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Back to School? 91���� Pandemic Expert Answers Most FAQs about COVID-19

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’s , M.D., M.P.H., M.B.A., chair and professor of pediatrics, Integrative Medical Sciences Department, and senior associate dean for clinical affairs, , provides answers to some of the most frequently asked questions regarding COVID-19 and return to school for school-age children. Adirim is a physician executive with senior leadership and executive experience in academic medicine and the federal government. Prior to joining 91����, she served as principal deputy assistant secretary of defense for health affairs for the United States Military Health Systems, a $50 billion complex acute care delivery system that serves 9.5 million beneficiaries. Her expertise includes pandemic planning and response, health care quality improvement and patient safety, and health policy and management.

1.���� Is it safe to open schools with COVID-19 cases so high in Florida right now?

It would be ideal for communities to set the conditions for a safe reopening of schools. For a variety of important reasons, children need to return to in-person instruction and parents need their children in school so they can work.

Reopening schools is not just important for children and families, but also important for the economy. In order to create a safer environment for reopening schools, communities should experience at least two weeks of declining numbers of cases and achieve fewer than 10 new cases per 100,000 people per day before reopening schools for in- person instruction. Lower numbers of cases in the community would reduce the risk of outbreaks, and when there are outbreaks, public health officials will be better able to contain these outbreaks with testing and contact tracing.

Florida has reported an extremely high number of new COVID-19 cases per day (approximately 58/100,000 people), which in fact currently constitutes the highest number of new cases per day per 100,000 people of any state in the United States. Therefore, if there is not a significant intervention to reduce COVID-19 cases in the weeks before schools are set to reopen, it is not advisable to hold in-person classes in or near jurisdictions where the rates remain unacceptably high.

2.���� My children are ages 2, 7 and 13. Is it safe to send them to daycare and school?

Assuming the right conditions within a community, the risk to young children is relatively low compared to adults.�� This is because children are less likely to get sick with COVID-19 if and when infected. The risk seems to be even lower in the youngest age groups. However, there is still a lot that we are learning about COVID-19, including its impact on children. What we know so far is that children tend not to get as sick when infected and may be less likely to transmit the virus to others. The thinking, based on the science to date, is that, as compared to adults, children have fewer of the receptors in their bodies where the virus attaches to enter the body and cause illness. Also, young children tend not to propel droplets, as far as adults can when they speak or cough, so they are less likely to transmit high concentrations of respiratory viruses. Still, children who are immune suppressed or have other medical conditions should consult with their pediatricians before being sent to school.

As of July 10 in Florida, there were 17,073 children under 18 years who have been infected with the coronavirus, according to the Florida Department of Health. Of these, 213 have been hospitalized and four have died. Studies have shown that children with more serious disease and who have died had underlying medical conditions.��

Under the right community conditions and in school settings where precautions are implemented, going to school in person is relatively safe though not without some amount of risk. We have observed that in other countries when appropriate precautions are undertaken, children have successfully returned to school. Each community will have its plans for readjusting the physical environment and for infection control for schools. Find out what these plans are in order to determine the risk you are willing to tolerate for you and your family.

3.���� My child has asthma. Can I send her to school?

From what we know so far, asthma has not been found to cause an increased risk of serious COVID-19 disease in children. However, there is still much we are learning about children and COVID-19. If your child has severe asthma with frequent hospitalizations, consult your pediatrician for guidance.

4.���� I have the option to have my child attend school virtually or go in person some days during the week. Which should I choose?��

If given a choice between virtual instruction or in-person instruction, you should consider a number of factors including the level of COVID-19 cases in your community, how well your school prepares based on guidance laid out by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics, your child’s health status, your child’s access to computer equipment and the Internet, parents’ need to work, and your tolerance for risk. Under the right circumstances, the benefit of returning to in-person instruction may outweigh the risks for your child.

5.���� What are the benefits for my child in attending school in person during the pandemic?

The American Academy of Pediatrics states in their Guidance for School Re-entry: “Schools are fundamental to child and adolescent development and well-being and provide our children and adolescents with academic instruction, social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity, among other benefits. Beyond supporting the educational development of children and adolescents, schools play a critical role in addressing racial and social inequity.” Therefore, under the right circumstances, children should attend school in person.

6.���� What should I look for or what questions should I ask to determine if my child will be safe at school?

