To the Editor:
After reading your editorial discussing the safety of children returning to school during the coronavirus pandemic (“Can Students Safely Return to School in the Age of COVID-19?”1) in the September issue of Pediatric Annals, I wanted to share my experiences in helping local schools and local s c h o o l districts in Metro-East Illinois (suburbs of St. Louis, MO) put the guidelines discussed in your editorial into place. As sole owner of a busy pediatric practice and mother of three teenagers, the arrival of the novel coronavirus not only consumed my already busy life but also launched me into active advocacy for safe return to in-person education.
After a spring spent under a stay-at-home-order and riddled with behavioral telemedicine visits (during which I encountered repeated stories of students unable or unwilling to complete their remote work), it was an easy decision to turn my focus to the safety of in-person schooling. In collaboration with other regional pediatricians, I began reviewing international data along with Centers for Disease Control and Prevention (CDC) and public health guidelines and reached out to local schools to offer my assistance. Truthfully, I did not expect our public schools in Ilinois would need much, as they surely had guidance and support from their state agencies. However, much to my surprise, they were desperate for help. It was a daunting task as I sat for hours at a time with administrators working through every moment of the students' day from leaving their home in the morning until they returned in the afternoon. We discussed in detail the coronavirus and kids, transmission data from international schools this spring, and infection control procedures like those outlined in your article.1 I met with school nurses, principals, superintendents, and special education directors. I explained the premise of increasing spacing and decreasing mixing as it pertained to all aspects of their day, as well as the importance of communicating their plans to staff and families.
Unfortunately, the CDC, American Academy of Pediatrics (AAP), and Illinois state guidelines for schools came out late, were either too vague or too restrictive, did not take into account the actual resources schools have to work with or the barriers they have to be successful, and often used verbiage that tied their hands legally. The Illinois state education system, by failing to include recommendations and support from governing bodies, by failing to provide funding and distribute resources, and by failing to empower local superintendents to make decisions, worked against our schools and the education of our children. Overwhelmingly, administrators and teachers genuinely wanted to do the right thing but felt handcuffed by misinformation, teacher unions, bus and support staff unions, legal advisors, politicians, and limited resources. The ability or lack thereof to adequately reach students at home, change bus schedules, create physical space, or replace windows and ventilation systems varies widely from district to district. Administrators were left to consider what guidelines were non-negotiable and which could be put in place as was reasonable and feasible to protect their staff and students. For example, most large school districts cannot functionally keep high school students in one classroom or out of hallways, but they can offer a remote learning track to decrease volume, shorten days to avoid serving lunch, assign seats (at lunch, in class, on the bus) to help with contact tracing and minimize exposures, and mandate mask wearing and frequent hand washing for all. If schools are serving lunch, students can eat outside when the weather permits or eat in classrooms and rotate lunch time in the cafeteria. These are only a few of the real issues the schools are facing. There will be positive cases, and this must be understood and accepted. Every decision the schools make will be based on this premise. These recommendations are meant to contain and minimize spread, not eliminate it. Administrators need our guidance and expertise. We need to ask questions about how we can best help and find out what challenges the schools are facing.
Just as school was to resume, we found ourselves amid a significant increase in positive cases in our region. Fear and anxiety increased, and my role morphed from explaining data behind mitigation strategies to answering questions from worried teachers, educational support staff, and school nurses as to the safety of returning at all. Knowledge of underresourced school systems propagated this fear but hearing directly from trusted pediatricians did much to assuage it. Many questioned the data, but I found that offering a brief explanation and providing a reference for them to read on their own showed transparency and bridged the gap of trust that may not have been there prior to our conversation. With desperation to communicate why the AAP and CDC continue to encourage in-person schooling, myself and my colleagues began writing letters reviewing current information regarding transmission from children and adolescents, effectiveness of mitigation strategies, reports of successful daycare attendance throughout the pandemic, and the long and short-term ramifications of remote learning. Like so many other essential businesses, the schools have been creative and intentional in their planning to keep both staff and students safe. We reminded people that activities outside of school likely pose a relatively increased risk for contracting and spreading the virus as compared to the supervised, masked environment of school.
In my community, some schools chose to begin the school year remotely, some chose hybrid models, and others began with full in-person education. Once school resumed, nurses were overwhelmed with the realities of what symptoms would necessitate sending students home, whether to send siblings home as well, when to allow them to return, and with what documentation. They needed help making decisions as to when a child with somatic anxiety symptoms, chronic headaches, asthma, and allergic rhinitis can stay at school. Like us, they were dealing with frustrated parents and working to explain the reasoning behind the decisions. When there is a positive case in a school with student cohorts and assigned seats, nurses can quickly remove all close contacts, and advise them to self-quarantine and call their physician while waiting to hear from the local health department. If we want to understand school transmission of the virus, we must learn whether the cases have been in contact only at school or in the community as well. This will be paramount in making proper decisions regarding school closures. As other businesses remain open during periods of high community transmission, every effort should be made to keep schools open as well so long as the school itself is not experiencing outbreaks. To do so we must look to more than metrics, as the numbers alone do not address the reality of where the transmissions are occurring.
Through the efforts of community pediatricians, added support of our state AAP chapter, and advocacy from the AAP, we have been an effective voice for students. As child health experts, parents, and business owners, we need to bridge the gap between public health departments and the education system. I anticipate the relationships that have developed among pediatricians, health departments, and school leaders will lead to further collaboration and benefit our community greatly in the years to come.