Reopening Schools Safely

I have been an outspoken critic of school boards making decisions to reopen schools for in-person classes in areas with high degrees of community spread of COVID without giving due consideration to public health advice and medical input and without articulating their reasoning when choosing not to follow this advice.

I do appreciate that the decision about whether to reopen schools entails more considerations than only medical ones. That is the reason that I have stated publicly that doctors should not be the ones to make these decisions.

But, if the board’s decision is to open schools for in-person classes against the public health advice, then, as Dr. Jim Souza, Chief Medical Officer for St. Luke’s Health System told a number of the boards, the likelihood of success will be directly related to the strength of their schools’ operating plans.

I totally agree. I believe that the schools with very well-thought-out operational plans with clear responsibilities and accountabilities will be the ones with the best shot of keeping infections under control and preventing an outbreak. Because if there is significant community spread, these schools will have cases, almost certainly during the very first week of school, and very possibly the first day.

While this is great advice, the few operational plans I have seen at the school board level have not qualified as the kind of well-thought-out, detailed operational plans that I think about, nor what I suspect Dr. Souza had in mind. I realized that the boards were likely expecting the individual schools to come up with more detailed plans, but I felt very sorry for those principals and teachers, few of whom, if any, have public health, infection control, or virology expertise.

Certainly, the schools have access to the excellent guidance put out by the CDC and the state public health departments, but seldom is that guidance understandable to these education professionals in terms of the application to the specific circumstances and challenges they face in operating a school.

So, in an effort to help, I have volunteered my assistance to schools that want a review of their operational plans and suggestions as to how to improve them, and then further offered to do walk-throughs to identify issues that you really can’t be aware of until you see the facility and hear what normally happens from the principal and teachers who work there. In addition, it gives me an opportunity to answer the many questions teachers have. I should point out that this blog piece is about K-12 schools. Colleges and universities have many more and, in many cases, different issues and concerns.

The following may be of interest to schools that have not yet re-opened. My hope is that what I have advised the schools that have taken me up on my offer may be of help to you in strengthening your own plans and that my framework for doing the walk-throughs might enable you to do think about issues that I raise on those walk-throughs.

So, the first step when a school does ask for my help is to ask them to send me a copy of their operational plan. This allows me to look through, identify elements that are not up to date or correct and identify missing elements. I then mark the plan up, return it to them for their review and they can accept whichever of my changes and suggestions they like.

What I often find is that the plans usually offer very little detail. The plans often include guidance from public health authorities, but the plans seldom indicate how that guidance will be applied in the setting of school, how often it will be done, whose responsibility it is to do it, and how it will be accomplished in settings outside of the classroom. (I’ll provide examples below in my discussion of the walk-throughs). The detail is important, because this is likely to be the biggest factor in whether you have contained, isolated infections or an outbreak in the school.

I also find that the plans generally have little information on informing teachers, students and parents on necessary preparations before they show up for the first day of class; education of teachers, staff, parents and students about COVID and their responsibilities under the operational plan; a detailed communications plan; and the safety precautions that need to be implemented on the school grounds before a student even enters the door of the school.

Finally, I seldom see the amount of detail necessary to address non-classroom activities safely – physical education, choir, band, cheerleading, athletics, cafeteria, etc.

With this said, let me state that I think the schools that I have reviewed did a really amazing job at putting these plans together. They are educators and not public health experts, and to have done what they did shows a tremendous amount of thought and care. But, the critiques I have made are a reflection that to create a really good plan requires the partnership of educators who know how things happen in the school and the issues they face everyday with public health or medical experts who can offer fresh eyes and identify areas of risk that are less likely to occur to non-medical experts.

So then, with my comments in hand, the school can decide if they want to do a walk-through. If so, I generally ask the principal, a note-taker, the building maintenance expert, a classroom teacher and each of the teachers of the non-classroom areas – PE, music, coaching staff, etc. – to meet with me outside the front door to the school.

