December 18, 2020 -- The nation’s educators are living through extraordinary challenges. Recommendations to get students back for in-person learning are necessary, for the good of students, and reasonable, because safety can be achieved.
Schools should use metrics of community spread as general points of information, not on-off switches for closure and opening, and should focus their own attention on developing ways to measure any in-school transmission and the quality of their infection control regime, in relation to the elements of infection control laid out below. For in-school transmission, the goal should be zero or near zero transmission.
These recommendations increase the workload on schools, however, by introducing the need for robust infection control programs, and short and long-term investment in our public education system’s infrastructure and workforce. Our nation's educators deserve full support from state and federal governments and the general public as they undertake the heroic labor of holistically transforming their practices to meet this urgent need.
In July, we published guidance for school leaders making decisions about school re-openings that offered a tiered structure for thinking about risk at different levels of community spread. We recommended that schools be closed once the average daily case rate rose above 25 cases/100,000 people, at the county level. Since July, our scientific understanding of COVID has increased significantly, as has our understanding of degrees of risk in schools, and we can now recommend that schools be open even at the very high levels of spread we are now seeing, provided that they strictly implement strategies of infection control. Evidence supports the view that student, staff, and educator risk can all be brought to acceptably minimal levels with robust infection control practices when implemented in a collaborative and transparent way among all stakeholders, including educators and other school personnel, administrators and district leaders, families, and students.
In our previous guidance we recommended closure above the 25 per 100,000 rate because we thought that was the level of community spread at which it would no longer be possible to implement contact tracing at levels that could keep up with the disease. Our metrics baked in the idea that opening for in-person learning hinged on judgments about capacity to implement infection control procedures. However, it is in fact possible to implement infection controls that minimize risk even at higher levels of community spread, and schools that can develop that capacity should seek to stay open for in-person learning even at higher levels of community spread. Also, when increases in community spread test a school’s capacity to maintain infection control practices, for instance, contact tracing, we should seek to remedy resource-constraints prior to determining that the necessary solution is to reduce in-person learning.
In June and July, we were still in crisis mode, delivering policy guidance on the basis of the best available knowledge at the time. Now we have a much fuller picture of the disease, its therapies, and the effectiveness of specific infection control techniques. It is time to transition from crisis management to the organizational and cultural change necessary for pandemic resilience.
Schools fill essential functions in our society including education, child care and provision of nutrition and health. School closures, combined with the lack of paid leave and limits on support for small businesses, have had profound impacts. Parents are forced out of work. The deep inequities of American society are reinforced and expanded. Despite the best efforts of education districts, there is no doubt that remote instruction generates large learning gaps and links to higher rates of mental illness, while depriving children of formative social and peer relationships. For untold thousands of children, schools are their only source of healthy meals. And for too many children, they are a refuge from a precarious home life, a place where observant teachers can be a safety net. Some children will struggle to make up the growing social and educational deficit caused by prolonged school closings.
The most critical question is whether schools can achieve in-building safety in support of in-person learning, even with broad community spread, between now and the end of the school year. Thereafter we can expect that widespread vaccination will reduce the challenge of maintaining a safe-from-disease environment for in-person learning. That said, even with widespread vaccination, ongoing infection control is likely to be necessary. The work we describe herein is likely to be a new and permanent part of school building practices.
Evidence gathered this fall around the world and in the U.S. suggests that schools can open, even in conditions of wide community spread, and achieve low and even near zero transmission in the school building. This evidence, combined with the benefits to learners of in-person schooling and harms of remote schooling, suggests that the time has come to pursue in-person learning across most school contexts, provided that the school in question has established reasonable infection control protocols to safeguard student, educator (including paraprofessionals), and staff safety. The federal governments should include investments in school infection control in the next coronavirus relief package.
To facilitate in-building safety for in-person learning, even in contexts with significant community spread, schools (and the municipal, state, and federal institutions that support them) need to address six central topics in setting their strategy: trust (which includes both labor-management issues and community relations); transportation; infection control; occupational health and safety standards; testing; and vaccines. Set against the backdrop of these six topics, this briefing focuses on measures of infection control necessary for in-building safety at high levels of community spread.
