Transcription:
Should We Send Kids to School This Fall

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos (Host):  Welcome back everybody. This is John Lantos from the Children’s Mercy Bioethics Center at children’s Mercy Kansas City, Missouri. We are doing a series of pediatric ethics podcasts and we’re thrilled today to have with us, Dr. Nathaniel Beers who is a General Pediatrician and a Developmental and Behavioral Pediatrician. He specializes in the care of children with complex needs with special healthcare needs and he’s also President of the HSC Healthcare System in Washington, DC. He’s been thinking a lot about COVID and particularly around the issues that surround questions about schools and schools reopening in the fall. Thank you so much for joining us this morning Dr. Beers.

Nathaniel Beers, MD (Guest):  It’s my pleasure to be with you today.

Host:  I know you were involved with the American Academy of Pediatrics working group or task force that put together a statement about schools reopening. Could you tell us a little bit about that effort and your role in it?

Dr. Beers:  I serve on the Executive Committee for the Council of School Health and one of the members that came together with experts from the Council on School Health as well as the Committee on Infectious Disease as well as the Council on Children with Disabilities, the Section on Developmental Behavioral Pediatrics, the section on Environmental Health among others who all came together to try and help put out guidance for pediatricians and parents and school districts on how to think about safely reopening schools for in-person learning. What we noted, was that many school districts were moving quickly forward with plans for the next school year, trying to eliminate all risks of COVID transmission but not taking into account all the additional risks that not having children in school have on children. And so, we felt it was really important to help people start to balance the risks of controlling spread of COVID as well as ensuring that the other services that children receive besides just the educational services are part of the conversation when we are thinking about how to safely reopen schools.

Host:  So, it was a broad and multidisciplinary group. When did the group start their work?

Dr. Beers:  So, we actually first started in March and we released a first set of guidance in March that was a much more general and focused on how to keep kids safe during the pandemic in schools. And came back together in June and over a two week period, pulled together the most recent guidance that’s come out and in fact, the group is back together again providing an update that should come out in the next week or two.

Host:  And as you went through this now five month process, what were the trickiest issues in your opinion that the group had to deal with?

Dr. Beers:  As I noted on the second guidance, right, it was really important for us to help highlight the inequities that exist in our society and the unequal impact COVID has had on different communities particularly if we look at Black and Latinx communities and how do we acknowledge that not only has disease had a disproportionate impact on those communities, but the ramifications for school closure have also had a differential impact on those communities. And so, as we stepped through the process of trying to capture that inequity and sinc together with schools and parents about how we could put out guidance that would be helpful for them in moving the conversation forward. The challenges of all the different opinions and different variables that exist, were really critical. The most important that got lost early on in the conversation when we released the most recent guidance was that it needs to be done safely. And that we have to take into account community transmission rates as part of the variables that we think about as we think about safely returning to in-person instruction.

Host:  So many issues here. I want to come back to community transmission rates, but could you just elaborate a little bit on the socioeconomic and racial disparity issue? How does that play out when looking at the implications of opening or closing a school in a poor community versus a more affluent community?

Dr. Beers:  You start at the very basics, right and sort of what’s the physical plan for the school. And so, as poor communities have been less able to invest in the physical infrastructure in their schools, you look at the ability to have enough space to ensure that students can physically distance from each other and safely return due to class sizes in the physical class size but also in the number of students that are in a class. You look at the heating and air conditioning systems and the level of air transfer that occurs and the ability that school systems have been able to invest in those has been certainly impacted based on the wealth of communities.

And then you start looking at other factors. Certainly, we know that many school systems tried to provide food for students who would normally be on free and reduced lunch and yet that is a challenge when students are not in school and so certainly we know that the impact of inadequate nutrition on children’s ability to attend to learning as well as to be able to retain the learning that they’ve done. And then you look as well at the digital divide. And the issues around access to adequate devices to be able to do virtual learning as well as access to the internet and Wi-Fi capacity to be able to do that learning and that certainly impacts our poorer communities but also our Black and Latinx communities more substantially than our white communities.

