As school officials debate whether to reopen this fall, physicians, teachers, and a prominent ethicist markedly disagreed on whether sending children back into the classroom is safe for their communities.
Some pediatricians are driving the push to reopen, while infectious disease specialists, family physicians, and teachers appear more wary, concerned that schools could become "new hotspots for the virus."
At the heart of the debate are many unanswered questions, with arguably the most important being: How often are children infected, and how contagious are their infections?
The American Academy of Pediatrics (AAP) in late June that strongly recommends children resume in-person classes in the fall.
While acknowledging that "many questions remain," the AAP was confident in reopening given "the preponderance of evidence" that children "may be less likely to become infected and to spread infection," as well as less likely to become symptomatic or develop severe illness when they do contract the virus.
However, NIAID Director Anthony Fauci, MD, has cautioned that there aren't enough data to make a definitive statement about transmission in children. His colleague on the White House Coronavirus Task Force, Deborah Birx, MD, that children are the least tested population.
The AAP guidance does emphasize the importance of responding quickly to "new information," but drives home its message that "all policy considerations for the coming school year should start with a goal of having students physically present in school."
President Trump has made it clear he wants governors to reopen schools, even threatening to withhold funding from states that don't force these reopenings.
His administration has leveraged the AAP's own recommendations at every turn.
On Wednesday, during the Wednesday task force briefing, Education Secretary Betsy DeVos quoted from the academy's guidance, stating that "keeping schools closed places children and adolescents at considerable risk of morbidity and in some cases mortality."
At the same briefing, Vice President Mike Pence recommended that "every American" review the AAP's guidance.
The White House has already shown its influence over these decisions. Following an angry Twitter storm from President Trump over CDC's "very tough & expensive" recommendations for reopening schools, Pence said the agency would be releasing new guidance next week.
However, in an on Thursday, Redfield clarified that the basic CDC guidance would remain in place, but additional reference documents would be included.
AAP's Evidence
The AAP's statement makes clear it determined that the risk of viral transmission is the lesser danger compared with the social, emotional, and academic consequences of remaining home, and believes the evidence is on its side.
Danielle Dooley, MD, an AAP spokesperson and medical director of community affairs and population health at Children's National Hospital in Washington, D.C., told 鶹ý that when schools closed in March, many experts assumed the virus would "behave like influenza" which spreads rapidly among children.
"But what we know now ... three months later is that it doesn't behave like influenza. ,'" Dooley said, noting that only "very limited cases" have shown children passing the virus to adults. A press representative was present during the phone interview with Dooley.
While "tens of thousands of children" of essential workers continued going to daycare centers and emergency childcare facilities throughout the pandemic, Dooley noted "there have not been cases of major outbreaks or spreading events in those areas."
The YMCA and the New York City department of education cared for a total of 50,000 children during the pandemic, and both organizations told in late June they had had no COVID-19 outbreaks.
The AAP also relied heavily on a May 15 from the (whose funders include the Sandler Foundation and the Ford Foundation). The report summarized the experience of China, Denmark, Norway, and Singapore in reopening schools in late March or April and also includes the experience of Taiwan, which kept schools open nationally, while implementing mandatory and temporary closures in areas with high infection rates.
All five countries' strategies were viewed by the policy brief's authors as successful "to date" in avoiding the spread of COVID-19.
All instituted temperature checks and a range of physical distancing measures. Denmark and China reduced their class sizes and Norway instituted a maximum class size of 15 students for younger grades and 20 for older grades. The five countries also developed quarantine or school closure policies. Taiwan will suspend a particular class for 14 days if one case is discovered and will suspend school for 14 days if two or more cases are identified. In Denmark, anyone who's sick is required to remain home for 48 hours.