We start off with a discussion of what is going to undermine the success of the plan? For example, if the plan has not been well communicated to everyone who has a role in the plan, then there is little chance the plan will be successful. Has the plan been circulated? Is the plan easily available? Does everyone understand it? Do teachers have incentives to come to school sick – e.g., loss of pay, lack of availability of substitute teachers? Do parents have incentives to send their children to school sick – e.g., consequences under the attendance policy, inability for the student to keep up on their school work from home, challenges accessing or paying for a doctor’s visit and note to return to school?

Then we move on to what are the issues and concerns on school day, before students even enter the front door. How early can students arrive? If there is a significant amount of time students could be on campus without oversight, we could have problems. This could result in congregating outside in close proximity without masks on and children seeing their friends that they may not have seen in six months. There may be hugging, high-fiving, and all kinds of high-risk interactions. As I told one school, you have a great plan for when students are in the classroom, but they may end up being infected in the parking lot before they even walk through the front door.

We then need to discuss how students arrive. Will they come by bus or by car? Buses pose threats of their own. Buses generally do not have as good of air circulation as we would like, so we need all students and the driver in masks, extra distancing and the windows open when weather permits.

There is also the question as to whether the school is going to do temperature checks and/or symptom screening. Some argue against this because only a minority of children have fevers and/or symptoms when infected with COVID. Thier concern is that teachers and others may develop a false sense of security or complacency if they know the children have passed the temperature screening and/or symptom screening. My position is different. First, even if we only identify a few cases this way, it is worth it to keep them out of the school building. Second, with cold and flu season coming, we are not just screening for COVID, but also colds and influenza. We don’t want any of that in the school because all are contagious and we seldom can tell these conditions apart without testing, so I would argue we should do everything we can to keep everyone who is ill, including those who may not realize it yet, out of the school and from contact with others. Finally, I think it is easy enough to educate teachers that they should assume that every person they interact with at school is potentially contagious, and temperature and symptom screening has only identified some of those who pose a risk.

Here is what the largest study to date of signs and symptoms of COVID in children showed us:

  • 30% will have a temp >100.4
    • 39% will have a temp 99.5 – 100.4%
    • 22% of kids will be truly asymptomatic
    • 8.5% will be symptomatic with characteristic symptoms.
    • 66.2% have symptoms, but not those that are commonly recognized as COVID.
    • 25.4% of kids developed symptoms after diagnosis.
    • Kids that were symptomatic were symptomatic from 1 – 36 days. (61% still symptomatic at 1 week; 38% at 14 days; 10% at 21 days)
      • 60% had respiratory symptoms – cough, rhinorrhea
      • 18% had gastrointestinal symptoms – abdominal pain, diarrhea
      • 16% had loss of taste or smell

So, the reason I go into this at this point is that ideally, we want to screen children if we are going to screen them before they get on the bus and before they get out of the parent’s car. Obviously, once the kid is handed off to the school, it could be some time before we get a parent back to the school to pick their child up and we really don’t want a potentially infectious child hanging out at the school. So, can someone go on the bus to screen temperatures and symptoms before the child gets on the bus? Can we have staff screen children in their parents’ cars in the parking lot before the child gets out of the car? And, if they are going to do the temperature check, what are they going to use for the temperature cut off? Guidance commonly states 100.4, but in light of the above, and to keep it simple for screeners, I recommend just using 100.

The other thing we need to do is ensure that before the child gets in the bus or out of the parent’s car, they have an acceptable mask on and are wearing it correctly. If they don’t have a mask or forgot it, we need to have masks there and available to give the child. It is important to note that face shields are not an acceptable alternative.

At one school, as we were doing this review outside the school building, I noticed a half dozen building contractors going in and out of the school without masks on. It was a great opportunity for me to remind them that everyone who goes in the school building must wear a mask, even contractors and visitors. In fact, I calculated the incubation period for them to demonstrate that if one of the teachers was infected by a construction worker, they would likely be at their peak infectiousness on the first day of school!

We are ready to begin the walk-through. I turn to the building maintenance staff. We discuss the difference between droplet and airborne transmission and discuss strategies to increase air circulation and ensure that air is exhausted to the outside rather than being recirculated. In addition, in cases where we cannot get a sufficient number of air exchanges per hour, we discuss options of opening windows, opening doors and having classes outdoors.