It is important to ask what safety and infection control precautions your child’s school plans to implement. They should follow the CDC and/or the American Academy of Pediatrics guidance as those documents were developed by experts. Some specific questions to ask to help you determine the safety of your child’s school environment include: ��

• How often will classrooms and other areas be cleaned?
• Will masks be required for students and teachers?
• How many children will be in the classroom and how will they be physically distanced?�� The CDC advises 6 feet between students, and evidence suggests that 3 feet may be adequate if all are wearing face coverings.
• Will children move between classes? How will the school prevent students from congregating?
• Will classes be cohorted so that students do not move from classroom to classroom and remain with the same students and teachers? Alternatively, for older students, will students remain in the same classroom and teachers rotate?
• Will outdoor spaces be used? Will larger rooms such as cafeterias be used to increase spacing between students and teachers?
• How will children social distance on buses?
• What would cause schools to reclose?
• How serious is your school about enforcing safety precautions, and how will it handle non-compliance?

7.���� My child has anxiety and won’t wear a mask, however, my school will require them to when they reopen. What can I do to help her?

Children can be anxious in general during this time, but additionally, they could be anxious about wearing a mask. In the weeks before schools reopen, practice wearing a mask at home so she gets used to the sensation of having the mask on her face. There are now some really fun designs on masks so let her choose her own with a design that excites her. By the time she gets to school, she may be very happy to wear a mask, especially when she sees all her friends wearing them.

8.���� My child is 5 years old. Can she really wear a mask?

The American Academy of Pediatrics and public health experts state that masks should be worn by all people over the age of 2. The younger the child, or if your child has special needs (e.g. autism), the more challenging it can be to get your child to wear the mask. In the weeks before schools reopen, practice wearing a mask at home so she gets used to the sensation of having the mask on her face. There are now some really fun designs so let her choose her own with a design that excites her.�� ��

9.���� I am hearing about the really bad disease affecting children, MIS-C, and I’m worried that my child will get that. How common is it and how do I prevent her from getting it?��

Multi-System Inflammatory Syndrome of Children (MIS-C) is a rare manifestation of infection with the COVID-19 virus. It is a post-infection condition and many children may not have the usual symptoms of COVID-19 as described by the CDC (e.g. cough, shortness of breath, vomiting, diarrhea, etc.). So they typically present with symptoms of MIS-C, instead of COVID-19 symptoms, and we learn through testing that they have COVID-19 ��antibodies, signifying past infection. It is not known who is at risk, but we continue to learn new things about the condition. What we do know is that MIS-C is exceedingly rare. Some children could sustain organ damage that is long lasting but most recover. The CDC reports that between March 16 and May 20, there were 189 cases of MIS-C in the 26 states that reported cases, with 2 percent who reportedly died from MIS-C. As of July 10, Florida reports that there were 13 children who had MIS-C with no reported deaths.

10.�� My elderly parents live with our family and they are high risk for serious illness if they get COVID-19. Does this mean that I should not send my child to school?

This is a challenging scenario. It’s not uncommon for families to have people in the household who are at high risk for serious disease if they get COVID-19. In fact, according to the Kaiser Family Foundation, 3.3 million people 65 and older live with school-age children – put another way, 7.3 percent of school-age children live with seniors. Based on current evidence, it is believed that children may be less likely to transmit COVID-19 to adults. Consideration should be given to whether the at-risk family members can be moved to another location and, if not, whether children can be separated from the at-risk family members, including separate bedrooms, different eating times, and different bathrooms. The risk to the other family members must be balanced with the critical need for children to return to school. On balance, families should make great efforts to get their children back to school.��

11.���� I am pregnant and have school-age children. What is my risk if they return to school?

There is still a lot that is not known about COVID-19’s impact on pregnant women and the fetus. A recent study suggests that pregnant women infected with COVID-19 are more likely to be hospitalized and are at increased risk for serious disease requiring intensive care than non-pregnant women with COVID-19. The risk of death was no greater however. Compared to the risk of exposure outside of the home, the risk to adults in the home from children may not be as great because children may not transmit the virus as effectively as adults. Families must balance the benefits and need for children to attend school with the risk of bringing the virus home.

12.���� My child is going back to school. How do I prepare her in the morning? What should I do when she returns home?

