*Updated September 15, 2020
On August 20, DISD announced that the first 4 weeks of school will be virtual only and in person school will be available starting October 6.
On July 31, Children’s Medical Center published their Back to School Guidance with recommendations for Low, Moderate, and High risk conditions.
On July 23, the Center for Disease Control published Safe Return Guidelines for schools K-12 as well as a Decision Making Tool for parents to help them decide if it is safe to return to in-person school.
On July 16, the Dallas County Health Department announced that all public and private schools are prohibited from offering face-to-face instruction until September 8.
As we reach the middle of summer and we see a steady increase in the number of COVID-19 cases in our community, many parents are appropriately questioning whether or not they should send their child back to school in the fall for traditional school or pursue Virtual Learning. If you read my answer to the question of “Should my child go to camp or daycare?”, you know that simple “yes” or “no” answers are hard to come by in a pandemic. The truth of the matter is that a global outbreak of a deadly virus is not a simple matter and there are no simple solutions, but I will do my best to provide helpful guidance.
To begin with, when we think about the question of whether or not your child should return to in-person school, we need to determine if we are talking about your individual child or all children in general. I would describe this distinction as being between the issues of Public Health or Personal Health. This is an important distinction because the answer to the question may be different when discussing the individual health of one child or one family compared to the collective health of all children.
In addition to clarifying whether or not we are considering a personal health or public health question, we must also define the potential benefits and the potential risks of our choice. While the question of whether or not you should send your child to school is a binary choice, the factors that must be considered to make that decision are anything but binary and must be assessed along a risk vs benefit continuum. With that in mind, let’s look at some specific questions related to school.
*Advisory: Please be aware that the following is not intended to be, nor should be received as, medical advice specific to your situation. This is intended to be information only, and any decisions regarding the care of your child should be discussed with your pediatrician.
Q: Should schools open for in-person learning?
A: Yes, schools should open. The truth is that if you have the option of choosing an educational model other than in-person school for your child then you have a privilege many other families envy. For single parent families, or families where both parents work, the adult supervision of children that in-person school provides is a necessity, not a benefit. Other benefits of in-person school besides childcare include: increased educational opportunities, opportunity for social interactions, special education, support for learning differences, identification of children who are being abused, and access to meals for those who are food insecure. The American Academy put out a statement saying that “the AAP strongly advocates all policy considerations for the coming school year should start with a goal of having students physically present in school… Policies to mitigate the spread of COVID-19 within schools must be balanced with the known harms to children, adolescents, families, and the community by keeping children at home.” While it is clear that there are substantial benefits to opening schools to in-person education, the AAP acknowledges that doing so is not without risk of increasing the spread of COVID-19. However, there is mounting evidence that children and adolescents are less likely to be symptomatic and less likely to have severe disease from this virus than adults. According to the Center for Disease Control,
The largest study of pediatric patients (>2,000) with COVID-19 from China reported that illness severity ranged from asymptomatic to critical:
- Asymptomatic (no clinical signs or symptoms with normal chest imaging): 4%
- Mild (mild symptoms, including fever, fatigue, myalgia, cough): 51%
- Moderate (pneumonia with symptoms or subclinical disease with abnormal chest imaging): 39%
- Severe (dyspnea, central cyanosis, hypoxia): 5%
- Critical (acute respiratory distress syndrome [ARDS], respiratory failure, shock, or multi-organ dysfunction): 0.6%
When compared to the flu, the data suggests that COVID-19 is not as dangerous for children as the seasonal flu. Per an excerpt from the American Academy of Pediatrics publication AAP News,
The risk of hospitalization in children and adolescents younger than 18 years from COVID-19 is less than one-fifth the risk of hospitalization from influenza during the 2019-’20 season for the same age groups (see table). Although these data may be skewed by school closings and social distancing, SARS-CoV-2 infection generally is considered to be less severe than seasonal influenza infection among children and adolescents.
While it is clear that there are significant benefits of in person school being available for all children and the rate of severe disease is low in children, it is also clear that COVID-19 is a dangerous disease for certain groups of people and there are many states and counties experiencing very high rates of cases. While there are infection control measures schools can implement to minimize the risk of student and teacher exposure, if rates of disease in the community are high then the risk of exposure in the school environment will also be high. The best measure of the rate of disease in a community is the number of cases per 100K persons in the community. This is typically calculated by county and the rates can be found at COVIDActNow.com. The rate of disease in a community is considered low when the number of cases per 100K people is < 4, although a rate of < 10 is considered low enough that schools should be able to reopen without substantial risk of an outbreak occuring (Sep 15: Dallas County 9, Collin County 7.2). Another key metric is the infection rate which is the number of people that a COVID infected person spreads the infection to. The goal for the infection rate is < 1 as that means that the rate of disease in a community is declining (Sep 15: Dallas County 0.88, Collin County 1.01).