The institute acknowledged that countries that reopened their schools "differ significantly from the experiences so far in the United States" with regard to their capacity "to test and track cases" and to "isolate individuals who have been exposed to infection," all factors linked to their success in avoiding viral spread. The policy brief further stated that it "has not investigated the health implications of using any of these practices in the United States and does not endorse the safety or effectiveness of these practices or of any medical practices."
Dooley also cited a , published in April, which cited data from the 2003 SARS outbreak in mainland China, Hong Kong, and Singapore indicating that closing schools "did not contribute to the control of the epidemic" while recent modelling studies of COVID-19 estimate that closing schools alone "would prevent only 2%-4% of deaths."
AAP also cited in May that leans on studies of widespread community testing in Iceland and South Korea which found children were "significantly underrepresented" in positive cases. The authors also cited a case study of a cluster in the French Alps in which one child with COVID-19 failed to transmit the virus to anyone "despite exposure to more than a hundred children in different schools and a ski resort."
The AAP recommends that older children in elementary and secondary schools wear face coverings, social distance, and space their desks 3-6 feet apart when feasible. They also suggested that schools eliminate lockers, and transition to a block schedule for older students (where classes run longer each day, but terms are shorter) and when possible, rotate teachers for each new class rather than crowd hallways with students transferring place to place.
For children in pre-kindergarten, the academy did not suggest face-masking and physical distancing, believing both too difficult to implement in that age group. Instead it advocated separating kids into cohorts, using outdoor spaces whenever possible, and limiting unnecessary visitors.
The AAP recommended that students use alternatives to buses when possible, and assign seats in cohorts for those who do take the bus. The guidance also suggested one-way hallways, limiting the number of children on a playground at once, and potentially using classrooms or outdoor spaces for meals.
When asked about children as vectors of the virus, NIAID director Anthony Fauci, MD, said on Thursday during a press conference at the virtual International AIDS Conference that there's "an assumption that we know for sure that children are poor transmitters when as a matter of fact, we don't have enough data to make a definitive statement in that regard."
He noted that there are "some suggestions that they are poor transmitters" and have less chance of an adverse outcome, but the research on transmission is ongoing.
"Right now, we are doing a natural history study on 6,000 families in the United States to determine definitively whether that suggestion ... is actually based in actual scientific data," Fauci said.
At the coronavirus task force briefing on Wednesday, Birx said current infection data are "skewed" to older adults, in part because initial testing protocols sought people with symptoms.
In recent weeks, case counts in children and teens 17 years of age and younger have been creeping up, nationally now at 5.9%, as of April 2. In California, infection rates in this age group have more than doubled from 3.4% two months ago to 8.2% this week.
In a statement on Friday, the Infectious Diseases Society of America and the HIV Medicine Association that school systems should be concerned about "instances in which children have fallen seriously ill ... and in which children have died," given that dynamics of the virus are unknown, and that teachers and other adults may be vulnerable to disease and death. The groups called for policies on symptom screening of students and staff as well as testing, and a recognition that a substantial proportion may be asymptomatic yet capable of transmitting.
On Friday afternoon, the AAP in coordination with the American Federation of Teachers (AFT), National Education Association (NEA) and AASA, The School Superintendents Association, issued a joint statement that looked like a reaction to statements from the White House calling for all schools to reopen.
While continuing to stress that "children learn best when physically present in the classroom" the new statement warned that public health agencies should base their recommendations on "evidence not politics."
The four stakeholder groups also emphasized that local school leaders, public health experts, teachers and parents should drive decisions regarding "how and when to reopen schools, taking into account the spread of COVID-19 in their communities and the capacities of school districts to adapt safety protocols to make in-person learning safe and feasible."
The groups also pointedly stated that "schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts."
Schools' Role, Beyond Educating Kids
Dooley said evidence has shown that online learning is "not sufficient to meet children's academic needs."
"We're already looking at children being now months behind in their school curricula," she said.
At a June 10 hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee, ranking member Patty Murray (D-Wash.) said she worried school closures could exacerbate inequities in education.