Many children will be excited about going back to school to see their friends. But some may be anxious. Parents can help their children by discussing with them what to expect in the weeks before school reopens and by emphasizing that they need to follow instructions from teachers and other adults carefully. For younger children, practice getting ready for school, wearing a mask, washing hands and sitting apart. Things may be very different from how they remember school before the pandemic – when a child knows what to expect, and that all the other kids going back to school will also be experiencing something new, there may be less anxiety.��

When your child returns home during the first few days, ask how her day went. Try to talk to her about things she found to be hard or strange. Look for signs of changes in behavior. Children are resilient and most will do fine. If you are hearing things that don’t make sense or don’t sound safe, you should feel empowered to ask your school about them. You have a right to expect that your child’s school will actually carry-out the safety procedures they outline in their plans.

13.���� I am an elementary school teacher and have been for more than 30 years. I am worried about getting the coronavirus. How do I stay safe when schools reopen?

For people who are in high risk groups due to age or medical conditions, discussing the risk to you personally with your physician will be important. Find out from the school system if there will be reasonable accommodations offered for teachers who are at high risk. If you go back to the classroom, ask about what safety and infection control measures will be instituted. It will be important for those at higher risk to make sure that their work environment adheres to CDC guidance. You have a right to expect that your school will actually carry-out the safety procedures they outline in their plans.

14.���� Are there measures/indicators we should use to determine if it is safe to reopen schools? Any measures/ indicators to guide us in determining if we need to close schools? ��

In general, the community is ready for schools to reopen when new cases per day are declining and the case rate within the community is low. There are a number of frameworks for assessing readiness, including the White House/CDC “Opening Up America” guidance that recommends “gates” or criteria for reopening. Based on these and other frameworks (e.g. from the Harvard Global Health Institute), communities should have 14 days in a row of declining new cases and less than or equal to 10 new cases per 100,000 people per day. If cases begin to increase, testing is not easily accessible and/or case numbers rise so high that contact tracing becomes ineffective after schools reopen, then closure of schools and switching to online learning should be considered.

15.���� What are the developmental concerns with children continuing to learn virtually?

The ability to sustain attention to their work with distance learning can be very challenging for children, especially the youngest. Part of the learning experience involves learning to socialize and child development relies on interactions with other children for socio-emotional growth. It is also challenging for teachers to virtually evaluate a child’s work and provide one-on-one attention. In communities with high case rates, it may not be possible to hold in-person instruction and therefore, virtual education is the only viable substitute. This widens disparities among children – those who are advantaged and have access to computers, the Internet and parental attention, versus children without access to these things. Children who are disadvantaged will lose many learned skills and risk getting behind in reading and math. This is why all efforts and resources should be dedicated to opening schools and keeping them open.

16.���� What are the numbers on children contracting COVID-19 and what are we seeing in terms of illness in these children?

The number of children in the U.S. who have had COVID-19 is not known. In Florida, 17,073 children 17 years old and younger have tested positive for COVID-19. However, there is an exceedingly high positivity rate with testing – 31 percent, but positivity goal is 5 percent - which means that Florida is not testing enough children to really know how many children have been infected.

There is still a lot that we are learning about COVID-19 in children, however, what we know so far is that children tend not to get as sick when infected or have no symptoms at all and are less likely to transmit the virus to others. The thinking, based on the science to date, is that, as compared to adults, children have fewer of the receptors in their bodies where the virus attaches in order to enter the body and cause illness. Another theory is that children have had other coronaviruses so may have partial immunity. But we really don’t know fully why children get less sick than adults, and we also do not have enough experience with COVID-19 to understand whether there are longer-term implications of an infection for children.

Children may present with a different array of symptoms than adults. Many children who develop symptoms have mild respiratory symptoms such as a runny nose and cough and are more likely than adults to present with vomiting and diarrhea.

17.���� Do we have data that truly shows that COVID-19 is not as serious or does not pass as easily in children?��

According to the World Health Organization (WHO), research indicates that children and adolescents are just as likely to become infected as any other age group, and they also can spread the disease to others, although perhaps not as effectively as adults. However, the studies to date suggest that children and young adults are less likely to come down with severe symptoms. But, severe cases can still happen in these age groups, especially children with chronic medical conditions. Children and adults should follow the same guidance on self-quarantine and self-isolation if there is a risk they have been exposed or are showing symptoms. It is particularly important that children avoid contact with older people and others who are at risk of more severe disease.

18.���� Is there an age at which risk of infection is higher or lower?��

According to WHO, research indicates that children and adolescents are just as likely to become infected as any other age group and can also spread the disease to others, although perhaps not as effectively as adults. Studies to date suggest that children and young adults are less likely to get severe disease and some may not exhibit symptoms, but severe cases can still happen in these age groups.