Americans are familiar with stories about educators buying supplies for their classrooms and for their students because schools are under resourced. We know that educators and school personnel regularly put their students’ needs ahead of their own. In asking school personnel to return to school we are, yet again, asking them to do this work. Instead of asking this of them, we should be equipping them with the tools they need to do their jobs effectively. This is precisely why we think focusing on infection control measures is so important. In order to reopen schools, we must make them as safe as we can - for children and the adults educating them, and for the families to which learners and school educators and staff return each day.
Different schools in different contexts will need to pursue different strategies for pandemic resilience and will necessarily make different decisions about how to balance the trade-offs between in-person and remote learning. Yet most agree that, where feasible, in person learning is a preferable option to remote learning.
To facilitate in-building safety for in person learning, even in contexts with significant community spread, schools (and the municipal, state, and federal institutions that support them) need to address six central topics in settling on their strategy: trust; transportation; infection control; occupational health and safety standards; testing; and vaccines.
Generally, only trust and infection control are matters that schools themselves can have a significant impact on independently of other actors. They can make significant progress on these dimensions especially when school leadership, educators, and families can work together effectively. In contrast, transportation, occupational health and safety standards, testing, and vaccines are areas for which schools need assistance from municipalities, the state, and the federal government. That said, in our highly politicized environment, even trust often depends on factors beyond the reach of schools themselves.
We first review all six topics, but then devote the rest of the briefing to infection control, which has rarely been addressed within the context of schools specifically and which is the element most under schools’ control.
One of the single greatest barriers to in-person learning at this point in time is challenges schools are having in staffing classrooms. Educators, including both teachers and paraprofessionals, and staff must feel safe at work and also in traveling to and from work, for in-person learning to resume. Trust is not a matter merely of levels of community spread. It is also a question of how school leaders make decisions, how well they do at incorporating educators, paraprofessionals and other staff in decision-making processes, how well they do at communicating around decision-making, and how well their decisions include an aligned focus on the health and safety of everyone in the building, students but also educators, para-professionals and other staff. Too much discussion about school reopening has focused almost exclusively on the question of risk to children. Their safety is critical but so too is the safety of staff and educators, and their ability to have a voice in decision-making.
Clear presentation of what we do and do not know about student, staff, and educator safety is critical to rebuilding trust as are effective and productive labor-management and community partnerships for decision-making School districts should assemble a diverse health and safety committee including representatives from all groups within the school community.
A second critical trust issue relates to the politicization of public health guidance. Schools face a greater challenge for safe re-openings in contexts where communities will not support mask-wearing in schools or, more broadly, contact tracing and community mitigation strategies.
A third critical trust issue relates to families’ trust in schools and districts to keep their children safe. Absence of such trust explains why many districts that are “open” nonetheless have a high percentage of remote learners. Very often families of color are less likely to trust in the safety provided by the school, leaving them unable to take advantage of potential opportunities for in-person learning. In New York City, for instance, the families of African American students have been much less likely to send students back for in-person learning, out of concern that students will bring the virus home to vulnerable family members. This trust issue is a significant barrier to success in restoring in-person learning and requires direct attention and engagement.
A fourth critical trust issue relates to the level of acceptance in any given community of vaccination. This will affect the pace of vaccination and rate of reduction of risk in a community.
For school reopenings to succeed, not only the in-building school environment needs to be safe, but so too the process of getting to school must be safe. In urban environments, where educators, paraprofessionals and staff are dependent on public transportation or ride share to get to work, rising levels of community spread meaningfully transform the degree of risk they face in getting to work. Depending on context, districts and public officials may need to address safety on public transport. Districts and principals, working with unions and staff, also need to include school buses in their infection control protocols. Simple measures like window cracked 3" and riders wearing masks make this lower risk. Monitoring of buses shows that 20-40 air changes per hour can be achieved when moving with windows down a few inches.At this level of air changes, air flow is much less relevant because dilution will be quick. Also, everyone should be masked on the bus.
