|Dr. Dora Anne Mills, Chief Health Improvement Officer for Maine Health and former Maine CDC Director|
Not-So-Brief COVID-19 Update, with a focus on School Closures. March 15th, 9 a.m.
Over the last five days, testing in Maine has increased dramatically. Between the Maine CDC’s lab and MaineHealth’s NorDx lab, about 300 people have been tested. Several have come back positive (a total of 6 as of yesterday, with updated numbers due out later today). So far, those whose geographical residence have been reported, live in Cumberland County except for one person in Androscoggin County. Expect the numbers of people testing positive to increase, as they have elsewhere around us – NH (7), MA (138), Quebec (24), and New Brunswick (2).
Many K-12 schools are closing in Maine, mostly announced the last two days. This has been an interesting phenomenon to follow, since new U.S. CDC guidance, based on data on COVID from other countries, does not encourage schools to close. For Maine at this point in time, their recommendation is not to close schools. But the reasons are complicated, and sometimes in an emerging epidemic, people feel it is best to “err on the safe side”, and I understand parents have put a great deal of pressure on school leaders to close. I’ll try to explain the reasons behind U.S. CDC’s recommendations.
First, we need to remember that COVID is not influenza. For a pandemic with influenza, schools in Maine would likely all be closed now. The reasons are that school children are known high community transmitters of influenza, and they are disproportionately impacted by the infection, in that they are at high risk for severe disease. What I mean by “high community transmitters” is it is well documented that school children, after spending all day together with typical school children hygiene that results in the sharing a lot of germs (through not covering coughs and sneezes, and not washing hands), they disperse home across the community, taking those germs with them, and then pass them on to mom, dad, siblings, grandparents, etc. Then mom and dad take those germs with them to work, the grocery store, and elsewhere. There is even evidence that if you have limited influenza vaccine, you should consider vaccinating school and daycare children, since that provides more protection for the entire community. (It is what we did early on in Maine during H1N1, which, according to published studies, is one reason why Maine was spared being impacted as hard as other states, including not having one child die to the pandemic). Additionally, influenza pandemics typically severely impact children, and they are in a high-risk group for severe disease.
By contrast, for COVID-19, the data are compelling from China and increasingly elsewhere, that children are mildly impacted by the infection. There are also data indicating they are not high community transmitters for COVID. That doesn’t mean they don’t transmit it, but preliminary data indicate they may not be high (major) community transmitters.
Secondly, U.S. CDC’s guidance discusses the major downsides to closing K-12 schools. For instance, with one in five Maine children living with food insecurity, and their most reliable source of food often being school, closures can mean more children going hungry. My son works in a local elementary school where a large proportion of students eat three meals per day there and take food home for the weekends. He is worried how they will fare during this closure.
Additionally, some children are safer at school than they are at home, due to a variety of reasons, including having parents with severe behavioral or physical health issues. Although a number of children can learn at home via distance technology, not all children have access to the technology, and children with some types of disabilities cannot learn through distant modalities. With one in six Maine children living in poverty, mostly in families with working parents, it may be a very challenging time for those parents to stay home to care for children.
In our rural areas, the issues of food insecurity, poverty, and safety are increased. For instance, six rural Maine counties have between 20% and 30% of children living in poverty.
One major purpose for closing schools is to increase social distancing. However, when New York City closed schools during the early phases of the H1N1 pandemic, many of them congregated in groups anyway. Teenagers got together in homes and parks. And younger children congregated in homes with parents sharing child care.
Finally, a major challenge directly related to the pandemic is that school closings mean more essential workers have to stay home. This includes nurses, doctors, and first responders – the very people we need to be working to take care of patients during the pandemic.
U.S. CDC’s guidance for schools tries to balance factors such as the emerging data on COVID and the downsides of school closure. Here are some highlights of their guidance.
If there is a person in the school with confirmed COVID-19 who was symptomatic while in the building, then the school may consider closing for 2 – 5 days for cleaning and disinfecting and to help stop the spread. During this time, it is okay for some staff to work in the building.
If there is no community spread in the school’s community, then U.S. CDC recommends: a strong focus on teaching and reinforcing hygiene; more frequent cleaning and disinfecting surfaces that are frequently touched with hands (door knobs, hand railings, etc.); postponing group gatherings and events; and requiring sick students and staff to stay at home.
