COVID-19 and Schools in Missouri
River City Data No. 7
Missouri Governor Parson announced last week that he was changing quarantine guidelines for Missouri schools. When this was announced, both he and St. Louis Children’s Hospital’s Dr. Rachel Orscheln made similar claims. “Transmission within our schools appears to be low,” Parson argued. Dr. Orshein stated that we need to “allow for those students, who have a very low risk of infection, to remain in the school environment.” Both statements raised eyebrows on social media, and I wanted to break down what we know about schools and COVID-19.
To help me do this for this special issue of “River City Data,” I’m joined by three colleagues from Saint Louis University who are experts in education or infectious disease:
Kristi Donaldson, Ph.D. is a Research Associate and Data Fellow at the Saint Louis University School of Education’s PRiME Center.
Evan Rhinesmith, Ph.D. is the Director of Research and Evaluation at the Saint Louis University School of Education’s PRiME Center.
Tim Wiemken, Ph.D. is an Associate Professor at Saint Louis University’s School of Medicine, where he specializes in infectious disease. Like Chris, he is a member of the AHEAD Institute.
The newsletter is organized as an FAQ with the following sections:
What do we know about transmission in schools?
What are the consequences of keeping schools closed?
What can we do to reduce transmission in schools?
Are we actually doing the hard work to reduce transmission in schools?
Is there a scientific basis for excluding masked individuals from quarantine?
What structural barriers do we face right now in MO regarding schools and COVID?
So, what can we do?
What do we know about transmission in schools?
Data we have to-date support Dr. Orshein’s core claim. We think COVID-19 transmission is potentially lower among young kids, and we do have some empirical evidence to support this position. A significant source of information comes from a South Korean study that is excellent science during a period of high transmission. These researches found that young children (below age 10) had lower transmission rates than older children. Other research has found that children are less likely to develop severe symptoms.
In Europe, schools have remained open in some countries even as other sectors of those societies temporarily shut down. Schools are rarely hotspots, and analysis of hotspot outbreaks found that transmission was primarily among staff when they did occur. In Sweden, for example, a small number of hospitalizations among children were reported early in the pandemic. In media reports and academic researchin Germany, infection rates among children are relatively low. Research in the United Kingdom came to a similar conclusion. Similarly, in Asia, schools in Taiwan were not closed in widespread fashion due to the country’s successful efforts to contain COVID.
Here in the United States, we have seen similar low rates of transmission in some schools. Research in child care settings here, which are not the same as schools, has suggested that very young children are less likely to be infected and transmit it.
Lower rates of transmission do not mean, of course, that students cannot infect others or become ill themselves. For example, a CDC case study found that a 13-year-old individual was the index patient who spread COVID-19 to at least 11 relatives during a three week, multi-family gathering. However, as research from the Netherlands shows, it is more likely to be transmitted from adults to children. Thus, when children do get sick and cases appear in schools, it may well be that they originate at home and not because of transmission within classrooms. These findings are similar to results from the 2003 SARS outbreak in Hong Kong.
It is worth underscoring that we do not fully understand why rates remain low and children do not get sicker. One hypothesis is that their frequent infection with seasonal coronaviruses (i.e., colds) may provide some level of pre-existing protection for children. Further, younger age groups appear to have fewer receptor sites for viral attachment.
We also want to be cautious about conclusions here. The absence of evidence is not the same as proof that something does not happen. Schools may still become hotspots, and we know that students can spread COVID-19 to family members. And even if this transmission is less common than with adults, it may still be too much of a risk for some parents.
There are a couple of crucial caveats worth pointing out. One is that the oft-cited South Korean study captured a point when South Koren schools were closed, so these low transmission and infection rates may not reflect a scenario where schools are open with high transmission levels in the community. Another caveat is that our policies, and some of our research, do not differentiate between younger and older kids. Age differences may be particularly significant, given the findings of that same South Korean study. Finally, it is crucial to remember that our science and knowledge on COVID-19 continue to evolve.
What are the consequences of keeping schools closed?
Given the lower rates of observed transmission, it should be unsurprising that we are not sure of the degree that school closures are useful tools for addressing the COVID-19 pandemic. A systematic review of school closures noted that, during the 2003 SARS outbreak, data suggest that closures did not affect transmission. Studies of influenza, the same review, and other research papers note, have found varying effects of school closures. In general, the effects seem to be modest and may be blunted by increases in the number of contacts students have outside of school when it is closed. Therefore, one consequence may be that schools are closed without a meaningful effect on community transmission rates.
