Bubble, Don’t Stagger, Elementary Schools: A Sample Letter for Parents

Dear [School System Leader],

As the parent of [family information], I am writing to strongly encourage you to follow empirical and scientific evidence and open elementary schools for full-day, full-week, in-person instruction. Staggered/hybrid schedules should be a last resort for young children. Here’s why:

Overarching points:

-A combination of international evidence, domestic evidence, and biological research are converging on the conclusion that young children (<12 years of age) are: (1) at low overall risk of contracting COVID-19, and at significantly lower risk than adults; (2) at low risk of experiencing serious health complications if they do contract the virus; and (3) if infected, at low risk for transmitting the virus to other children or to adults. While not zero risk, pre-K and elementary schools simply do not appear to be significant transmission settings for COVID-19.

-In contrast, young children are at a high risk for lasting adverse effects to their physical, mental, and socioemotional health, to say nothing of their educational development, by not having access to in-person school settings. This risk is especially high for children from lower-income backgrounds, who are disproportionately children of color.

-These two arrows point in the same direction: Elementary schools (and preschools) should prepare to reopen for regular in-person instruction, following a normal full-day, full-week schedule. This can be done most effectively and safely through a “bubble” method where one teacher stays self-contained with one group of students, limiting contact with other adults and other classes. Within the bubble, physical distancing is — while utilized when reasonable (e.g. spacing out desks if there is room, limiting touching) — not the driver of decisions; close interaction between students (e.g. playing together, group work) is permitted. This is the model Spain is using in their return to school.

-This is not about getting parents back to work or economic recovery, this decision should be led by the health and well-being of young children; keeping them home or utilizing a hybrid model with staggered in-person schedules will cause unnecessary harm in search of marginal risk reduction from an already low-risk setting.

-The same evidence base that exists for young children does not yet exist for teenagers, and as such, secondary schools should still consider models that enable smaller group sizes and more physical distancing.

Quotes from medical & public health professionals:

-“Initially, there was a lot of thought that this virus could be spread by children in congregate settings, which is common for other respiratory viruses like influenza. What we’re seeing more and more from the data that comes out is that child-to-child or child-to-adult spread is actually not common.” -Dr. Jennifer Schuster, pediatric infectious disease physician, Children’s Mercy Hospital (Kansas City, MO)

-“There is converging evidence that the coronavirus doesn’t transmit among children like the flu — that it’s a lower risk … [we just don’t know how important it is to limit group size.] I think it’s a failure that we haven’t prioritized opening schools.” -Dr. Josh Sharfstein, Vice Dean for Public Health Practice and Community Engagement, Johns Hopkins Bloomberg School of Public Health

-“Remarkably, contact tracing studies in China, Iceland, Britain and the Netherlands failed to locate a single case of child-to-adult infection out of thousands of transmission events analyzed.” -Daniel T. Halperin, epidemiologist, University of North Carolina

-“Children are less capable of spreading it even if they get the infection, and certainly are at very low risk of getting ill from the disease … there have not been many cases described of children transmitting it to others, particularly within school settings.” -Dr. Soumya Swaminathan, Chief Scientist, World Health Organization

-“The daily school schedule routine should not be disrupted to accommodate smaller classes for physical distancing ... to the extent possible, cohorting classes could be considered for the younger age groups and for children with medical and/or behavior complexities … children rely on structure and schedule for stability, which supports the need for a daily school model … [that stability is needed to avoid the] massive secondary adverse health and well-being implication [of restrictions].” -The Hospital for Sick Kids [a top Canadian children’s hospital] (Toronto, CA)

International evidence:

-No nation in the entire world is reporting elementary schools as the site of significant spreading events. This is despite tens of millions of students being back in school for well over two weeks, and in some cases well over a month. Denmark, the first nation to reopen schools, has seen no outbreaks in over two months. Twenty-two European Union member states are back and report no outbreaks. The list of nations that have returned and report no significant incidents include most of western Europe, most of Southeast and Eastern Asia, as well as Australia.

Domestic evidence:

-As reported by NPR’s Anya Kamenetz, “The Y says that during the pandemic it cared for up to 40,000 children between the ages of 1 and 14 at 1,100 separate sites, often in partnership with local and state governments. And in New York City, the pandemic’s national epicenter in March and April, the city’s Department of Education reports that it cared for more than 10,000 children at 170 sites.

Working in early days, and on very short notice, these two organizations followed safety guidance that closely resembles what’s now been officially put out by the Centers for Disease Control and Prevention. The Y says a few staff members and parents at sites around the country did test positive, but there are no records of having more than one case at a site. This, among a population of essential workers.