While on the subject of airborne transmission, we check the bathrooms out. Many of the newer restrooms do not have lids on the toilets. I discuss the aerosolization that occurs with flushing toilets, the benefit of closing the lid of the toilet before flushing if there is one, and the need to restrict the number of students using the restroom if there are not lids. Further, we discuss the implications for virus to contaminate all surfaces in the restroom – the floor, the stall doors, the counters, the faucets, the paper towel dispenser, the door to exit the bathroom, etc. Therefore, in addition to washing their hands, I recommend placing a sanitizer just outside the bathroom for a final hand-sanitizing after exiting the restroom.

That leads to the next point. Sanitizers. Schools have done a good job of placing sanitizers near the classrooms, however, many of the ones I have seen do not give a visual cue that the sanitizer is empty. Therefore, I stress that it is important that someone has it in their workflow to make periodic rounds to fill sanitizers. Unfortunately, when empty, rather than finding another, kids will often just forego sanitizing their hands.

I then look at classrooms and ask the teacher to tell me all the movements in the classroom a child might be expected to make. It turns out that while they do a great job of distancing desks, there are places in the room where books or other resources are kept and where many students may go at once to get or return something. That then compromises our distancing. So, we talk about other ways to accomplish it by the teacher handing them out or staggering the students as they go to the area.

Speaking of airborne transmission, an important feature to look at in the classroom is the air return. Sometimes it is over the door at the entry way, but on other occasions, I have seen them right over the teacher’s desk (this is the worst possible location) or sometimes over a student’s desk. Given that aerosols will follow the airstreams, the virus will travel in a directed manner right over the teacher’s or student’s head. I always suggest that the teacher’s desk be moved if that is the case, or if it is over a student’s desk, then I advise moving the desk as much as possible (to reduce the risk of airborne transmission) while still maintaining distancing (to reduce the risk of droplet transmission), but if it is going to have to be near that airstream then keep that in mind and don’t put a vulnerable student under it or a student who for some reason is unable to wear a mask or unlikely to be compliant with mask wearing.

I also take this opportunity to discuss the need for cleaning – desks, chairs, keyboards, etc. I advise them to be clear in their plan who is responsible for cleaning what and how often. In addition, we discuss whether there are special education teachers or teachers or interpreters for the hearing impaired. These teachers often want to use face shields. I explain the limitations of face shields and the need for even greater than 6 feet of distancing when they are going to be used, but pointing out the likelihood that they provide little, if any, protection to the teacher or student for airborne transmission. Therefore, I suggest that they at least try to use face masks that have a clear area over the mouth.

Then we discuss movements of students in hallways between classes, for recess, lunch, or fire drills. I recommend that they stagger hallway movements (other than for fire drills, or obviously, a real fire) to minimize contacts that one class has with any other class. This will help contain isolated infections from becoming outbreaks. Teachers often express that they have no idea how to maintain distancing during these hallway movements. My suggestion is for teachers to assign students an order in which they will walk single-file out of the room, down the hallway and to their destination. For example, Jimmy is to follow Susie. Then, tell each student (except the first one) to extend their arm out in front of them, but not to touch the person in front of them. While not six feet, this distance will be sufficient for people while walking to ensure adequate distance to minimize the risk of exposure. Of course, all students should be wearing their masks, as well.

We then finish up with special risks – those not in a traditional classroom. Many schools are having students eat outside or in their classroom. This is great. However, for those who will be having students eat in the cafeteria, we discuss the need to stagger lunch periods so that we reduce crowding in the cafeteria, the need for distancing being even more important because masks come off to eat and drink, the risks of the meal time not being structured and supervised (students sharing food/drink, visiting friends and getting too close with their masks off, or yelling, shouting or cheering which expels greater amounts of virus in respiratory droplets and transmits them further than six feet.