Our knowledge about the virus and about mitigation strategies for infection control has increased significantly from July. Based on 3 months of varying school re-openings across the country that have served as a national natural experiment, it is now clear that schools with in-person learning that use effective mitigation strategies are very unlikely to create super spreader events and, even more importantly, can create safe environments. Effective mitigation strategies can achieve lower secondary transmission rates than the primary transmission rates of the surrounding community. While we are still in the process of studying schools that have had outbreaks, it is now reasonable to expect that those situations reflect breakdowns in systems of infection control. The most important elements of infection control that matter are:
Importantly, the regulations of the Occupational Safety and Health Agency (OSHA) do not apply to the vast majority of school employees who work at public schools, and many states have no comparable workplace safety laws in place for public sector workers. It’s time for states to fill this gap. Schools need clear, adequate, and enforceable rules and protocols for protecting students, education workers, and their families—regardless of where they live. While the development of these policies is critical in the long-term, the process of developing them should not slow down the adoption of best practice infection control measures and a return to in-person learning.
Screening or surveillance testing can make infection control significantly easier and more effective and can restore trust in the safety of the environment. It can help stabilize an infection control regime by giving public health officials and school leaders full visibility into the prevalence of covid-19 in the school community and can help identify potential failures of infection control more rapidly.
Testing may engender trust in the individual being tested, but also on a population level based on the knowledge that other educators, paraprofessionals, staff, and students are also being tested and unlikely to be in school with COVID-19. That said,testing programs must be carried out with transparency in the reporting of results, or they risk engendering distrust.
Surveillance testing for educators, paraprofessionals, and other staff is recommended in order to reduce the risk of asymptomatic transmission, once the level of community spread has exceeded 20/100,000 daily new cases. Surveillance testing for high school students is recommended once the level of community spread has exceeded 100/100,000 daily new cases. These recommendations are drawn from the work of the Duke-Margolis Health Policy Center (Risk Assessments and Testing Considerations for Reducing Sars-COV-2 Transmission in K-12 Schools.). Group testing, which is much cheaper, is now available and can be used effectively to increase infection control in schools.
That said, testing infrastructure varies considerably across the country and from school district to school district, and disciplined implementation of infection control protocols can also serve to substantially reduce risk even in the absence of testing. The perfect should not be the enemy of the good, and the absence of testing should not be an obstacle to schools’ developing robust infection control protocols.
Each state is currently developing its plans for vaccine prioritization. While healthcare workers, those in high-risk categories, and essential workers who work in higher transmission and risk contexts are often and rightly being prioritized for early access to vaccines, those who work in schools should be among the next categories in the population to receive vaccines for covid-19 when they become available. Pediatric vaccines are likely to come behind vaccines for the adult population. Consequently, infection control will continue to be necessary in schools for the next 6-9 months. While the U.S. Department of Health and Human Services has not asked states to submit testing plans beyond December 2020 and has shifted the focus to the submission of vaccine plans, in fact we will need both for much of 2021.
The rest of this briefing document will focus on infection control.
To make assessments about the level of risk involved in in-person learning in contexts of community spread, we need to look to data around the world, where schools have commonly been open, as well as to data in the U.S. All the data is partial. Here we present what the data can currently tell us about outbreaks and transmission in schools, and the degree of risk affecting the safety of students and of the adults in the building (educators, including paraprofessionals, and staff).
There is a growing body of evidence that students are not at heightened risk from school re-openings (and as we said above, in-person schooling brings lots of benefits to students and families). A wide range of scientific papers find that both susceptibility and infectivity increase with age. A CDC report on Covid infections in children in the U.S. has found that between March and September 2020, children 12-17 years old have been diagnosed with Covid about twice as often as children 5-11 years old, while both groups’ infection rates have consistently been significantly lower than those of adults. The most comprehensive data tool currently available for understanding what is happening with schools and Covid in the United States is the National COVID-19 School Response Dashboard. It records data from over 8 million students (out of 57 million nationally), of whom roughly half participate in in-person learning. Within the database, from September through November 2020, cases in schools largely mirror community trends: The cumulative percentage of in-person students who are assumed or confirmed positive for Covid is 1.2%, compared to a community case rate of 1.5% in the same areas during the same time frame. That said, these numbers capture a variety of different mitigation and testing methods across communities and schools and therefore provide only an initial impressionistic picture, warranting further analysis.