In a separate, unscientific survey of child care centers, Brown University economist Emily Oster found that, as of Tuesday afternoon, among 916 centers serving more than 20,000 children, just over 1% of staff and 0.16% of children were confirmed infected with the coronavirus.”

Research evidence:

-“Low case numbers in children suggest a more limited role than was initially feared. Contact tracing data from Asia, the USA, Europe and Israel have all demonstrated a significantly lower attack rate in children than adults, including testing of asymptomatic household contacts on both PCR and serology. Coupled with low case numbers would suggest that children are less likely to acquire the disease. The role of children in passing the disease to others is unknown, in particular given unknown numbers of asymptomatic cases. Notably, the China/WHO joint commission could not recall episodes during contact tracing where transmission occurred from a child to an adult. Studies of multiple family clusters have revealed children were unlikely to be the index case, in Guangzhou, China, Israel, the USA, Switzerland and internationally. Limited data on positive cases in schools have not demonstrated significant transmission. A SARS-CoV2 positive child in a cluster in the French alps did not transmit to anyone else, despite exposure to over 100 people.” -UK summary of current pediatric literature.

-“We’ve had a tremendous number of case numbers throughout both the United States and the world. And really a minority of those have been identified in children,” [Megan Culler Freeman, virologist and pediatrician at the University of Pittsburgh School of Medicine] says. “Somewhere between 2 and 5% of all of the [reported] infections are in children under the age of 18, which is kind of amazing.”

There are a couple of hypotheses as to why, Freeman says. One is that kids get a milder form of the disease. If they aren’t showing symptoms, they may never get tested. And thus those infections aren’t counted.

Freeman adds there’s also some research showing that the receptors in human cells that the coronavirus latches on to are less developed in younger people.” -NPR report

-Implications for practice and precautions (I recommend this 11-page guidance document from the Hospital for Sick Kids):

-As mentioned above, a “bubble” approach should be adopted for pre-K and elementary school classes.

-Health precautions should primarily focus on protecting adults from one another. This implies resources should go to, for instance, ensuring there is a large substitute pool available so that teachers showing any symptoms of illness whatsoever are comfortable remaining home; ensuring adults are not spending prolonged periods in poorly ventilated rooms; staggering drop-off and arrival times and requiring mask usage during these high adult-to-adult exposure periods; and so on.

-While all reasonable cleaning and sanitation measures should be taken, including frequent hand-washing and wiping down high-touch surfaces, the relatively low risk of surface transmission does not support the need to take an entire day from the school week, nor the expense, for regular deep cleaning. It is not prudent to trade 20% of instructional days, to say nothing of the disruption for students and families, for a marginal risk reduction.

Limitations & Risks

-This is not settled science. While the evidence is converging, no one can say anything with absolute certitude about young children and COVID-19. More research is both needed and is underway.

-There will be occasional cases of COVID-19 that appear in schools. Importantly, this does not necessarily mean COVID-19 is spreading WITHIN schools. In an overwhelming number of cases when schools do have cases, those cases have come from outside (i.e. the child/adult was infected at home or in another setting, and then came into the school). Approximately 98% of child care and school settings have been operating with zero cases, but that does mean 1%-2% will have cases, particularly in states with spiking overall case counts (further emphasizing the need to broadly get community transmission under control). To my knowledge, there have been no reported cases worldwide of elementary schools acting as a “super-spreader” setting (there has been a single case of a high school, in Israel).

-Staff and children who are medically vulnerable must have special accommodations made to protect them, as they are still at higher risk despite the low general risk of schools. Virtual learning may be appropriate for these children, and vulnerable staff should not be required to be in the building.

-There is a communications challenge here that will need to be thoughtfully and directly addressed by school system leaders and other community leaders. Parents and the media, broadly speaking, seem to have an erroneous perception of:

• How likely children are to contract COVID-19
• How likely children are to transmit COVID-19 to other children and to adults
• How dangerous COVID-19 is to children (and the risk of children having a multi-symptom inflammatory response)
• How likely elementary schools are to act as “super-spreader” settings
• How important reducing group sizes and enforcing physical distancing among self-contained groups of children is for risk reduction
• How much benefit is gained from a hybrid/staggered schedule, given that many children will have to attend a separate setting for child care during their “off” cycles, and will therefore actually be exposed to more children and adults (this is one reason why the Illinois State Board of Education “strongly encourages” districts to do full in-person instruction for elementary school students).
• How much young children will incur harm from staggered/fully virtual schedules

Thank you for your attention to this matter, and I urge you to show leadership in responding to the most current, encouraging evidence about young children and COVID-19.

Gratefully,

[Name]