Researchers project that "Black children could lose over 10 months of learning, Latino students could lose over 9 months of learning, compared to white students who are projected to lose 6 months of learning," she said.
She also cited the story of a mother in Yakima, Washington, whose children are sharing one iPhone for distance learning and who's not certain she can continue to pay the phone bill.
Despite these challenges, Murray underscored the importance of school districts following the advice of public health officials and letting "science drive decision-making."
Dimitri Christakis, MD, MPH, a pediatrician at Seattle Children's and editor-in-chief of JAMA Pediatrics, agreed that distance learning for young children simply doesn't work.
"No one thinks you can teach a kindergartner, a first-grader, or second-grader entirely over Zoom," he said.
In cases where it has worked, a parent has been present and helping, but that isn't sustainable in the long-term, particularly for parents who work outside of their homes, Christakis said.
"I think we have to confront the reality that for primary school kids, not having the schools open means that a sizeable percentage of children are not learning at all," he said.
If a child isn't reading at grade level in the third grade, he or she is 3 to 4 times less likely to graduate high school, Christakis said, and even less likely if the student comes from a low-income family.
"We're going to see the impact of this years from now, in terms of high school graduation rates," he predicted.
But Dooley emphasized that beyond academics, schools are "absolutely critical" for children's social and emotional well-being, providing free or reduced price meals and health services including mental health programs.
"Schools are also critically important for socialization for children," she said.
The concern over is one factor driving Dooley's support for reopening.
In her practice, she's seeing children and families "every single week" struggling with anxiety and depression, as a result of not being in school, not having contact with peers, and being socially isolated.
She's also seeing challenges with food insecurity -- 30 million children receive free and reduced price lunch in schools -- and children who've gained weight because they aren't involved in physical education classes, she said.
Howard Taras, MD, a pediatrician at the University of California San Diego Center for Community Health and the district physician for the San Diego Unified School District, also sees the importance of in-person learning for children.
"At every stage of development, children learn how to make friends, and learn how to deal with bullies, and they learn how to test their personalities, and try different ones on," Taras told 鶹ý. "There's just all these things going on that are also part of the normal, natural education of children aside from formal education of children."
That in-person contact with supportive adults is also important, Taras said.
"Abuse is often detected by school personnel," and while child abuse rates appear to have plummeted, it's possible that abuse has actually increased but simply isn't being reported, he said in an email.
Other Perspectives
If the AAP is full throttle on reopening, the American Academy of Family Physicians is perhaps in first gear.
Gary LeRoy, MD, president of the AAFP, told 鶹ý in an email that family physicians "understand the importance of in-person learning for children."
"They also understand the potential health risks of sending children back to school during a national pandemic," he added.
Looking ahead to the 2020 school year, LeRoy stressed the need to carefully monitor COVID-19 cases in individual cities and communities "to help signal if and when the risks of attending school begin to outweigh the benefits."
Any guidelines on returning to school should be "evidence-based and flexible" because the science concerning the spread of COVID-19 is still evolving and we "cannot predict where the next outbreak will appear."
Asked whether the AAP's own guidance would apply in states where cases are currently climbing, Dooley explained that the academy "would hope that even in areas that are seeing a surge in cases, that school systems are still working towards an opening of schools in some format, in-person for children, because this is really vital for their survival."
Kris Bryant, MD, president of the Pediatric Infectious Diseases Society (PIDS), said it's important to consider all sides of this discussion.
PIDS currently does not have an official position on schools reopening; she emphasized that she was giving her personal opinion.
Bryant echoed many of the concerns mentioned by other pediatricians around the danger of isolation for children's development and mental health and the "variable" benefits of distance learning depending on how well-resourced a family is or isn't.
While she described data from Iceland, for instance, showing no transmission among children as "encouraging," she remained skeptical.
"When everything is said and done. I'm not convinced though that we will see zero transmission from children to adults or zero transmission from child to child," Bryant said.