Host:  So, as I’m thinking about it, it seems the digital divide would push us towards more likelihood or stronger recommendation to open schools physically in poor communities, but the overcrowding and the inadequate facilities would push us away from it.

Dr. Beers:  Yes, they are competing data points when we’re trying to think about how to do this and how to do this safely and put a great tension on many school districts as well as many families in thinking about what is going to be safe for them and the teachers as well in what they think can be safely done for them to make sure that the teachers are also safe.

Host:  So, it seems like there cannot be any one size fits all in this. That each district will have to assess its physical facility, its students and families access to broadband as well as perhaps prevalence rates in the community.

Dr. Beers:  Exactly and I think there has been a lot of requests since we released our guidance for us to come out with some more prescriptive measures about what disease burden would allow you to open or not open and yet, that is only one piece of this puzzle. And so, giving that prescription about community transmission rates does not acknowledge all of the other critical steps that have to be in place in order to ensure that we can do this in a safe manner and support all the needs of the staff, the students, the families and the community at large.

Host:  Let me shift focus just a little bit to talk about the scientific evidence base for making recommendations. What sort of data did you have? Did you use data from other countries? Were there studies from other outbreaks of different viruses? How did you try to gather the evidence that grounded your recommendations?

Dr. Beers:  As I jump into that, what I will say, is that one of the most important things from my perspective that we reminded people that the plans need to be flexible and nimble because the evidence does continue to change and continue to update. And so, when we were looking at this data in June, we definitely reviewed data from other countries, as well as data that we were able to glean from jurisdictions here in the United States and I think the data that helped us feel like it was reasonable for us to push towards in-person learning was the increasing evidence that shows that children are less likely to get the disease. They are less likely to get complications from disease and they are less likely to spread disease.

Now, since we’ve released that, there’s been additional data that’s come out, much of which has supported those statements. There is however, several data points that require a little more nuance that we will be addressing in our next round of guidance which is certainly the study from South Korea as well as the mounting evidence from Israel suggests that adolescents in particular, in the South Korea Study, that cut off line was above ten do seem to be able to spread disease more frequently than younger children and more like an adult.

That being said, those are small data sets and there’s some confounding variables certainly when you look at the data from Israel which is that while they initially had relatively good control of community spread, the speed at which they opened the broader community, created additional spread in the community and when that happened, we did see increased rates in schools as well as the broader community. There’s not necessarily a correlation between opening schools and the increase in numbers of students who had it versus the broader community piece that people seem to be feeling like is a stronger correlation for the reason we saw increased cases. But most of those cases were in Israel were at the middle and high school level again, reinforcing this belief that the spread between adolescents and from adolescents to adults does seem to be stronger than for younger children.

Host:  And what do we know about whether younger children are getting infected but just remain asymptomatic and not transmitting the virus?

Dr. Beers:  There’s some evidence that suggests that they are less likely to get the disease even being asymptomatic but again, there have not been wide scaled studies that have done significant testing of asymptomatic individuals at this point. And certainly, in the United States we are largely only testing individuals if they have symptoms or if they have known exposures. Now, the studies that do look at the asymptomatic children still reinforce that even those children who have been asymptomatic are not likely spreaders of that disease. And so, those continue to be sort of data that we need to continue to gain more understanding about as we move forward in this.

Host:  You mentioned South Korea and Israel as examples where problems have arisen. Are there examples of countries where schools have been opened without problems?

Dr. Beers:  There’s actually many examples of schools that have been opened without problems and I would say that South Korea is not a problem but rather sort of they’ve done really good job of collecting data and they actually did not have increased numbers of children getting disease or spreading disease. But they did a great job of looking at children as index cases in a household and whether or not they spread that disease to other members of their household. And so, what we know about schools is that in China as well as Taiwan and Singapore and Germany, France, Denmark, Austria; that they have been able to reopen schools when they had control of community spread and they have not seen subsequent increases in community spread due to school reopening. And so, those certainly are schools where they put in place good measures around face coverings, as well as physical distancing. There is some range – some of them use six feet, some of them use three feet but none of them saw substantial increases in community spread due to the reopening of schools.

