This story is part of Fast Company’s Reinventing Education package. As millions of students begin school during a deadly pandemic and global recession, we’re highlighting the ongoing efforts to keep children safe in the classroom, educate them remotely, and help their parents manage a new second shift. Click here to read the whole series.
In March, when many states were scrambling to respond to a novel deadly virus that was spreading quickly, a small elementary school in Glocester, Rhode Island, made the decision to use its upcoming spring break to pivot to online-only classes.
“Teachers had that one week, while being on vacation, to prepare for full virtual learning,” says Amy Dark, Rhode Island’s director for the National Association for School Nurses and an elementary school nurse in the town of Glocester. The remainder of the school year was taught online. That experience is now informing how her school will return to classes in the fall. Its current in-person plan is to break students up into “pods” or “cohorts” of 30 students or fewer to take classes together for the remainder of the year. The idea is that when a student turns up sick, it’s easy to identify who they came into contact with. Pods cannot mingle with those outside their assigned group. In addition to staying in these pods, students will have to wear masks, which the school is willing to provide, and stay six feet from one another at all times. The plan also includes how the school will respond to cases of COVID-19.
School reopenings around the world and in certain U.S. states have shown that opening up classrooms means opening up an opportunity for COVID-19 transmission among teachers and students and therefore to the wider community. Still, epidemiologists agree that the social-emotional learning that kids get from school is too important to forgo altogether, even if COVID-19 presents risks to reopening.
“The socialization part of schools is huge,” says George Rutherford, a pediatrician, epidemiologist, and professor of public health at the University of California, San Francisco. “Any is better than none.”
The question now is how to do it, what to do if cases start to emerge, and what will mark the tipping point for closing schools back down. Public health departments in close coordination with state governments are still largely in the process of figuring out what exactly this tipping point will be. Much of it will be determined by what’s happening on the ground in the community and in schools. For tracking the latter, school nurses are set up to play a crucial role in how well a school weathers a return to in-person classes.
Rhode Island, where Dark is based, represents a case study for reopening measures, as its case numbers have been relatively stable over the past two months. In July, the state tested reopening daycare centers for a total of 18,945 children with strict measures in place for quarantining in the event of probable cases. Only 101 possible daycare-center-related cases emerged. However, the protocols resulted in 89 class closures, and 687 children, 166 staff members, and all of their close contacts were quarantined. Now, the state’s schools are preparing for a similar demonstration. They’ve all submitted plans for returning in-person, online, or via a hybrid model, with some instruction taking place in physical classrooms and some over the web. They also have plans for what to do in the event a case of COVID-19 pops up. To give schools time to implement these new frameworks, Rhode Island governor Gina Raimondo pushed back the start of the school year to September 14.
However, at the end of August, Raimondo announced that all but two school districts in Rhode Island are allowed to fully reopen for in-person classes. Districts need to have less than 100 cases per 100,000 residents on a weekly basis in order to bring students back into schools. Raimondo would like all schools that meet this criterion to offer full in-person learning by mid-October. Schools and parents will ultimately determine how students attend school this fall. Many, if not all, are offering online and hybrid learning formats, in case parents are uncomfortable sending their children back into school full time.
The state saw a slight uptick in COVID-19 cases in August, though not enough to keep students from going into school. Still, if cases substantially increase over the fall or winter, the state may have to reassess whether schools should stay open. What will ultimately determine whether students can get instruction as they always have, at scratched-up desks with gum stuck underneath, will largely depend on how well the larger community surrounding the school is able to contain the virus’s spread and how well-resourced the school is.
The tipping point
Public health experts say that school districts should not open classrooms until COVID-19 infection in a given community has been contained; otherwise, it will transit into schools. That advice is playing out in real time. On the first day of school in an Indianapolis suburb, where case numbers have been growing since mid-June, the school learned that one of its attending students had tested positive for COVID-19. The school immediately went into action, isolating the positive student and their various contacts in their respective homes. But the school is not shutting down.
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“This should be driven by the level of community spread and the ability of the school to implement appropriate public health measures,” says Rachel Patzer, an epidemiologist and health services researcher at Emory University. Areas with 25 or more cases per 100,000 people shouldn’t reopen, she says, and it will be hard for regions with even 10 to 24 cases per 100,000 people to keep students in classrooms, because the prevalence of the disease in the community may be too high to ensure it won’t permeate the school.
These community-spread thresholds for closing schools vary by state. Rhode Island’s threshold for closing schools is 100 positive cases per 100,000 residents. In New York, Governor Andrew Cuomo is telling school districts they can reopen as usual if the community daily infection rate stays below 5% using a two-week average. Meanwhile, the California Department of Public Health advises county health departments not to allow schools to have in-person instruction if the surrounding community registers more than an average of 200 cases per 100,000 people on a 14-day basis. However, some states don’t have any official guidelines that tell districts what circumstances warrant closure.
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While decisions about whether individual schools and school districts can have students in their hallways are up to state and local public health departments, there’s little guidance at the federal level. The CDC’s guidelines are especially light on this subject. It does not list a threshold for school closure, nor does it give specific infection rates, only advising that schools should consider closing if community transmission is “substantial” and “uncontrolled.”
“One of the concerns is that we don’t really have a coordinated national strategy,” says Preeti Malani, chief health officer and professor of medicine at the University of Michigan’s Taubman Center for Infectious Disease.
