12 schools preparing for students, teachers, and staff to return to US schools in the fall of 2020.

“This guidance is meant to supplement—not replace—any state, local, territorial, or tribal health and safety laws, rules, and regulations with which schools must comply,” guideline authors wrote.

According to the document, administrators are advised to:

• Encourage community preventive behaviors outside of schools.
• Implement SARS-CoV-2 mitigation strategies such as provision of face masks and intensified hand hygiene in ways that are developmentally appropriate for students based on age.
• Integrate mitigation strategies into co-curricular and extracurricular activities.
• Cleaning and disinfecting frequently touched surfaces.
• Base decisions on up to date community transmission rates.
• Reclaim underutilized school or community spaces to decrease classroom sizes and facilitate physical distancing, including outdoors when feasible.
• Draft a plan for when a student or staff member tests positive for COVID-19, including coordination with state and local health officials to conduct contact tracing.

Prior evidence from other countries is limited and should be interpreted with caution, but according to the release suggests that the majority of children with COVID-19 were infected by a family member in the household rather than a fellow student at school.

The guidelines also detail strategies used internationally:

• In Taiwan, students returned to school with mandatory temperature checks and use of face masks.
• Rather than national school closures, Taiwan relied on local decision-making to determine if classroom or school closures were needed, based on community infection rates.
• Denmark, the first European country to reopen schools, staggered students’ reentry in waves with limited class sizes and using other social distancing measures.
• Students under age 12 in Denmark returned first based on their lower health risk (suspected to be due to a difference in ACE-2 receptors between age groups).
• China, Denmark, Norway, Singapore, and Taiwan required temperature checks at school entry.
• Swedish health authorities, in conjunction with health authorities from Finland, recently released a joint report in which Finland (which closed schools) signed off on the claim that Swedish teachers had been at no higher risk of SARS-CoV-2 infection than the general population.
• Some countries have staggered attendance.

There is mixed international evidence about whether returning to school results in increased transmission or outbreaks, authors explained, and surges may be multiply determined.

For example, Denmark reported an increase in cases after reopening schools and child care centers for students between 2-12 years, followed by subsequent declines in cases among children between ages 1-19 years. In contrast, the guidelines caution, Israel experienced a consistent surge in schools after reopening.

To present a balance sheet of risks and benefits, the guideline authors also highlighted the logistical challenges associated with relying exclusively on remote learning, despite the need for serious prevention measures and adaptations.

“Schools...provide critical services that help to mitigate health disparities, such as school meal programs, and social, physical, behavioral, and mental health services. School closure disrupts the delivery of these critical services to children and families, and places additional economic and psychological stress on families, which can increase the risk for family conflict and violence,” the authors wrote, highlighting impacts on the most vulnerable.

In-person instruction may be particularly beneficial for students with additional learning needs, some of which may not be able to be met as easily remotely.

If schools are fully closed to in-person instruction without community-adaptive, context-based exceptions, disparities in educational outcomes could also be exacerbated. Amid a pandemic where racial and economic health disparities have been thrust to the center of attention, the guideline authors note that working families may not have the resources to fully participate in distance learning “due to issues with e.g., computer and internet access issues, lack of parent, guardian, or caregiver support because of work schedules.”

The authors go on to weigh the complex balance of competing priorities raised by attempts at an equitable reopening of schools:

“While concern over higher rates of COVID-19 among certain racial/ethnic groups may amplify consideration of closing a school that educates primarily racial minority students, there should also be consideration that these may also be the schools most heavily relied upon for students to receive other services and support, like nutrition and support services,” the authors write.

Evidence further suggests COVID-19 related isolation increases pediatric anxiety and depression, but guideline authors also raise that there are legitimate concerns for the health and well-being of adult staff in light of rising COVID-19 case numbers in some states.

In Texas, for example, few students were infected during reopening. Yet teachers and staff experienced an increase in transmission. Texas reported over 1300 COVID-19 cases in childcare centers, but twice as many staff members had been diagnosed as children.

“Evidence from schools internationally suggests that school re-openings are safe in communities with low SARS-CoV-2 transmission rates. Computer simulations from Europe have suggested that school re-openings may further increase transmission risk in communities where transmission is already high,” authors explained.

The mixed results of reopening align with prior evidence that children appear to be at lower risk for contracting COVID-19 compared to adults, particularly outside the home where viral load exposure may be lessened by the ability to physically distance.

Adults make up nearly 95% of reported COVID-19 cases. When children do acquire COVID-19, they generally experience less severe illness.

The guidelines do raise concern that some children have developed multisystem inflammatory syndrome (MIS-C) after exposure to SARS-CoV-2, but note that as of July 21, 2020, less than 0.1% of COVID-19-related deaths are among children and adolescents less than 18 years of age in the United States.

The CDC guidelines ultimately conclude that international experiences demonstrate that “even when a school carefully coordinates, plans, and prepares, cases may still occur within the community and schools. Expecting and planning for the occurrence of cases of COVID-19 in communities can help everyone be prepared for when a case or multiple cases are identified.”

The full guidance, including further safety precautions for administrators to consider, can be found here.