The major question is about adult risk, which we'll focus on for the rest of this section. On that front, we know the following:
Our knowledge about the virus and about mitigation strategies for infection control has increased significantly from July. It is now clear that schools with in-person learning that use effective mitigation strategies are very unlikely to create super spreader events, can create safe environments, and can achieve lower transmission rates than characterize the surrounding community. Additionally, in person schooling is so important that despite the moderately heightened infection risk to educators even under good infection control measures, we think that schools can reopen safely and should do so. While we are still in the process of studying schools that have had outbreaks, it is now reasonable to expect that those situations reflect breakdowns in systems of infection control. The most important elements of infection control are, again:
In our July guidelines, we recommended phased approaches to re-opening. Now the point of phasing reopening is less about risk in the surrounding environment and more about ensuring that, at each step of the way, schools and districts have the capacity to deliver the necessary infection control measures for each school building opened. Capacity for maintaining infection control protocols is the best guide for determining the safety of opening for in-person learning.
1st priority for re-opening: Grades preK-5 and students in particularly vulnerable groups at grade levels preK-8 open if conditions for pandemic resilient teaching and learning spaces with robust infection control practices can be achieved at scale. Districts also invest in a remote learning option for those who choose it.
2nd priority for re-opening: Grades 6-8 and students in particularly vulnerable groups at grade levels 9-12 open if conditions for pandemic resilient teaching and learning spaces with robust infection control practices can be achieved at scale. Districts also invest in a remote learning option for those who choose it.
3rd priority for re-opening: If sufficient pandemic resilient learning space with robust infection control practices is available AFTER allocation to K-8 and all students in particularly vulnerable groups K-12, then the rest of grades 9-12 open. Districts also invest in a remote learning option for those who choose it.
Finally, capacity requirements can also be adjusted by adjusting the percentage of students in the building based on context-specific prioritizations or hybrid schedules.
The recommendations that follow presume that it is possible for educators, staff, and students to get to schools safely. Where transportation risks are insurmountable, as they may be in some urban settings, remote education may be necessary even if it is in principle possible to make school buildings safe.
Achieving pandemic resilience for in-person teaching and learning requires focusing on the safety of students, staff, and educators first and foremost. This focus requires:
Fig. 1. Infection control has the job of blocking in-school transmission, even when cases have come into school from the community, and of blocking onward spread back out into the community.
The work of that team should be organized around that goal of zero transmission, and administration and agencies should support toward that goal. That said, transmission itself does not mean that in-person learning has failed. We have to distinguish between occasional transmission and an outbreak, between correctable mistakes (transmission that can be prevented with infection control measures) and non-correctable mistakes (viral spread dynamics that are beyond what can be addressed in a school setting). An ambitious drive for comprehensive health and safety programs will protect those in school buildings in the near term and would also be likely to lay the foundations for a healthy school culture more broadly. Where unions play a role, joint health and safety programs will be critical.
Infection control measures are categorized as individual, environmental, and systemic. Individual controls are those that every individual must be responsible for enacting for the good of self and others. Environmental controls are those that can be built into the physical environment. Systemic controls are those that require changes in organizational practice and process.
Contrary to common practice, in which personal protective equipment is characterized as the last infection control measure to be layered in, and is expected to be added only when the hazard cannot be eliminated and engineering efforts have not sufficed, safety in contexts of community spread during the COVID-19 pandemic requires holistic risk reduction, with masks as a critical and necessary strategy. The hazard has not been eliminated in the broader community, and it is not possible to fully reduce risk indoors through engineering controls alone. Therefore, masks are an essential and required control strategy. An exception is those situations where schools can rely extensively on outdoor classrooms.
Below is a chart of the individual, environmental, and systemic controls that pertain to Covid-19. “Universal precautions” are those for which every single individual has responsibility and the fall in the column labeled “individual.”
Notes: As we said above, testing infrastructure varies considerably across the country and from school district to school district, and disciplined implementation of infection control protocols can also serve to substantially reduce risk even in the absence of testing. The perfect should not be the enemy of the good, and the absence of testing should not be an obstacle to schools’ developing robust infection control protocols.