19.���� Is there a data point we should consider when deciding to open schools? Positivity rate, number of cases, etc.?

Local communities should consider multiple measures in deciding whether to open schools for in-person instruction. In particular, communities should experience at least two weeks of declining numbers of cases and achieve fewer than 10 new cases per 100,000 people per day before reopening schools for in-person instruction. Lower numbers of cases in the community would reduce the risk of outbreaks and when there are outbreaks, public health officials will be better able to contain these outbreaks with testing and contact tracing. It is important to consider carefully the root cause of an elevated positivity rate. While elevated positivity rates may just indicate that a community is not testing enough, it can also indicate that there is significant community spread.

20.���� What should the procedures be if/when a student in the classroom tests positive? Does everyone get tested five days later? What should the policy be if they test either positive or negative?

The CDC recommends in their return to school guidance to (1) isolate any student exhibiting symptoms of COVID-19 from others immediately, (2) establish procedures for safely transporting the child home or to a health ��care facility, (3) notify local health officials of a possible case, (4) close off areas where the child has been, (5) clean and disinfect those areas 24 hours after the child was removed from the areas, and (6) advise those who had been in close contact with the child to stay home and quarantine and self-monitor for symptoms. The school would not have to close if the CDC guidance is followed. Additionally, schools should have plans in place to perform contact tracing (within the school community) for any student who tests positive and was in close contact with other students. Those students and school personnel with significant exposure to the student testing positive for COVID-19 should quarantine at home and self-monitor for symptoms.

21.���� If one child in the class gets sick, do they need to shut down the entire class?

The CDC recommends the following: “In the event a person diagnosed with COVID-19 is determined to have been in the building and poses a risk to the community, programs may consider closing for a short time (one to two days) for cleaning and disinfection.” It really depends on the situation and school officials will need to determine the significance of the exposure and procedures required to make the classroom safe.

22.���� Do all children need to get tested? What about teachers?

Testing students and school personnel prior to the start of school is not really feasible right now and may not be helpful since test results are taking an exceedingly long time. Also, it is not clear that such testing would reduce the likelihood of spread within schools. It is important to recognize that COVID-19 testing only shows whether a person is infected at that specific moment in time.��Therefore testing prior to school reopening has not been recommended by the American Academy of Pediatrics. As the pandemic progresses, we learn more, testing becomes more accessible, and more school systems plan for and reopen schools, these recommendations may change.

23.���� Are you able to pinpoint the “safe” number of children in a classroom?

The CDC recommends that people remain at least 6 feet apart and the American Academy of Pediatrics states that there is evidence suggesting that children wearing face coverings can be 3 feet apart and not be at high risk of virus transmission. Therefore, there is no “safe” number, but rather how many children can fit in a space while maintaining 3 to 6 feet of distance. Moreover, desks should not be facing each other and it is recommended that students should remain in one room with the same students throughout the day to minimize exposures (as much as is practicable). It is critical that school personnel monitor for and enforce social distancing throughout the school day.

24.���� Would it be okay for children to wear face shields instead of face masks to allow teachers to see the movement of their mouths to help them with reading and pronunciation of words?

There is currently no evidence that face shields are as good as face masks and the concern with using face shields alone is that they are not likely to keep particles from being transmitted into the air as the sides and bottom are open. However, some face masks are clear and conform better to the face, which would be more effective.

25.���� Is it safe for children to wear a facemask for hours during the day?

Yes, masks are safe and in fact recommended for children of 2 years of age and older. There is no credible evidence that there are any medical conditions that would preclude anyone from wearing a mask. To the extent you are concerned about a medical condition that might be a reason for not wearing a mask, that condition – rather than whether the child can or cannot wear a mask – will make it far more likely that a child should not go to school or be out in public. A mask being uncomfortable is not a medical reason for not wearing a mask. For any child with anxiety or a developmental disorder which makes wearing a mask challenging, consult with your pediatrician.

26.���� As a parent, when would you feel comfortable allowing your child to go back to school full time?

Under the right community conditions, such as declining new cases and the school following CDC guidance for safety and infection control, I would be comfortable for my children to go back to school full-time.

27.���� Is it feasible to implement all of the guidelines required to safely allow our children to go back to school?

