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Reopening Primary Schools during the Pandemic | NEJM – nejm.org

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The safest way to open schools fully is to reduce or eliminate community transmission while ramping up testing and surveillance. Adults would need to maintain social distance from each other and engage in other measures to reduce adult-to-adult transmission: for example, wearing personal protective equipment (PPE), closing school buildings to all nonstaff adults, and holding digital faculty meetings. These precautions are especially important insofar as 17.5% of teachers are 55 or older.25 But we believe that schools in low-transmission settings could probably provide pedagogically sound and socioemotionally appropriate instruction to all students, in person, in ways that do not put educators or families at undue risk.26

Any region experiencing moderate, high, or increasing levels of community transmission should do everything possible to lower transmission. The path to low transmission in other countries has included adherence to stringent community control measures — including closure of nonessential indoor work and recreational spaces.11 Such measures along with universal mask wearing must be implemented now in the United States if we are to bring case numbers down to safe levels for elementary schools to reopen this fall nationwide.

Epidemiologic evidence suggests that death rates can be lowered by 90% within 9 to 11 weeks after stringent control measures begin (see the Supplementary Appendix, available with the full text of this article at NEJM.org). Given the lag between new infections and deaths, an equivalent effect on new infections should be apparent in less than 2 months. If such measures were adopted now, transmission in many states could probably be reduced to safe levels for mid-September or early-October school reopenings. Many school districts would be able to open even sooner — although large improvements in testing volume and speed of reporting would be needed to enable appropriate levels of community surveillance.

Districts and states that refuse to implement these essential public health measures, on the other hand, face a profound social and moral dilemma: namely, how to weigh the known risks to children, families, and society of closing school buildings or operating at reduced capacity against the unknown risks (especially to school personnel and to educators’ and children’s household members) of opening schools when the virus is still circulating at moderate or high levels.27,28 This dilemma is exacerbated by school segregation and racial and class injustice: reopening schools that serve poorer and predominantly minority populations poses the greatest risk to families’ and educators’ safety — but their ongoing closure also imposes the greatest harms on children and families.14

Many families — particularly those with medically vulnerable household members — will choose to keep their children home under these circumstances regardless of whether schools are physically open.29 We understand this risk calculus. Remote teaching and other school services (including meal provision and medical and therapeutic services) should be available to all families who choose this option, with designated educators being responsible solely for remote teaching.

But educators and other school personnel cannot necessarily dictate the place or terms of their employment, even (perhaps especially) when the social compact has broken down. It is tragic that the United States has chosen a path necessitating a trade-off between risks to educators and harms to students, given other countries’ success in reducing transmission and opening schools with routine control measures in place. This dilemma represents a social and policy failure, not a medical or scientific necessity.

Nonetheless, we would argue that primary schools are essential — more like grocery stores, doctors’ offices, and food manufacturers than like retail establishments, movie theaters, and bars. Like all essential workers, teachers and other school personnel deserve substantial protections, as well as hazard pay. Remote working accommodations should be made if possible for staff members who are over 60 or have underlying health conditions.5,18 Adults who work in school buildings (or drive school buses) should be provided with PPE, and both students and staff should participate in routine pooled testing.30

Schools’ social and physical infrastructure will also need to be modified. Students and teachers may need to eat lunch in their classrooms, and staff rooms may need to be closed to discourage adult congregation.31 Crowded buildings or open-plan layouts may make it impossible for adults to maintain distance from one another32; in such cases, schools may benefit from spreading out or relocating to local middle or high schools, unused college classrooms, community centers, houses of worship, or businesses whose employees are working remotely.11,12 Such shifts will not be easy. Spaces and furniture will need to be retrofitted for younger children; kindergartners will need easy access to appropriate bathroom facilities; and schedules may need to be redesigned to accommodate special-education providers and specialty teachers so they can access children and classrooms at appropriate times.

Even if schools can make creative short-term use of additional space, thousands of schools — particularly those serving low-income students of color — will require significant federally funded upgrades to improve ventilation, sanitation, nurse’s offices, and hand-washing and bathroom facilities.33 These improvements have long been needed regardless of Covid-19; they are essential investments in educational equity and opportunity.

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