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Last week's revised CDC guidance on how schools may operate during the COVID-19 pandemic got generally good marks from pediatricians and public health specialists -- even though teachers' representatives were less than enthusiastic.

The new guidelines tie decisions around phased reopenings to rates of COVID-19 transmission in the community and prioritize masking and physical distancing over other mitigation measures.

Danielle Dooley, MD, a pediatrician at Children's National in Washington, D.C., and a spokesperson for the American Academy of Pediatrics (AAP), applauded the guidance for underscoring the importance of in-person learning for students.

"I think the CDC is really taking a holistic look at how children are doing throughout the pandemic and recognizing the huge impact that school closures are having on kids," Dooley told 麻豆传媒 in a phone interview, during which a Children's National representative was present.

Dooley was pleased to see the agency acknowledge that some schools are safely holding in-person classes even in districts with high levels of community transmission -- and that low levels aren't a green light to reopen if mitigation measures can't be maintained.

More Options for Schools

The emphasis on mitigation sat well with Tina Q. Tan, MD, a pediatric infectious diseases physician at Northwestern University's Feinberg School of Medicine and Lurie Children's Hospital of Chicago, and a spokesperson for the Infectious Diseases Society of America. Regardless of the mode of learning a school chooses, she said, "you really have to have good mitigation protocols in place in order to prevent the spread of COVID."

The recommendations include a color-coded grid to help school leaders determine the best mode of learning for a district -- in-person, reduced attendance, hybrid, or remote -- based on rates of community transmission, but the agency also stressed that "[a]t any level of community transmission, there are options for in-person instruction," according to a , that accompanied the guidance.

This represents a significant shift from CDC guidance issued last fall when many experts, including Tan, viewed community transmission rates as determinative factors in reopening decisions. That guidance didn't go as far as the revision in recommending options for instructional models.

Tan recalled that, in the fall, most public health experts believed "basically 5% to 8% is okay," but "anything ... above 8% to 10%, we wouldn't do" -- meaning reopening with a positivity rate of 8%-10% over the last 14 days would not have been recommended.

Now, she said, a high rate of community transmission wouldn't definitively close the door to reopening.

"Yes, there are high rates of transmission in the community. Yes, there are other variants out there that seem to be more transmissible. However, we know that universal masking, good hand hygiene, social distancing all work," Tan said.

Dooley, citing the research behind on school reopenings, pointed to a study from in January focusing on rural Wood County, Wisconsin, which found that schools with strong adherence to mask-wearing had lower rates of COVID-19 among students and school personnel than in the county as a whole (3,453 vs 5,466 per 100,000). Of the 191 cases discovered in students and school personnel, just seven (3.7%), all students, were found to have been contracted in school.

She also highlighted a January editorial in asserting that there's "little evidence that schools have contributed meaningfully to increased community transmission."

Better Data Needed

Joshua Michaud, PhD, associate director for Global Health Policy at the Kaiser Family Foundation, has been tracking the data on school reopenings since the summer.

"The issue is we can find studies that ... make any point we want to make about school reopenings," he said -- so what matters is how the study is conducted and how generalizable it is.

For example, it's important to consider whether Wood County's mitigation protocols could be replicated, given that different schools are experiencing the pandemic differently and have differing levels of resources.

"Would an inner-city public school system, if it followed the same recipe as these schools in Wisconsin at the height of the [pandemic], would they come out with the same outcome?" Michaud said. "I think that it's hard to say."

Looking at the overall accumulation of data, he said, "the trend has been towards reopening schools and lowering the bar a little bit as to when schools should be closed during this epidemic. But it's still open to interpretation and plenty of people place that bar in different locations."

No single system is tracking education modes -- fully remote, fully in-person, or some type of hybrid -- adopted in the country's 13,000-plus school district, according to , whose own data collection shows that many of the largest school districts have some form of in-person teaching.

Teachers' risk also isn't well known. During a press conference on Thursday, when NIAID Director Anthony Fauci, MD, was asked whether anyone had modeled how many teachers might die or be hospitalized under different reopening scenarios, he replied that such data probably weren't "readily available," but he wasn't sure.

Emily Oster, PhD, an economist at Brown University in Providence, Rhode Island, has been tracking cases of the virus among some students and school faculty in certain school districts -- in collaboration with Qualtrics, an online survey platform -- on since early August.

But Oster's data is limited to schools that voluntarily submit numbers.

Mixed Views on 'Flexibility'

The CDC exercised a certain degree of flexibility in its recommendations.

In introducing the new guidance, CDC Director Rochelle Walensky, MD, MPH, stated that masking and physical distancing should be prioritized above other mitigation measures. But she also said the standard 6-foot rule could be relaxed in areas of low to moderate transmission. Insisting on it could prevent otherwise low-risk schools from returning to "full in-person learning," she said.