If there is minimal to moderate community spread, U.S. CDC recommends implementing multiple social distancing strategies, such as spreading students out in the classroom, as much as possible, such as increasing the spaces between desks and having students face the same direction rather than each other; having students not congregate in large groups, for instance, staggering their times in the cafeteria, recess time, and dismissals; limiting nonessential visitors; and identifying staff and children who are at high-risk for severe disease, and consider having them stay home.
If there is substantial community spread, then U.S. CDC says schools can stay open with strict hygiene and social distancing practices implemented. Or, schools can dismiss for an extended time (more than 2 weeks).
U.S. CDC strongly recommends that no matter what circumstances schools close, they continue meal programs and other essential services for students.
Quotes from U.S. CDC’s Guidance:
“Available modeling data indicate that early, short to medium closures do not impact the epidemiology curve of COVID-19 or available health care measures (e.g., hospitalizations). There may be some impact of much longer closures (8 weeks, 20 weeks) further into community spread, but that modeling also shows that other mitigation efforts (e.g., hand washing, home isolation) have more impact on both spread of disease and health care measures. In other countries, those places who closed school (e.g., Hong Kong) have not had more success in reducing spread than those that did not (e.g., Singapore).
In places where school closures are necessary, the anticipated academic and economic impacts and unintended impacts on disease outcomes must be planned for and mitigated. Provision of academic support (e.g., tele-ed), alternatives for school-based meals as well as other services (e.g., behavioral and mental health services) for economically and physically vulnerable children, support for families for whom telework and paid sick leave is not available, ensuring that high risk individuals continue to be protected must all be addressed. Special consideration must be given for health care workers so that school closures do not impact their ability to work.”
I should mention that although Singapore did not close schools, they also implemented very strict respiratory hygiene and social distancing policies that may be difficult to enforce in many U.S. schools.
Some have pointed to the odd paradox of public health officials encouraging employers to allow people to work from home when possible as well as the closure of colleges and universities. Having employees work from home when possible is a way to increase social distancing, even if some workers remain at the workplace.
For colleges, universities and other boarding schools, there are two major concerns. First, it is nearly impossible for many of these institutions to control the spread of the infection. Some are able to isolate and cohort sick students, such as placing them in an infirmary or extra rooms. But many do not have such facilities, and students are typically live in crowded dorms. Second, this pandemic spread across the U.S. during the typical spring break season, making it risky to re-open. Bowdoin College, for instance, had adjourned for 2 weeks’ of vacation 2 weeks ago, before there were many known cases in the U.S. outside of the Seattle area. Before the first week of vacation had ended, COVID-19 had spread to Boston, New York, and more than half of states. Bringing Bowdoin students back from all over the country today would have meant also bringing COVID-19 onto campus. They wisely chose to not re-open.
So, this is a long explanation about the U.S. CDC’s recommendations on school closures. While I understand why many schools are closing, I also understand why many are staying open for now. There are many complicated factors to consider, and as of this morning (keep in mind the situation could change in a matter of hours), it seems that education leaders in Maine have made some very difficult decisions and will continue to assess the situation and what is best for their communities, including considering the factors mentioned here.
A decision that is made for one school and community may not be the same for other schools and communities, even with a similar COVID-19 situation in their community. And that is appropriate for this point in time. Again, the situation could change at anytime, e.g. if the country goes into a shutdown. I hope by sharing this information we can all make more informed decisions, including ways communities with closed schools can help assure the health and safety of our children.
Finally, today is Maine’s official Bicentennial. Although celebrations have been postponed due to COVID-19, I hope we Mainers can also pause to give thanks for the many gifts we have as Maine – the gifts of our diversity, of our caring for each other, and for the beauty of our state. On this sunny day, I hope everyone can take a few breaths of fresh outdoor air as well as reach out to the many working parents whose children will be home tomorrow, to see what we can do to help. And with all of the focus on school closures, let’s keep in mind the stress this has on our children. Below are a number of resources including an article on how to talk with children about COVID-19. Be well.
Considerations for School Closure
Guidance for Administrators of K-12 Schools and Childcare Programs
Checklist for Teachers and Parents for K-12 Schools and Childcare
Children and COVID-19 FAQ
How to Talk with Children on COVID-19