Q: Should I send my child back to school if she, or someone she lives with, is high risk for a negative outcome?
A: No. While it is clear that children are at low risk for negative outcomes from COVID-19 and are less likely to spread it compared to adults, it is also clear that children can still spread this disease and those with certain medical conditions are more likely to have severe illness. When considering the increased risk for a bad outcome that is present in this scenario, it is reasonable to conclude that the risks outweigh the benefits described above. With this understanding, we must then qualify what is considered high risk. Due to the low numbers of children who have been infected relative to adults this is still a hard question to answer; however, UpToDate has reviewed numerous studies and complied this list of conditions that are at greatest risk for severe disease in children:
- Medically Complex (defined as dependence on technological support in association with developmental delay and/or genetic anomalies)
- Congenital Heart Disease
- Neurologic, Genetic, or Metabolic Conditions
- Age <1 year also has been associated with increased risk for severe disease, but this finding has been inconsistent.
Other conditions that increase the risk for severe disease in people of all ages include:
- Chronic kidney disease
- Immune compromise from solid organ transplant
- Obesity (body mass index >95th percentile for age and sex)
- Sickle cell disease
- Type 2 diabetes mellitus
Conditions that may increase the risk for severe disease in people of all ages include:
- Cerebrovascular disease
- Chronic pulmonary disease (eg, cystic fibrosis, moderate to severe asthma, pulmonary fibrosis)
- Immune compromise from hematopoietic cell transplant, primary immune deficiency, HIV, medications (eg, glucocorticoids)
- Liver disease
- Type 1 diabetes mellitus
Children’s Medical Center has created a helpful guide that clearly identifies whether a child’s condition is Low, Moderate or High risk with COVID with corresponding back to school recommendations.
If your child, or someone in your child’s home, has one of these conditions, then please discuss whether or not your child should attend in-person school with the health care professional who is managing that condition. It is important to recognize that while all of the categories above represent a higher risk for severe COVID-19 disease than the baseline population, there are different degrees of elevated risk for the above categories. Only in consultation with your doctor will you be able to correctly quantify the specific risks to your child or to the high risk people in your home.
Q: If I have the ability to provide a safe environment where my child can attend a Virtual Classroom and no one in my home is high risk, should I send my child to in-person school anyway?
A: Maybe. This is a much more difficult question and different families may end up with different answers. As discussed above, the risk of getting severe disease is incredibly low in healthy, school aged children. In fact, this is the age group least likely to have a negative outcome from infection with COVID-19. It is also clear that children are not as efficient spreaders of COVID-19 as adults; however, it is also clear that they can spread the disease and that the traditional school environment is one that can easily facilitate spread of a highly contagious illness such as this one. Consequently, if schools are going to be open for in-person education, then they must enact measures to reduce the risk of spread among students. Unfortunately, there is no single action or set of actions that will completely eliminate the risk, but implementation of the following interventions can significantly reduce the risk:
- Proper Hand Hygiene – washing hands for 20 seconds with soap and water or allowing a hand sanitizer with at least 70% alcohol to sit on the hands for at least 20 seconds both before meals and also after any encounter with an object another person has touched.
- Physical Distancing – keeping students physically as far apart as possible. Ideally students would be 6 ft apart but this is unlikely to be possible in the typical classroom environment. This virus is spread primarily through aerosolized droplets that are exhaled into the air when we cough, laugh, or breath. One of the reasons that this virus is so contagious is that people who are infected, but are not yet showing symptoms, can spread the virus into the air just by breathing. This is a concept referred to as asymptomatic spread. Studies have shown that asymptomatic carriers of COVID-19 do not spread these aerosolized viral particles further than 6 ft.
- Decreased exposure to other people – the less number of people your child is exposed to, the less risk there is of exposure to COVID-19. This is typically accomplished by eliminating visitors to the school.
- Eliminate exposure of symptomatic persons – if your child has symptoms of COVID-19 defined by the CDC as the following, then he must stay home:
- Fever or chills
- Shortness of breath or difficulty breathing
- Muscle or body aches
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Face Masks – have 2 benefits. The primary benefit is that they prevent people who are infected from expelling the virus into the air. This is why face masks with a valve are not recommended; they protect the wearer but do not restrict the wearer’s exhaled breath from exiting the mask. The other benefit of a face mask is that it will decrease the amount of virus that you inhale from air. This is considered a secondary benefit because not all face masks are created equal. Most homemade face coverings do not have sufficient filtration to reduce the amount of inhaled virus. Surgical face masks filter about 75% of small particles and N-95 respirators filter 95%. Ultimately, the act of wearing a face mask is more about protecting your neighbor than it is about protecting yourself.
