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Thursday, July 23, 2020

Post #50 School Reopening during the COVID-19 Pandemic

There is probably not a more emotionally charged topic of discussion currently than that of school reopening this fall. And for good reason - nearly everyone has a stake in it.

Society is concerned because of the real risk of increased community spread.

Teachers are concerned because of the COVID-19 risk to themselves and how the logistics of school will directly affect their livelihood and stress level as they have to constantly adjust to the barrage of changes and duties. 

Families are concerned because of the COVID-19 risk to their children and to those living at home. Not to mention, many depend on school to allow for both parents to work. And what about the educational risks if everything is remote learning? And if kids stay home, will mom and dad working from home stay sane?

The number of different factors weighing in on the discussion is overwhelming. The implications affect the economy, family lives, the future of our country, and society as a whole. Superintendents, teachers, and those directly affecting school policy have their work cut out for them - thank you in advance for everything you are doing.

A good place to start the discussion is assessing the real risk to the different groups as listed above.


A recent study of nearly 65,000 people in South Korea made an important distinction in children younger than 10 and those between the ages of 10 and 19, in that the younger group transmits the virus much less often than adults do. 

Ten years is not some magical demarcation as almost everything in medicine is a continuum with COVID-19 risk increasing commensurately as a child ages. For those seeking a technical explanation of this, it is likely related to the lower number of ACE2 receptors in the respiratory tract of children. 

Other possible factors that may contribute to children posing lower risk could stem from their smaller volume of breaths and the fact that they are short and thus their inhalation and exhalation is closer to the ground and not in the same plane as adults. Obviously, if they are in school and with their peers, the latter advantage becomes less relevant.

The take home message here is that younger children pose a substantially lower risk for COVID-19 spread than older children and adults. Elementary school is likely safe. Middle school and high school remain suspect. 

As for deaths in children, the CDC keeps a provisional death count by age, and as of July 22, 2020, there have been a total of 36 deaths in children younger that 15 years for the entire country. To put things in perspective there have been 185 deaths due to influenza in children younger than 18 for the 2019-20 season. Overall, children have fared extremely well with the pandemic in terms of deaths and medical complications.


There is a real risk that students attending school will bring the virus home to their families. For those living with their grandparents or an immunocompromised individual or family members with underlying health issues, this poses a difficult conundrum. 

A recent systematic review of 700 scientific papers found that children are rarely the index case in outbreaks and were unlikely to impact the COVID-19 mortality in older people. While this data gives a great deal of reassurance, children still contribute to some level of spread, and as the South Korean data demonstrated, older kids are likely on par with adults in terms of risk.


The best data on school spread comes from other continents where school reopenings have already taken place.

An excellent case study in Australia looked at 18 infected individuals (9 students and 9 staff) from 15 schools from March to mid-April of this year. 735 students and 128 staff were close contacts of these initial 18 cases. No teacher or staff member contracted COVID-19 from any of the initial school cases. However, one child from a primary school and one child from a high school may have contracted COVID-19 from the initial cases of their schools.

Another paper from the Journal of Pediatrics reviewed outbreaks in Switzerland, China, France, and Australia (cited above) and found that children are rarely drivers of COVID-19 transmission.

This is not to say that there is zero risk to teachers from students, but the data suggests it is minimal. And while children are unlikely to infect teachers, other staff and teachers pose a real risk to each other; adult to adult transmission is real and South Korea suggests students 10 and older are on par with adults.

Guidelines are Needed

If school reopening is to happen, detailed guidelines must be in place. The American Academy of Pediatrics (AAP) recently published excellent guidance for reopening schools.

A key phrase they used was that "policy makers should acknowledge that COVID-19 policies are intended to mitigate, not eliminate, risk." This is important to bear in mind. If we are attempting a zero risk solution, it will not happen.

AAP outlines key principles in consideration of reopening schools:
  1. School policies must be flexible and nimble.
  2. Strategies may need to be revised and adapted depending on the level of virus transmission in the school and community.
  3. Policies should be practical, feasible, and appropriate for the child's developmental stage.
  4. Special considerations should be made for the medically fragile, impoverished, and those with developmental challenges or special health care needs.
  5. Minimize exclusion.
  6. Policies should be guided by supporting the overall health and well-being of all involved.

Strategies recommended by the AAP include to cohort classrooms to minimize crossover, utilizing outdoor spaces when possible, limiting visitors, mandating face coverings, spacing desks 3 to 6 feet apart, eliminating lockers, having teachers rotate instead of students, and creating one-way hallways.

As states consider the different options before them, some are appropriately using local COVID-19 caseload numbers and hospitalization rates as a qualification to reopen schools. Especially for middle school and high school this seems prudent. The data from Australia, Europe, and Asia school reopenings came from countries where the pandemic was under far better control than it currently is within the United States. 

Moving forward, should COVID-19 numbers improve within the community at large and thresholds are met, school reopenings should merit serious consideration. But in states where the intensive care units are at capacity and caseloads are rising, prudence makes sense.

Of course, this poses a dilemma for working parents. This is where a novel idea such as Safe Centers for Online Learning (SCOLs) could come into play. Essentially, for those who cannot watch their children at home, students could do online learning and be cared for in large venues, such as convention centers, stadiums, performing art centers, and parks that are currently going unused. 

Whether it be SCOLs or some other concept, relief must be provided in some form to allow for parents to return back to work. This will be an essential component of moving our economy forward. 

Without question, for the upcoming school year, there will be a new normal. Each school district and family will be faced with a plethora of decisions as they weigh risks and benefits. Luckily, many countries have wrestled with these same questions ahead of us and provided helpful data. Ultimately, each family understands their needs and risk appetite best. 

Ideally, schools will have the ability and resources to offer multiple options to accommodate each family. Hopefully, the information provided here will empower parents as they navigate school reopenings during the pandemic.

One thing is and has always been true: children are the future - let's keep them safe and make sure we provide them the best education possible.


Beth said...

Thank you Dr. Jung! We can always count on you to give us evidence-based advice and I know that the standards you set for your patients are the same that you believe for your own family. said...

Thank you for your wise current advice. I thought your blog post was wonderful and shared it with my close teacher friends.

Cox said...

Great information..sharing with my family and friends.

Joshua said...

Excellent post. Thank you for taking the time to compose.

Marcus said...

I appreciate you words of wisdom on this topic. Thank You Dr. Jung!

Lindsay said...

Thank you for being so thoughtful on this topic...excellent article and so helpful! Blessings to you all as you care for our kids.

Unknown said...

Thank you Dr. Jung. We always appreciate your practical and well thought out perspective. We are struggling with the information we are receiving from our local school district (Fort Bend ISD).

The panel of doctors advising the district are giving a different, more alarming scenario as evidenced in this Houston Chronicle article that includes interviews with these same physicians:

Statements such as “This virus has created a situation of having no symptoms to being on a ventilator and dying within two days,” creates panic that distorts what is relevant to the impact on school students. This panic and misinformation also feed into the feasibility of existing drugs that may be able to mitigate the effects of the virus, but are not being fully discussed for other non-medical reasons.

Michelle Rego said...

Thank you Dr.Jung for your thoughts on this topic.You know us:)..we trust you without a shadow of doubt.I know whatever you tell your patients is what you and your family would practice yourselves!Also appreciate the evidence based factual information that you provided to help us make a safe and informative decision for our kids!

MissyK said...

Wow! You have done your research. I have a teenager that can’t wait to get back to school and see his friends live vs virtual. I also have a daughter that is in her first year of teaching at an elementary school in Houston. I feel better knowing this information. Thank you so much!