Another activity with increased risk is choir, for the same reasons that students may not be wearing masks, and singing expels greater amounts of virus in respiratory droplets further than six feet. There is also risks of airborne transmission with singing. So, we discuss options for choir to convene outside or if indoors, with good air exchanges or alternatively doors and windows open, and with double the physical distancing. The same thing goes for cheerleading. Yelling and cheering will increase the amount of virus in respiratory droplets and spread them further.

Band has similar issues as a number of band members cannot play their instruments with masks on. Worse, all of the brass instruments I can think of have spit valves and players have traditionally emptied their spit valves by blowing hard into the instrument with the valve open and allowing the spit to fall to the ground. This could be problematic if a player is infected. Obviously, the best solution is to practice outside. Marching bands will be used to this. This can be more of a challenge for concert bands or orchestras. If the practice is going to be indoors, everyone who can wear a mask should. While all band members should be spread six feet apart, brass instrument players may need to have this distance doubled. In addition, it may be best to use a pee pad or similar floor covering below the player for emptying their spit valves. The pads should generally be picked up and disposed at the end of the practice by someone who knows how to handle potentially contaminated materials and dispose of them and that person should wear gloves. If students are going to dispose of them, then there is a need for careful hand washing or sanitizing afterwards. Since we don’t know whether emptying a spit valve may be an aerosolizing event, it may be best to have a trash receptacle, tissues and hand sanitizer at each brass instrument player’s seat so that as they open the spit valve, they can put tissues up to the opening and collect saliva into the tissue rather than allowing it to fall to the ground.

Physical education presents some additional concerns. Like singing, yelling, shouting, and cheering, heavy and fast breathing associated with exercise will potentially spread more virus in respiratory droplets and for a further distance than six feet. Physical distancing at all times will be important. Also, it is likely that equipment will be shared among students, so there needs to be extra attention to cleaning balls, ropes, and gym equipment in between uses. Certainly, activities involving close contact (e.g., wrestling) or frequent passing of a ball (e.g., basketball) should be avoided if possible. Special consideration to physical distancing must be given to locker rooms and showers. Locker rooms tend not to have high efficiency air circulation. One quick test – if you can smell the odors of sweaty kids in the locker room, then you are breathing enough stagnant air that you could also be breathing in the virus.

Finally, I often get asked about sports. Each sport needs to be examined with particularity, and I will not go through every sport here, but let me take one sport and give you an example. Swimming. Swimming should be a relatively safe sport from a COVID point of view. A swimmer swimming in a lane is going to be distanced and we are not aware of any risk that a swimmer could contract this virus from the pool water. However, while the act of swimming might be very safe, associated activities could be very dangerous. For example, swimmers obviously shouldn’t wear masks while swimming. But, if the teammates who are not swimming are congregating on the side of the indoor pool, without masks and are cheering their teammate on, this may be a very high-risk situation. Similarly, for all sports, we have to know how all the associated activities are going to be handled. Are there going to be in-person team meetings? Will distancing be possible? Will everyone be required to wear a mask? What about away games? Will students carpool? This would be risky given the close proximity students would be in in a car and likely without masks. Will they be travelling by bus? (See the concerns I mentioned above about school buses).

Well, this is how I am trying to help schools have detailed operational plans and be the best prepared they can be for the beginning of in-person classes. I hope that this can be of use to other schools that have not yet opened and that you might consider some of these risk points and questions as you do your own assessment of your plan, and hopefully a walk-through. But, I encourage you to engage someone who is knowledgeable about this virus, but not an educator to do your review and walk-through. Fresh eyes are very important. Good luck. I am hoping that we can keep students, their families, teachers and your staff safe.

9 thoughts on “Reopening Schools Safely

  1. Hi Dr. Pate, I enjoyed your live QA for the Idaho Statesman today. My question didn’t get asked so thought I’d send it directly to you. Do you know the current false positive rate for COVID tests and/or if that’s even an issue anymore? I ask because I’m due to deliver at St Luke’s in the next couple days and in order for Nitrus Oxide to be a pain management option for me I would need a negative test result (within 48 hrs). Thanks again for your guidance and congratulations on your recent wedding anniversary! Alex and mine was on the 15th this month but we are only a fifth of the way to your milestone 🙂

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    1. Hi Laura,

      Congratulations on your anniversary and the impending birth of your child, though I fear that I have not gotten to answering your question in time for your delivery. False positives for the PCR and antigen tests have not been a significant problem for us with one exception. The persistence of positivity for some period of time following infection when we believe that the patient has recovered from COVID. We believe that the test is picking up molecular debris from the virus as opposed to “live’ infectious virus. However, if you have not had COVID (and I certainly hope not), a positive test should be presumed to mean current infection.