Still, some of the factors that should determine if a school should close or stay open are based on individual characteristics, such as school size, Malani says. A few cases in a larger school may not warrant closure, whereas in a smaller school they might. She says these decisions around whether students can stay at their desks will also depend on the resources of local health authorities.
“Some places have a health department that’s better resourced than others. King County, in Seattle—that public health department is premier. But there’s places where it’s literally one person. They’re just overwhelmed, and they can’t keep up with this,” she says. “We need more people to clean, we need more supplies to clean, we need school nurses to help with some of this management. If the student doesn’t feel well, who’s going to do that assessment? Where is that student going to wait until they’re picked up?”
A new role for school nurses
School nurses such as Amy Dark have a key role to play both in understanding COVID-19 presence in schools and in implementing containment policies. They are the ones tasked with assessing symptoms and coordinating with parents to retrieve their sick child. They are also likely to know who a sick child has been in contact with and can inform parents about self-isolating other children who may have been exposed.
They’re just overwhelmed, and they can’t keep up with this.”
Rhode Island requires schools to have a certified registered nurse, who also teaches health class, though they don’t have to be full time. School nurses in Rhode Island also have a strong relationship with the state health department and are further supported by the Rhode Island Certified School Nurse Teacher Association. But other states may have less infrastructure to provide assistance to school nurses as they embark on the coming school year. A quarter of U.S. schools don’t have a school nurse at all, and some states don’t require schools to have a nurse. In Montana, where cases blew up at the end of July, 98% of students have scant access to a registered school nurse; nearly half of all counties in the state have no school nurse at all. Even in Rhode Island, while the majority of schools have a registered nurse, a few districts lean on a single school nurse for multiple schools.
Going into the fall, states will be putting a whole new set of responsibilities on school nurses or whoever handles school health programs. That includes helping manage when students should stay home and when they should quarantine. Rhode Island’s Outbreak Response Protocol outlines several scenarios that will lead to students being physically pulled out of school. If a student or teacher is frequently coughing, having difficulty breathing, or has lost their sense of taste or smell, they will be considered a “probable case.” There are a set of secondary symptoms, including fever, body ache, fatigue, and sore throat, that, taken together, would flag students as a possible case of COVID-19. Under the guidelines, such students will be required to self-isolate at home and get tested for COVID-19. If they test positive for COVID-19, they’ll have to quarantine for two weeks. Close contacts of that person will be asked to quarantine at home for 14 days as well and monitor for symptoms; in some cases, they may be asked to get tested. However, the plan does not include what conditions could lead the school to shut down its building.
Over the last six months, Dark’s work as a school nurse and health teacher has vastly changed. “I have worked more hours in a day since March 16, than ever before,” she says. Dark and her school’s social worker recognized early on that families were facing incredible difficulties because of the pandemic. In some cases students didn’t have the attention span for online learning. In others, students didn’t have access to the appropriate technology. Some parents, laid off from work, had lost their health insurance and were unable to get their children the care they needed. They resolved to make contact with each and every family to see how they were doing and connect them with whatever outside resources they could.
“We are now really on the front lines of acute care. We have children who are fragile diabetics, we have students who have frequent seizures at school. We have students coming to school on ventilators. We have students requiring tube feedings throughout the day. This is in addition to our very busy caseload—add on COVID-19 to that,” says Dark.
Destined to close?
As the school year draws near, many districts are pushing back start dates or starting the year off digitally with the potential to move students into classrooms later on. In some cases, teachers’ unions have pushed back on in-person classes, afraid that their members will get sick. In other cases, a new start date was enacted to give schools more time to prepare. In New York City’s public school system, the start of classes has been delayed from September 10 to September 21.
We are now really on the front lines of acute care.”
In Rhode Island, the two-week buffer may provide the state with some needed leeway. Parents are increasingly concerned about the state’s testing capacity. In July, a local Providence paper reported that a young girl who developed COVID-like symptoms wasn’t able to get her test results for seven days.
“What’s going to happen in the fall?” her mother asked the paper’s reporter. “We’re going to isolate children like this? That’s not OK. Have the whole class in quarantine for 14 days?”
Rhode Island started out strong on testing. By May, the state had tested 5% of its population. However, recent high demand has forced the state to limit testing for asymptomatic cases. In mid-August the state told local reporters that the turnaround time for diagnostics tests was nearly five days on average. Understanding how many cases are in a community is key to developing strategies that prevent schools from becoming hotspots. For a disease that has a high proportion of symptom-less infections, the backlog does not bode well. Public health officials are at risk of being a week behind actual infection rates, therefore delaying mitigation efforts and allowing the virus more room to spread.
Raimondo is now working with additional labs to increase testing capacity and shorten turnaround times to 48 hours. But there are still other potential weak points in the plan to return to school. Young kids may not follow mask-wearing policies closely. Parents might let their kids slip in a playdate with the friend next door who isn’t in their pod. Cases are destined to crop up. Still, a single case on its own doesn’t merit closure. The CDC suggests that closure should really only be up for consideration if the school has higher infection rates than its region or if it is the source of an outbreak.
“I would say for this to be successful in a full in-person return scenario, the strict adherence to the recommended guidelines is going to be key, allowing for flexibility as those guidelines change,” says Dark. Ultimately, she says, the moment a school closes will be dictated by the local public health and education officials based on contact tracing of cases. She says she just learned that the Rhode Island Department of Health will be handling contact tracing not just in communities but in the schools as well, meaning a little less work on her plate. Of course, she’ll still be helping out on that end.
“I don’t imagine going back to the days of 9 to 3:30 anytime soon,” she says.