- Face Shields – these are clear plastic barriers that can be secured to a child’s head so that the eyes, nose, and mouth are covered. The benefit of the face shield compared to the face mask is that it allows for the whole face to be seen by another person and is easier to wear for long periods of time. While some studies suggest that face shields can decrease how much virus is exhaled into the environment by asymptomatic carriers the CDC reports that there is insufficient evidence to recommend their use and “does not recommend use of face shields for normal everyday activities or as a substitute for cloth face coverings.”
- Flu Vaccine – while the flu vaccine will not prevent disease from COVID-19, vaccination against the flu provides two significant benefits. The first is that it decreases the number of febrile respiratory illnesses we will see in the Fall and Winter. The Flu and COVID-19 look very similar, the only way to discern between the 2 is a test. The less Flu in the community this year the less missed school and the less confusion regarding what illness a child has. The other benefit is that there is evidence that if a person has both Flu and COVID-19, their illness is significantly worse than if they had just one of the infections.
For additional information on measures that schools should be taking to reduce the risk of spread of COVID-19, see this Guideline published by the AAP. This Risk-Based Approach to Reopening Schools published by the Children’s Hospital of Colorado is also very helpful.
Ultimately, the decision regarding whether or not to send your child to in-person school in the Fall is up to each individual family, and the needs of the individual child must be considered. Additional considerations for families should include:
- What is the best learning environment for your child? During forced home schooling in the Spring, some families learned that their child loved learning from home. If this is true for your child and you have the ability to provide a safe environment in which your child can learn virtually, then go for it. With time to prepare, there is good reason to believe the virtual learning that will be offered in the Fall will be vastly superior to what was offered in the Spring. For a description of what Virtual Learning will look like in the Dallas Independent School District click here. Conversely, many parents learned that for their child, learning from home was a complete disaster. If that was the case for your family, then sending your child back to in-person learning in the Fall is likely a good decision.
- Would your school benefit from having fewer children in the classroom? While it is clear there is a public health benefit of keeping schools open, it is also clear that the fewer children who attend school in-person, the easier it will be to physically distance and limit the spread of disease when someone in the school gets sick. This is not a situation in which any family should feel the need to be a martyr and keep their child out of school when that is the best learning environment for that child. However, if you have the ability to effectively provide Virtual Learning from home, there is a public health argument for that action. Having said that, it is important to recognize that while the health and safety of your child is your primary responsibility, all of us should approach this pandemic with the health and safety of every child in mind. Therefore we should advocate for policies that allow for all children to be equally educated in a safe environment. If our response to the pandemic is to create two different classes of students based on their available resources, then we risk increasing the educational inequalities that already exist in our communities.
- What is the current spread of COVID-19 in your community? The risk of exposure to COVID-19 in the school is directly related to the prevalence of the disease in the community and this should be part of the equation when considering whether or not you should send your child to school. Based on current trends of this virus, as well as historical patterns of pandemics and the typical pattern of viral respiratory infections, it is expected that rates of disease will increase in the Fall and Winter. When this happens, it is possible that schools will be forced to shut down again or public health officials will recommend that anyone who is able to remove their child from school should do so. Ultimately, this is more of a public health consideration, but the expectation is that the State will do its best to keep schools open for as long as possible, so it is appropriate to take this information into consideration when making decisions for your family. This means that even if it is appropriate to send your child to school at the beginning of the school year, you may find the need to revisit that choice in November or December.
I hope that you found all of this information helpful and not overwhelming. Unfortunately none of us have a magic crystal ball or the ability to see into the future. All we can do is make the best choice for our families with the information we have available. Whatever choice you make, please know that we will be here to support you in the care of your child no matter what may come. Whether or not your child attends in-person school in the fall, the risk of exposure to COVID-19 is still present and it is important to be aware of the protocols for a high risk exposure or confirmed or suspected infection.
- High Risk Exposure: The CDC defines this as prolonged (15 cumulative minutes or more) close (less than 6 f to someone confirmed to have COVID-19. If this criteria is met, then the exposed person must quarantine at home for 14 days from the last exposure to the infected person.
- Confirmed or suspected COVID-19 infection: If someone tests positive for COVID-19, then they must quarantine at home for at least 10 days from the start of symptoms AND be fever free for a minimum of 72 hrs AND have improving respiratory symptoms (cough) for a minimum of 72 hrs.
With this information in mind, be aware that it is appropriate to make plans for the need to quarantine at home should you or your child have a high risk exposure or suspected infection. It is expected that every school will have at least 1 positive case in the coming year. While we hope for the best, it is appropriate to plan for the possibility that you may need to keep your child home for at least 2 weeks during the coming school year.