At the same time, these school closures may have a significant impact on students and families. As we have seen throughout this pandemic, schools serve many functions beyond educating students. These services include meal provision and services for our most vulnerable student populations. Among the many concerns throughout the pandemic is whether students who rely on school for their meals can access food. In Missouri, roughly half of our students receive free or reduced-price meals through federal nutrition programs. During March and April of the 2018-19 school year, Missouri schools served over 20 million lunches. During the pandemic, Missouri served just 8 million lunches. This is a sobering reality both in Missouri and nationally. Early estimates show that roughly 14 million children nationwide are food insecure, and students who rely on schools for meals are not getting them.
In addition to disproportionately impacting students of color, school closures have also highlighted differences in in-person and online services for general academic growth and services for specific student populations. Families of English language learners have been more adversely impacted by the digital divide. At the same time, some districts reported that less than one-fifth of their English learner population regularly accessed distance learning activities. Disruptions from closures and quarantine may have stunted student growth in English and math by anywhere from a third to half of a school year. Potential solutions to catch students back up are heavily dependent on in-person or authentic interactions that are often difficult to implement during short-term disruptions brought about by virus spread in schools.
Finally, closing schools may have steep consequences for families. Several million women have dropped out of the labor force to take care of their families. Job loss has economic consequences and also affects their wellbeing. A mother in the Shaw neighborhood of St. Louis told St. Louis Public Radio that “it just feels like I take care of everybody. And there’s not much time for myself.” These consequences are why European countries have prioritized keeping schools open, even as they face a wave of new infections right now. As our Indiana University colleague Jess Calarco told Anne Peterson, “other countries have social safety nets... the U.S. has women.” The pressure this has placed on families, and women in particular, will reverberate through Missouri for years to come.
What can we do to reduce transmission in schools?
Just because children, particularly young children (below age 10), may be less likely to spread COVID-19 does not mean that that unfettered reopening without mitigation measures is appropriate. Schools in Israel went back to face to face instruction in May without substantial precautions, only to face hundreds of new infections across the country as a result. If we want to avoid the long-term disruptions in learning that come with school closures, including barriers to school meal access, services, and learning posed by shutdowns and quarantines, we need to take steps to reduce transmission in schools.
Research in child care settings about COVID-19 transmission and our literature on influenza both suggest several vital policies. For example, routine hand washing and disinfection are standard in child care settings. Hand hygiene takes work. It must be done regularly throughout the day since there is no residual killing power of soap or hand sanitizer. Children likely require close oversight. Lotions and other skin products may limit hand sanitizer’s effectiveness. However, it is substantially more effective than soap and water otherwise. Hand washing requires at least a twenty-second scrub followed by a substantial rinse since soap alone will not kill pathogens.
There is also evidence that face masks can reduce transmission, including in St. Louis counties with mandates. Masking is also not without difficulties. First, people must be vigilant with mask-wearing and be honest about their use, especially as part of case investigation and contact tracing efforts. Second, students, faculty, and staff must wear appropriate masks at all times. Two- or three-ply cotton masks, or masks approved by the FDA, or recommended in CDC guidance, must be used.
The types of masks used are crucial because homemade and commercial non-medical masks vary significantly in their ability to contain droplets. Some masks, like neck gaiters and bandanas, may be particularly ineffective. Saying students and teachers are masked treats all masks as the same, which not an empirical reality. Third, like handwashing, this requires monitoring on the part of teachers and staff. Outdoor gatherings and other activities where there is minimal oversight are next to impossible to monitor. Other face coverings in addition to masks, such as face shields, may add additional personal protections.
Classroom sizes are generally smaller in child care settings due to teacher to student ratio licensing requirements. Small classroom sizes make it easier to monitor hand washing and face mask use. It also means that there are fewer potential contacts between individuals. De-densifying school settings and ‘podding students’ in small groups are other tools we can use. We can also eliminate high-risk activities like assemblies, choir, music ensembles, and some athletic competitions and practices. These events are all situations that increase the exhalation or spread of infectious particles. Regular disinfection of high-touch areas is also an important tool. We can also add HEPA air filters to HVAC systems or place portable HEPA filtration units. Adjusting HVAC airflow and using natural ventilation may also reduce transmission. Schools must ensure that changes do not accidentally increase exposure by pulling contaminated air across a room in front of individuals.
