Should we open school this fall?
Has anyone else noticed that most of the debate around COVID is a “should we?” vs “shouldn’t we?” competition?
Should we open up the economy?
Should we be using hydroxychloroquine?
Should we give people a vaccine before Phase 3 trials are completed?
And the question that I’ve been getting asked over and over again, should we open up schools?
Of course we *should* open schools!
These aren’t the types of conversations that take place in a healthy society. We should be debating how to do things rather than whether to do them. After all, don’t we all want to work towards a society where a pandemic isn’t controlling every aspect of our lives?
Everyone wants the economy to be functional again.
Everyone wants safe and effective COVID treatments.
Everyone wants schools to be open.
Making the debate about “should we” versus “shouldn’t we” makes it easy to question someone’s motivations and presume bad faith behind an argument. In other words, a fitting debate to have for the cable news country that we seem to live in.
It’s clear that tele-education is inferior to in-person education for child development. As the CDC website says:
Reopening schools creates opportunity to invest in the education, well-being, and future of one of America’s greatest assets—our children—while taking every precaution to protect students, teachers, staff and all their families.
Moving a discussion toward the nuts and bolts of how to “protect students, teachers, staff, and all their families” enables constructive debate and the possibility of progress.
So what are the risks to children?
Take a look at this from the CDC’s conclusion on school reopening:
The best available evidence from countries that have opened schools indicates that COVID-19 poses low risks to school-aged children, at least in areas with low community transmission, and suggests that children are unlikely to be major drivers of the spread of the virus.
We know that children seen to have significantly better survival than adults if they get infected with COVID-19. Kids also seem to spread COVID less than adults do.
But there is certainly at least one major COVID complication to be concerned about with kids: a multisystem inflammatory syndrome in children (MIS-C) that appears to be similar to Kawasaki disease.
Based on the New England Journal of Medicine report, MIS-C is probably rare - only found in 95 confirmed cases out of presumably many thousands of infected children. MIS-C is also serious, with 80% of these kids admitted to an intensive care unit, although only 2 children died.
Caveats abound, of course. This report likely misses quite a few cases, it’s only representative of one geographic area, and it’s probably smart to assume that we’re undermeasuring the impact on kids.
And you can’t forget that some kids died and most needed intensive care because of MIS-C!
Opening schools with an incomplete understanding of the medical impact means unquantifiable risk exists. But being prepared for kids to get sick - and some kids to get really sick - is part of the drill.
It certainly doesn’t mean an absolute contraindication to opening school, but it’s food for thought.
Take one more look at that CDC conclusion (emphasis mine):
The best available evidence from countries that have opened schools indicates that COVID-19 poses low risks to school-aged children, at least in areas with low community transmission, and suggests that children are unlikely to be major drivers of the spread of the virus.
“Areas with low community transmission” is doing a lot of work there. The downstream consequences of opening schools in areas with higher levels of community transmission need to be considered even more carefully.
There’s a lot to think about!
What approach should we be taking?
Each school district needs a plan for surveillance and a plan for containment. Some questions that I’d be contemplating if I worked for a school district:
What should we do about testing?
Do we test students everyday? Every week? Every month? Do we test only those with symptoms? Do we test a random assortment of students? Do we test teachers daily?
How do we distance in the classroom?
Do students all wear masks? How much do we separate their desks? What changes about walking through the halls?
How do we approach lunch and recess?
Can kids play together? Can they have gym class? Can they eat together?
What do we do if students or teachers test positive?
Do we quarantine their whole class? Just the ones who sit near them? How long do we quarantine them for and how often do we test those in quarantine? Can teachers of infected students still go to work if they haven’t tested positive?
How do we decided if schools should be closed again after they’ve opened?
This happened in South Korea. Before opening, we need a game plan with coherent criteria for when to close and when to re-re-open.
The biggest question for schools is the biggest question for the country: testing
It all comes down to testing. Community testing is taking more than a week to come back in many places around the country. We may as well not have testing if we’re going to have such a long delay.
CDC guidelines seem to be drawn up with our national testing limitations in mind rather than based on true expert guidance on how to do this best. Indeed, they’re almost comically vague on how to test (emphasis theirs):
Universal SARS-CoV-2 testing of all students and staff in school settings has not been systematically studied. It is not known if testing in school settings provides any additional reduction in person-to-person transmission of the virus beyond what would be expected with implementation of other infection preventive measures (e.g., social distancing, cloth face covering, hand washing, enhanced cleaning and disinfecting). Therefore, CDC does not recommend universal testing of all students and staff. Implementation of a universal approach to testing in schools may pose challenges, such as the lack of infrastructure to support routine testing and follow up in the school setting, unknown acceptability of this testing approach among students, parents, and staff, lack of dedicated resources, practical considerations related to testing minors and potential disruption in the educational environment.
Ultimately, I suspect that the success and sustainability of reopening school is going to be dependent on the amount of community spread and our ability to perform adequate local surveillance.
The evidence seems to be pointing towards frequency and turnaround time as being more important test characteristics than accuracy.
I suspect that mass deployment of more rapid, frequent, and slightly less sensitive testing will be an important facilitator of successful school re-openings.
I’ll conclude this newsletter with a polite and tactful plea for more frequent testing from Nassim Taleb:
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