Return to School FAQ

by Jeffrey Starke, MD, FAAP

It is fall and children are heading back to school. However, this year COVID-19 has caused more anxiety and apprehension than chemistry midterms. Symposia Medicus faculty member Dr. Jeffrey Starke shares a list of frequently asked questions (FAQ) concerning COVID-19 and returning to school.

This FAQ was developed by several pediatric infectious disease physicians based on the best available evidence at the time it was written. It is not intended to give specific guidance but it reflects general principles which may change as more information becomes available. For specific advice, please consult your local school and health authorities and pediatric experts.

Guiding Principles:

The following strategies serve as the guiding principles that might help reduce (but not eliminate) transmission in school:

1. Staying home when sick: staff and students should stay home if sick or if they have been exposed to someone with COVID-19
2. Physical distancing of 6 feet whenever possible
3. Smaller class sizes to enable physical distancing of desks by at least 3 to 6 feet
4. Face covering: cloth face covering or mask is preferred. Probably feasible only for older elementary school, middle and high school students, and for teachers and staff.
5. Hand hygiene: Using soap and water for 20 seconds or alcohol based hand sanitizers containing minimum 60% alcohol to be placed throughout the school for easy access (CDC – When and How to Wash Your Hands)
6. Cohorting: Forming groups of students to stay together throughout the school day to minimize exposure and disease spread. Attempts should be made to cohort staff if possible. Moving teachers instead of students to minimize exposures. Different strategies would be needed for elementary, middle and high schools.
7. Well-ventilated spaces: Outdoor spaces to be utilized as much as feasible and safe. Opening doors and windows as much as feasible and safe.

General FAQ

1. What are the most common signs/symptoms of COVID-19 in children?

• Temperature 100.4 degrees Fahrenheit or higher when taken by mouth
• Sore throat
• New uncontrolled cough that causes difficulty breathing (for students with chronic allergic/asthmatic cough, a change in their cough from baseline)
• Diarrhea, vomiting, or abdominal pain
• New onset of severe headache, especially with a fever

2. What is meant by a “close contact” of COVID-19?

• You were within 6 feet of someone who has COVID-19 for at least 15 minutes
• You provided care at home to someone who is sick with COVID-19
• You had direct physical contact with the person (touched, hugged, or kissed them)
• You shared eating or drinking utensils
• They sneezed, coughed, or somehow got respiratory droplets on you

3. Can children have COVID-19 without symptoms? Is there a difference between symptoms of COVID-19 in children and adults?

Currently, it appears that, in general, children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection. However, children and adolescents can get severe COVID-19 disease and require hospitalization, particularly if they have underlying risk factors including (but not limited to) underlying immunodeficiency condition, obesity, heart or lung disease.

4. Is it safe for students and teachers to return to school in person?

Both the American Academy of Pediatrics [AAP] and CDC have published guidance documents addressing safety measures that schools and parents can practice to reduce risk. These measures (reviewed in part below) do just that—reduce—but they cannot eliminate all risk of acquiring SARS-CoV-2. The risk of infection in school will likely mirror the risk in the community; the higher the community rate of transmission, the higher the risk in school.

Ultimately the decision of whether to send a child back to school will be a personal one for each family, incorporating the overall physical and emotional health of the child, presence of high risk underlying medical conditions in the child or other family members, ability to learn virtually, extent of community spread, the family structure and finances, and parental/child’s comfort level.

5. Are the numbers of children who have COVID-19 lower because they have not been in school?

We still do not know definitively how likely children are to acquire and spread COVID-19 compared with adults. A recent study by Park and colleagues analyzed 59,073 contacts of 5,706 COVID-19 index patients (those first identified to clearly have the virus in a given group) in South Korea from 1/20/20 to 3/27/20, when mitigation efforts including school closures and social distancing were in effect. This study showed that household contacts of 10-19-year-old index patients had as high, or higher, a rate of infection as household contacts of adults, whereas household contacts of children 0-9 years had a lower rate.

Another study in JAMA by Auger et al. published July 29, 2020, showed that between March 9, 2020, and May 7, 2020, school closure was associated with a significant decline in both incidence of COVID-19 and mortality. However, a subsequent editorial by Donohue and Miller pointed out that, since school closures were implemented in addition to other measures such as physical distancing in the community, closure of nonessential businesses and stay-at-home orders, it was difficult to interpret the effect of each intervention separately.

A conclusion of the editorial was:

“Whether the estimated associations between school closures and COVID-19 outcomes derive from reducing contacts among children or among their parents and caregivers, who are also less mobile as a result, is not known.”

6. What is the likelihood of transmission of COVID-19 on a bus that is well-aerated vs. a bus that on some days may have the windows closed? 

A well-aerated bus has less likelihood of promoting transmission of COVID-19 than a closed one. Consideration about safety or health risk (e.g., risk of falling, triggering asthma symptoms) should be taken into account while considering keeping bus windows open.
The AAP guidelines encourage the following about school buses:

• Reducing the number of students riding the bus (especially if parents are able to provide their own transportation)
• Cohorting the same students
• Physical distancing of 6 feet between students if feasible—tape marks showing where students can sit
• Symptom screening is ideal prior to boarding bus but might not be feasible
• Face covering for students
• Drivers should be a minimum of 6 feet from students; driver must wear face covering; consider physical barrier for driver (e.g. Plexiglas)
• Adults who do not need to be on the bus should not be on the bus
• Have windows open if the weather allows

7. Are HEPA filters in classrooms effective?

There is no direct evidence that a HEPA filter by itself would be effective in classrooms and has not been recommended by the CDC. Physical distancing, face covering, hand hygiene and cohorting are the key ways to reduce transmission. Doors and windows can be opened (if not with health or safety risks) for increased air circulation.