Finally, in some higher risk settings in schools, for example where close contact is unavoidable and students may be unable to wear masks (e.g., some special education contexts), additional controls and PPE may be warranted. This could include higher efficiency masks and the use of face shields for teachers and paraprofessionals, lower occupant density in the room, and enhanced engineering controls.”
An infection control team has the job of training all students, staff, and educators in the use of universal precautions and also of ensuring that all necessary environmental and systemic infection control measures are in place. Small school-based teams could be supported by district or regional teams with deeper expertise and more frequent access to professional development.
The model of an infection control team comes from the hospital setting. The risk level in schools is significantly lower than in hospitals. Schools do not need the same level of infection control as, for instance, an intensive care unit. The Department of Labor categorizes schools as a medium-risk environment, on par with grocery stores, in “Guidance on Preparing Workplaces for COVID-19.” Both environments are lower risk than healthcare settings. However, schools do organizationally need to bring an equivalent degree of intentionality to the project of infection control. This is not a new function for schools but does now need to be operationalized with a greater degree of discipline, as is also true for grocery stores.
In our original guidance, we offered recommendations that were tiered in relation to the level of community spread. Given the level of community spread we now have in the U.S. and are likely to have through the first quarter of 2021, however, it no longer makes sense to offer tiered guidance since the vast majority of regions in the U.S. are (or unfortunately soon will be) at dangerously high levels of community spread. It is also clear that many schools and districts intersect with many communities (e.g. not just those in which they are physically located, but also those that teachers commute in from), and hence a precise calculation of community spread for any particular school or district may be misleading or impossible. Finally, achieving safety for school communities will best be done simply by pursuing all the infection control measures needed for the highest level of risk that could pertain in a school setting.
The recommendations provided above are targeted at maintaining in-building safety even when a high percentage of students, teachers, or staff may have exposure risk outside the building and are at risk of bringing covid-19 into the building and even when a high percentage of the people in the building have underlying conditions or other kinds of vulnerability. Infection control teams should help their schools act on all the items listed above in the infection controls chart. They can in addition refer to the Guidance for Medium Risk Workplaces in the OSHA handbook linked above.
By the time current levels of community spread recede, infection control teams will have built up sufficient knowledge that, working with local departments of public health, they can guide their school communities in determining how to loosen or remove infection control measures as appropriate.
The nation’s educators are living through extraordinary challenges now, regardless of whether they are teaching remotely, in a hybrid setting, or in person. A recommendation to get students back for in-person learning increases the workload on schools by introducing the need for a robust program of infection control. Such a recommendation in effect proposes an evolution in the nature of the teaching profession and in the demands placed on educators. Such a recommendation is both necessary, for the good of students, and reasonable because safety can be achieved. That said, acting on it will take hard work, supported by significant short and long-term investment in our public education system’s infrastructure and workforce. Our nation’s educators deserve full support from state and federal governments and the general public as they undertake the heroic labor of holistically transforming their practices to meet this urgent need.
Communication can be directed to Danielle Allen at Harvard’s Edmond J. Safra Center (firstname.lastname@example.org); Joseph Allen at Harvard’s Chan School of Public Health (email@example.com); Helen Jenkins at Boston University’s School of Public Health (firstname.lastname@example.org); Meira Levinson at Harvard’s Graduate School of Education and Edmond J. Safra Center for Ethics (email@example.com); Ashish Jha and Stefanie Friedhoff at Brown’s School of Public Health (firstname.lastname@example.org); Emily Oster at Brown University (email@example.com); Michael Murphy at MASS Design Group (firstname.lastname@example.org); Elena Silva at New America (email@example.com); Jacob Fay at Harvard’s Edmond J. Safra Center (firstname.lastname@example.org); Ben Linville-Englerat MIT System Design and Management (email@example.com); Nien-he Hsieh at Harvard Business School (firstname.lastname@example.org); Natasha Warikoo at Tufts University (email@example.com); Todd Rogers at Harvard Kennedy School (firstname.lastname@example.org); Thomas Tsai at Harvard Chan School of Public Health (email@example.com)
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