She stressed the need to "look at the experience of other countries that have already gone down this path ... [and to] try to identify models that are similar to our situation in the U.S."
Arthur Caplan, PhD, an ethicist and population health expert at NYU Langone Health, called the AAP's guidance "optimistic."
"I think we're reopening schools just like in some ways Texas, Arizona, Florida reopened restaurants, bars, and beaches," Caplan said. "And I don't think it's going to work any better."
"I'm terrified that what's going to happen is, kids will go back, they won't have had their shots for measles, or mumps," he continued. "The flu will come and COVID will stay, and we will have one viral, toxic stew that will lead to many hospitalizations and deaths, not just from COVID but from these other infectious diseases."
The CDC identified a year-over-year and for measles-containing vaccines funded through the Vaccine for Children Program (VFC) from early January through mid-April 2020 compared with roughly the same period in 2019. (The program provides federally purchased vaccines to roughly half of all children 18 or younger in the U.S.)
What About Teachers?
Lily Eskelsen García, president of the National Education Association, on Tuesday that she worries what school reopenings will mean for teachers.
"I had 39 sixth graders one year in my tiny little classroom with one window," she said. "My classroom was a germ factory."
Every year she knew one of her students would pass a cold onto her, García said, adding: "This is different. This is a virus that kills people."
She acknowledged the argument by pediatricians that "'we have to consider the mental health of children' – of course we do – but they didn't say at the expense of their physical health, and they didn't say that you should do it under all circumstances. They said when it's safe and where it's safe."
Gov. Greg Abbott (R-Texas) announced last week that public schools in his state will reopen this fall, but without a state-level requirement for testing or masking.
In response, Zeph Capo, president of the state's AFT affiliate, called on the governor to consider students' and teachers' safety.
"We want to see kids return to school in some way, but prudence requires that there be a health and safety plan in place to reduce the chances of spreading the deadly virus," , suggesting that the state require every school district to develop a plan for a safe reopening and submit it to the Texas Education Agency.
National AFT President Randi Weingarten said all schools need plans to ensure they don't become the "new hot spots of transmission."
"A no-mask, no-testing, no-worries attitude is exactly what will spread the virus," Weingarten said.
Bryant said she tells parents asking about their children returning to school that there is no "one-size-fits-all" answer. It depends on the individual child's health, the school's protocols, and the level of transmission in the community, she said.
While it isn't feasible to keep schools closed until the virus "goes away, because that's likely to be a long time," Bryant expects a rocky transition.
"[T]here will be cases," she said. "We need a plan for what to do when cases occur."
Parents are accustomed to sending a child with a mild illness or a cold to school, she noted, but in this context that decision could have serious consequences: from now on, "sick children need to stay home."
The Experiment Continues
While a suggests 56% of parents of children in grades K-12 support their children returning to school full-time, that leaves another 44% who have qualms.
The Clark County, Indiana school district near Bryant is offering a three-tiered model: all in-person, a hybrid of in-person and online, and an entirely virtual option.
Bryant said the model recognizes that some children may be at risk for infection, have an underlying condition, or live with someone who's immunocompromised and need that at-home option.
"[W]hen school systems have the capability to do that and transmission in the community suggests that bringing everybody back and resuming school as usual is not the best choice, it's great," Bryant said. Her colleagues are also currently developing a white paper focused specifically on schooling challenges for immunocompromised students.
The AAP's guidelines also emphasize the importance of being flexible and practical, Dooley noted.
"We may have to revise plans as we go along, and as we're learning what works best ... both from our country, but also the experiences of other countries, " Dooley said.
She also underscored the need for robust research to monitor the return to school and to identify best practices for "mitigating the spread and the risk of the virus."
Still, Dooley emphasized the need to "start from that starting point of having children physically present in school and then working together between our health system, our public health department, [and] our education system on how we can do that as safely as possible."
Associate Editor Molly Walker contributed to this story.