Our policies in MO do not take into account levels of community transmission. In the research on child care settings we have mentioned before, community infection rates were one of the strongest predictors of infections in staff. Community transmission almost certainly extends to schools as well - in areas where infections are more prevalent, it becomes harder to reduce transmission in schools. If our goal is to keep schools open, we need to prioritize other restrictions and measures that reduce transmission in the community as a whole. This means putting schools first, and if community transmission warrants it, closing other businesses so that we can keep schools open.
Are we actually doing the hard work to reduce transmission in schools?
As districts and charters were putting together their reopening plans over the summer, the Department of Elementary and Secondary Education (DESE) released health-related reopening guidance. In August, DESE recommended districts require staff to wear masks, especially when near others. However, early guidance did not recommend masks for young children due to potential compliance issues (e.g., mask trading, face touching). DESE only recommended districts consider mask use for older students when unable to socially distance or interacting outside of their class or cohort. In their most recent guidance, DESE again stopped short of mask mandates. Instead, they recommended districts and charters require all staff and K-12 students to wear masks and added opportunities to opt-out for medical exemptions.
Though DESE has consistently communicated the importance of masks in reducing virus transmission, final decisions have been left to individual districts and charters in the interest of local control. At the PRiME Center, we have been analyzing reopening plans. In our review, we see wide variation in mask policies across the state. Some districts referenced specific times when masks would be required, such as when social distancing was not possible, on buses, or during class transitions. Other districts recommended or encouraged mask use but did not require it, leaving decisions to individual students and staff. At least one district indicated they would allow teachers to decide on mask requirements for their students' classroom(s). This is a far cry from statewide mask mandates for school children in states like Michigan, Illinois, and Kansas.
Is there a scientific basis for excluding masked individuals from quarantine?
No. The CDC’s definition of “close contacts” does not make an exemption for mask-wearing. While we have evidence that masks reduce transmission, that does not mean that they are 100% effective, especially given the variation in mask types and compliance discussed above. Adding this exemption also may complicate contact tracing efforts. The best way to keep students, faculty, and staff in schools is to reduce transmission. Moving the goalposts is not a long term strategy for success.
What structural barriers do we face right now in MO regarding schools and COVID?
Missouri has pursued only limited statewide restrictions since COVID-19 cases appeared in March. Instead, our state government has preferred to let local governments manage policies as they see fit. Local control leaves county executives and school district superintendents, few of whom have public health backgrounds, to make consequential decisions about their jurisdictions' policies. Many of these same officials are relying on small local public health departments for guidance. These public health departments are chronically underfunded and short-staffed. They are also facing the full force of all-time high numbers of new cases.
Many of the policies we have discussed also cost money. So too do services like Zoom, community WiFi hotspots, and laptops for students who lack technology at home. Our schools do not only need guidance, but they need the financial resources to follow that guidance and to safely educate their students.
This is precisely the scenario where state-level leadership can be a difference-maker. Local schools need clear, unambiguous guidance and financial resources. The Governor and state-level agencies like DESE and the Department of Health and Senior Services (DHSS) are well-positioned to provide it.
So, what can we do?
First and foremost, we need statewide leadership that prioritizes their education, sets standards, and creates a framework that local jurisdictions must use to implement or loosen restrictions. We need to take the pressure off schools to figure out which policies they will follow. We also need quarantine policies that follow CDC guidelines and best practices. We need school districts to require masks and take other steps to reduce transmissions. Given the current levels of transmission in many parts of Missouri, virtual learning may be necessary even with schools following all of the science we have on reducing transmission of COVID-19.
We also need to ensure that schools have the funding they need now for safe operations, and we need to ensure that schools are not financially penalized for short-term reductions in the number of students they may be experiencing.
Finally, we also need to reorient our priorities, especially once we see high transmission rates subside. We should be ensuring schools are open before high-transmission venues like bars, clubs, gyms, and restaurants. We also need to make sure that, when kids are home at night or on weekends, they are in spaces where they are least likely to bring COVID-19 with them back to school the next day. This means that mask-wearing, physical distancing, reducing contacts, disinfection of surfaces, and hand hygiene are not just for schools. Students and family members must be committed to following these at home.