Host:  And are there areas of the United States that look like those countries in terms of community prevalence?

Dr. Beers:  There certainly are though those numbers have been getting smaller and smaller with the recent increases in cases that we’ve seen around the country. But there still are somewhere in the sort of 15 to 20 states that have community spread at a rate that’s consistent with what those countries were experiencing and where they were able to effectively reopen schools.

Host:  So, we may end up with quite a patchwork of policies across the United States based either on prevalence rates or politics or preferences of key stakeholders. How do we study this? How will we know what’s working and what’s not? Does the Academy have plans or do you know of any other agencies are going to do some research on this?

Dr. Beers:  I do know that there’s a group out of Johns Hopkins who has been doing some analysis of those state plans. They have been looking at 12 different areas of guidance that they were looking for schools to have. They’ve done an initial pass on all of those plans just commenting on whether or not the state had those areas covered in their plans. They are now doing a qualitative analysis of the quality of those recommendations that they’ve made in each of those areas, but I do think that that is going to be a group that is looking hard at what we are seeing relative to that. There is another group out of Harvard that has also been a very closely monitoring states plans and as well as the disease burden together. And I think will be another space for us to rely on for good high quality data about what is going on in different jurisdictions and what we can extrapolate from those plans as we continue to move forward.

We, in the American Academy of Pediatrics will not be doing the primary data collection but rather will be relying on other sources and pulling those together. We will continue to update our guidance based new data on a monthly basis for as long as it’s relevant for us to be doing that.

Host:  One last question. There’s a group that seems to me to be key in implementation of many of the policies and that’s school nurses. School nurses in many places, were – there weren’t enough to go around. It was inadequately funded. What do you see their role in all of this as being and do we have enough of them?

Dr. Beers:  I think school nurses are a critical part of our public health infrastructure and much like the rest of our public health infrastructure, we have chosen to underinvest as a country and as local jurisdictions, generally. There are areas of the country which have invested in school nursing and they will be better positioned to be able to effectively reopen schools by having staff in place with health expertise who can help them assess the symptoms of children and staff in the building but also to help them manage all of the screenings and additional processes that need to be put in place from a health perspective. What we know, because when the American Academy of Pediatrics released its guidance around the fact that every school should have a school nurse; we know that that is not the case in many jurisdictions and that many jurisdictions may have one school nurse for the whole school district if they are lucky. But certainly, we know that if we are going to be able to effectively trace contacts in schools, if we are going to be able to ensure that students are getting tested if they need to get tested because of symptoms, and that people are self-isolating as needed; we are going to need to invest in the public health infrastructure in order to make that possible. And so, it’s certainly an area for us to evaluate how we do currently and then I think the hope that we have as well is that it will help us understand the long term value of school nurses in helping students be able to attend school as well as stay in school.

Host:  Well this has been incredibly informative, and I really appreciate all the work you’re doing. Do you have any final comments or things I didn’t ask that you’d like to talk about?

Dr. Beers:  The only thing that I would say that we really need to continue to keep our eye on as well is the other sort of public health issue that is coming out of COVID which is the falling number of children who are receiving their childhood vaccines in a timely way. And it’s really critical that during this period of time, over the next month as schools get ready to restart, whether that is in-person or virtual, that families are getting the vaccines that they need to ensure that we don’t have an outbreak of another disease because people are under immunized. And so, that is critical as well as making sure that people receive their influenza vaccine this fall because we know the symptoms of COVID and influenza are so similar and we know that there are cases that have shown that you can have both viruses at the same time and so the more we can do to reduce the spread of influenza during this winter season, the better off we are going to be in managing the COVID pandemic.

Host:  Very important point and thank you very much. I’ve been talking to Dr. Nathaniel Beers, a Developmental and Behavioral Pediatrician who is President of the HSC Healthcare System in Washington, DC. I’m John Lantos from Children’s Mercy Kansas City. Thanks so much Dr. Beers for talking to us today.