Dooley, speaking on her own behalf (because she had not consulted with the AAP on the issue) agreed that the 6-foot requirement often isn't practical, particularly in smaller schools lacking space to accommodate smaller class sizes.

But, she noted that schools can reduce the risk of transmitting the virus by maintaining cohorts or pods of students, which both reduces the potential for transmission and simplifies contact tracing.

Mark Collins, an art teacher at Oak Park and River Forest High School in suburban Chicago, chuckled when he read the guidance. "There's a certain amount of hedging and equivocating," he said.

The agency's advice on physical distancing is one example.

It's as if the CDC is saying, "We'd really like you to [take this safety measure] but if you can't, we'd really like you to still reopen," Collins told 麻豆传媒.

And others working in education were openly critical of the CDC's new flexibility.

Robert D'Amico, a spokesperson for the American Federation of Teachers in Texas, called the distancing recommendations "disappointing and problematic.... You don't want kids crammed into a classroom next to each other. That's just not a good idea."

As for surveillance testing, Arthur Goldstein, an English as a second language teacher and union representative at Francis Lewis High School in Fresh Meadows, New York, said New York City has been testing a random 20% of school staff and students.

"If we find one case of the virus we close the classroom. If we find unrelated cases we close the school. I think what we're doing is the minimum," he said.

The CDC's guidance does not recommend any form of surveillance testing, though it says schools that conduct screening should do it weekly.

Dooley said she believes the CDC is right not to mandate surveillance testing, because it's "hugely expensive," and there isn't yet enough data to demonstrate its impact on reducing transmission rates.

Vaccinations and the Lack Thereof

What Collins found most problematic was the CDC guidance concerning vaccinations for teachers -- specifically, that it's unnecessary.

He said the message for months has been that vaccination is "the absolute foundation" to ending the pandemic.

"Well, logically, if teachers are in a situation that they're in close contact, why wouldn't you essentially require that?"

Goldstein agreed. "If you're talking about a full return, with 18 to 34 students in a classroom, that simply cannot happen until we do something to control the virus," he said.

D'Amico said most schools in Texas have been operating under a hybrid model. On campuses where the leadership enforces mitigation protocols, teachers feel safe, he said.

But, he added, "we'll have campuses that are a train wreck, where they're not enforcing mask rules, there's no possible distancing... [and] they're not being honest about the reporting of cases." Those are the districts where teacher vaccination should be a focus, D'Amico said, emphasizing that it doesn't have to be mandatory when the school environment is safe.

in the country have followed recommendations from the CDC's Advisory Committee on Immunization Practices to recognize teachers as essential workers in phase 1B of their vaccination programs.

But Texas is one of the 23 states that have not.

The state's top health officers, and even the State Board of Education, have written letters supporting the Texas AFT's position, urging higher priority for teachers to receive vaccines, D'Amico said, but to no effect so far.

A handful of Texas school districts have partnered with local hospitals to immunize teachers eligible by virtue of their age -- over 65 -- or a health condition, D'Amico said.

Collins said he has felt safe teaching at his school, even without being vaccinated.

"There are directional signs on the floor, there's stand-up cardboard signs [reminders to maintain] 6 feet and masking, and ... we do a saliva test for faculty," Collins said.

About one-quarter of the students are allowed in the building each day. He has up to five students at a time in-person. The rest, around 20 to 26, he teaches online.

Goldstein said that, despite what critics may think, teachers do want to teach in person.

"There's no substitute for being with the kids ... having them confide in you, and having them trust you," Goldstein said.

"We're not any happier than the people who want to open the schools. We just think that as important as education is, safety is paramount."

The AAP is aligned with the CDC on the vaccination issue, Dooley said, and does not currently believe that it should be a requirement for reopening schools -- the group has long stressed the harms from keeping kids out of school for long periods -- but it has also backed prioritizing teachers for vaccination.

School Closures' Impacts

Dooley, in a prior interview (also with a press representative present), agreed that school closures adversely affect children's psychological well-being. Evidence during the pandemic includes in outpatient emergency departments and inpatient settings, as well as driven by social isolation, she said.

She hears from pediatric patients every week who are socially isolated, unable to connect with their friends except through screens, and unable to play sports.

"[T]hat really, for children, adds up to a feeling of hopelessness and 'What is there to look forward to in the future?'" Dooley said.

Despite his strong beliefs about vaccination, Collins hopes teachers, administrators, and politicians all recognize that "kids are really taking a hit on this," he said.

"Ultimately, it's about their experience," he told 麻豆传媒. "You're taking away someone's sophomore year or senior year... Maybe it's worth a little bit of bending and twisting and flexibility, so that these kids have a life, an academic and social life in school," Collins said.

All the major medical associations, Tan said, including the AAP, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society of America, want kids back in school, not just for their academic development but for their social and developmental growth.

"I think what different districts have to do is they have to figure out the safest possible method for making that happen."

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