Yes, and it’s important that schools follow the CDC guidelines for safety and infection control. With the right amount of planning and resources, it is very doable. We need to do this for the sake of our children, for the sake of parents’ ability to work and for the sake of our economy. If you are hearing things about your child’s school that don’t make sense or don’t sound safe, you should feel empowered to ask your school about them. You have a right to expect that your child’s school will actually carry-out the safety procedures they outline in their plans.

28.���� Do you think it’s possible to keep children from socializing and maintaining appropriate social distancing?

It can be challenging, especially among certain age groups. The very young have shorter attention spans so they may forget to maintain proper physical distancing. However, that should be manageable so long as school personnel are there to remind them. School-age children tend to be rule abiders, but visual clues and engineering controls, along with adults to remind them, are vital tools for supporting social distancing and safe behaviors. Adolescents are naturally social so even though they are older, they, too, will need reminders.

29.���� Other countries have already opened schools. What can we learn from them as it relates to best practices?

The most important lessons we can learn from other countries include the importance of having effective plans for reopening when COVID-19 cases are low and of making sure schools implement safety and infection control procedures. These include physical distancing of students, good hand hygiene, screening with symptom and fever checks and cleaning of rooms and objects children handle. Those countries that have been successful at opening schools were effective in driving down the virus in their communities through suppression and mitigation measures, testing, contact tracing and quarantining/isolation.

30.���� Are there any words of encouragement that you can share for frustrated and overwhelmed parents in Florida as well as the entire nation?

The American Academy of Pediatrics and pediatricians all over the U.S. recognize the importance of getting our children back into the classroom. We are advocating for communities, states and the federal government to create the safe conditions required to reopen successfully. Pediatricians all over the country are working with their local school systems to provide expert input and support for their plans. Schools will reopen this fall for in-person instruction in some places, and others may not be able to open in the fall except for virtual instruction. However, we can be hopeful that all schools will be ready to reopen by the spring of 2021. Parents can and should advocate with their state legislators and congressional representatives for the allocation of appropriate resources to effect successful school re-openings.

31.���� What are the essential tips that we need to provide to our children about staying safe during the pandemic?

Washing hands is really important. Practice at home with soap and water – singing happy birthday twice so your child knows how long to wash their hands, like we advise for tooth brushing. Also practice wearing masks.�� Demonstrate what physical distancing is. Practice ways they can show excitement when they see their new friends without hugging or otherwise touching.There are all kinds of websites with ditties about hand washing for little children.�� Some recommend “Wash, Wash, Wash Your Hands” to Row, Row, Row Your Boat. Also, a video from Raffi may be fun for the littlest of children: .

32.���� Do children have healthier and more resilient immune systems than adults?

Children tend to be healthier than older adults. Older adults (65+ years-old) tend to have waning immune function and therefore may be more susceptible to infections. This does not mean that children are at low risk for contracting the coronavirus. In many outbreaks of various diseases caused by viruses and bacteria, children are the most likely to be infected. This is because they tend not to adhere as well to good hygiene practices and also tend to congregate closely in groups. At the start of the pandemic, schools closed and children stayed home so we don’t have a lot of information about how the virus is transmitted among children. So once schools reopen, we’ll learn more.

33.���� What advice would you provide to teachers who are concerned for their health and safety as well as their families?

This is a challenging question. While children do relatively well when infected with the coronavirus, adults tend to fare less well, especially older adults and adults with chronic medical conditions such as heart disease, diabetes, high blood pressure and other chronic conditions. I would advise that, before schools reopen, teachers should consult with their physicians about their level of risk and things they can do to protect themselves should they choose to return to in-person education. For those teachers at higher risk of serious disease with COVID-19, explore alternatives and reasonable accommodations such as remote teaching – some schools are looking into having younger colleagues teach in person and older colleagues do the virtual classrooms, or having teaching assistants work with young children while older teachers maintain physical distancing. Make sure in any case that your school system is adhering to CDC guidance with regard to safety, engineering control and infection control measures in their planning.

34.���� When school opens in the fall, we also we be heading toward peak flu season. Will all children and teachers have to get a flu shot?

While flu shots are always important, this year especially it is imperative that all Americans should get a flu shot, particularly children and the elderly. We have yet to see how devastating COVID-19 may be for patients also suffering from the flu.

DISCLAIMER:

The answers to these questions are not meant as medical advice. They are intended to provide information that during a pandemic can change as we learn more about the virus and its impacts on children. The information provided is the best available as of July 16, 2020. For questions about specific circumstances, consult with a physician.

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