      All the best and let us know about the new addition to your family!

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  2. Dr. Pate.

    I am fortunate to be the superintendent of the Kuna Jt. School District. We have implemented many of the recommendations you have listed in this blog post and I am grateful to have your advice to guide us, along with that of CDH. We do wonder about your thoughts regarding the risk involved with young children eating breakfast in the classroom. Would you be willing to give us some guidance as to the best approach? Thank you so much!

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    1. Thank you, superintendent! I appreciate all you are doing to keep teachers, students and their families safe. The concern about eating is that one must obviously take their mask off to eat. It also tends to be a social time. So, the biggest risks are people being too close to one another without their masks on. This risk will be even greater if there will be any loud conversation or yelling (which tends to increase the amount of droplets, virus in the droplets, and distance the droplets will travel. So, my recommendations – make sure children remain seated and distanced, at least 6 feet, but with airborne transmission risks, and especially if there will be loud talking or yelling, you need more distance and that could mean double the 6 feet. Anything that can be done at your schools to increase the number of air exchanges and ensure that air is being exited to the outside and not recirculated will also be helpful. Make sure children put their masks back on as soon as they have finished eating. Washing their hands before and after eating will be important because of the likelihood of them putting their fingers in their mouth. Finally, a best practice I have seen, but one that may not be an option for you is a three-sided plexiglass barrier around each student’s eating area to help block droplet transmission. I did hear of a risk in another school where the students were not distanced in all directions, with students sitting behind them within a foot, even though they were sitting in different directions. Good luck and let me know if I can be of additional help.

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    2. Thank you, superintendent! I appreciate all you are doing to keep teachers, students and their families safe. The concern about eating is that one must obviously take their mask off to eat. It also tends to be a social time. So, the biggest risks are people being too close to one another without their masks on. This risk will be even greater if there will be any loud conversation or yelling (which tends to increase the amount of droplets, virus in the droplets, and distance the droplets will travel. So, my recommendations – make sure children remain seated and distanced, at least 6 feet, but with airborne transmission risks, and especially if there will be loud talking or yelling, you need more distance and that could mean double the 6 feet. Anything that can be done at your schools to increase the number of air exchanges and ensure that air is being exited to the outside and not recirculated will also be helpful. Make sure children put their masks back on as soon as they have finished eating. Washing their hands before and after eating will be important because of the likelihood of them putting their fingers in their mouth. Finally, a best practice I have seen, but one that may not be an option for you is a three-sided plexiglass barrier around each student’s eating area to help block droplet transmission. I did hear of a risk in another school where the students were not distanced in all directions, with students sitting behind them within a foot, even though they were sitting in different directions. Good luck and let me know if I can be of additional help.

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  3. Hello Dr. Pate,

    I’m a principal at an elementary school, and a parent of ours who also happens to be a an employee of St. Luke’s shared with me your blog. Thank you for the insight and expertise you have shared. Although the year has already started I think it would be extremely valuable to have someone, as you suggested, knowledgeable about the virus, review our procedures. I feel this is especially important as we are now in the process of having all our students attend daily. Do you have any recommendations regarding who I might contact or the best way to go about contacting someone to do a review?

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    1. Hi Matt,

      Thanks for what you are doing to provide a safe environment for kids. I am tardy in getting back to you, but if you have not already found someone to do the review for you, I believe that Dr. Kenny Bramwell at St. Luke’s or Dr. Mark Nassir at Saint Al’s have been assisting the Boise School District and have completed their work, so they might be available to help you. I would offer my services, but I am completely tied up with West Ada School District and a couple of other schools.

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