8. Does a daily screening survey need to be administered by a school nurse?

Yes, temperature measurement and symptom screening of students, teachers and staff should occur daily. This screening does not necessarily need to be administered directly by a nurse. Screening may be done at home with screening results transmitted to school or performed on site prior to admission to the school. Some guidelines recommend that teachers and staff self-screen for symptoms and should take their own temperature every day before school.

Identifying COVID-19 and considerations

1. How can I help determine if a student has COVID-19 or another illness?

Unfortunately, other respiratory viruses can cause many of the same symptoms as COVID-19. It also is possible to have co-infection of another virus with COVID-19, meaning, one can have more than one infection at the same time.

In an area with high prevalence of COVID-19, if a child presents with the typical COVID-19 symptoms (fever, congestion, cough, alterations in taste or smell, diarrhea as in question 1), the likelihood of having COVID-19 infection would be higher.

Parents should be instructed to keep children home if they develop any signs or symptoms of COVID-19 OR if the child has been in contact with a person with COVID-19. 

2. If a student is sent to the nurse’s office with COVID-19 symptoms, including a fever, should they automatically be sent home?

Yes, if a child has fever or other typical COVID-19 symptoms, he/she should be promptly sent home to be evaluated by a health care provider.

3. What is the best possible way to isolate a student who is suspected of having COVID-19? What characteristics should the isolation room have?

Each school should designate an isolation room which could be any private room with a door that can be closed. A well-ventilated room is preferable. It does not have to be a negative pressure room. Every effort should be made (including signage) to minimize exposure to other students and staff. Once a child is identified as having symptoms consistent with COVID-19, a face mask should be placed on the child and the child isolated in the private room with doors closed. The school nurse or other caregiver should wear appropriate PPE (at least a face mask and eye protection; isolation gowns and gloves should be used if physical contact with the ill person is necessary) and do a formal evaluation of the child to ascertain severity of illness. A fever reducing agent can be given if the child has fever and the guardian should be called to pick the child up for evaluation and testing by a health care provider. It is optimal to wait at least 24 hours before cleaning and disinfecting the area where the ill person was isolated; if 24 hours is not possible, wait as long as possible.

Reference: CDC Disinfecting Building Facility

4. What is your advice on return to school following the development of COVID-like symptoms?

If initial testing is positive: Students are to stay home. Negative follow-up testing is NOT needed for return to school. Students who were initially symptomatic can return to school once all the following are met:

• Fever free for 24 hours without fever reducing medications
• At least 10 days since symptoms first appeared
• Other symptoms are improving

Immunocompromised children can be infectious for a longer period of time. Consult with a health care professional and the local health department regarding the child’s specific underlying condition and the safest time frame to return to school.

If initial testing is negative: Students can return to school once fever free for 24 hours AND other symptoms improving. It is to be noted, testing can be negative early in the disease process and does not eliminate that COVID-19 is the cause of the illness. Hence it is imperative to continue to wear face masks, perform hand hygiene and maintain physical distancing at school.

If an asymptomatic student is COVID-19 positive: He/she should stay home for 10 days following the date of their positive test.

5. Should asymptomatic students whose family members are COVID-19 positive stay home from school?

Yes, according to the CDC guidelines, students with a positive household contact are considered exposed to COVID-19 and should quarantine at home for 14 days. School officials should communicate with the local department regarding testing of the asymptomatic contact and guidelines regarding ending of quarantine and return to school.

Reference: CDC Contact Tracing 

6. How long is a symptomatic person contagious? What about an asymptomatic person?

Studies have shown that the concentrations of SARS-CoV-2 RNA (a measure of the quantity of virus) in upper respiratory samples decline with days of illness. For patients who are asymptomatic or have mild to moderate illness, contagious viral particles generally decline after 10 days following symptom onset or 10 days after the positive test if the person remains asymptomatic. In patients with severe disease or in immunocompromised patients, contagious viral particles are not detected beyond a maximum of 20 days following symptom onset in available studies.

7. If children test positive for COVID-19 and continue to test positive even though their symptoms have subsided, are they still contagious?

No, they are not considered contagious as noted above. Recovered persons can continue to shed detectable SARS-CoV-2 RNA in upper respiratory specimens for up to 90 days after illness onset, but at concentrations significantly lower than during illness and contagion is unlikely beyond the 10 (mild, moderate) to 20 (severe illness) days of illness.

8. Can kids of all ages be tested for COVID-19?

Yes, infants, children and adolescents of any age can be tested for SARS-CoV-2.

Testing

What are the acceptable tests for COVID-19 available in the community?

Per CDC, below are acceptable specimens for RT-PCR testing for COVID-19:

• A nasopharyngeal (NP) specimen collected by a health care provider; or
• An oropharyngeal (OP) specimen collected by a health care provider; or 
• A nasal mid-turbinate swab collected by a health care provider or by a supervised onsite self-collection (using a flocked tapered swab); or
• An anterior nares (nasal swab) specimen collected by a health care provider or by home or supervised onsite self-collection (using a flocked or spun polyester swab); or
• Nasopharyngeal wash/aspirate or nasal wash/aspirate (NW) specimen collected by a health care provider

Reference: CDC Guidelines – Clinical Specimens

However, there are studies demonstrating lower sensitivity of anterior nares swabs as compared to NP or OP samples.

Antibody tests do not detect current, active infection. A positive test likely indicates a past infection with SARS-CoV-2. However, it is unclear how often patients with previous COVID-19 infection make antibodies that can be detected with this test.

Antigen POC/Rapid testing for COVID has a low sensitivity rate, meaning there is a high percentage of false negative results. Point of care PCR tests such as the Cepheid GeneXpert® Xpress are more sensitive than antigen tests and are less likely to give false negative results.

With any testing, negative result at one point in time does not mean that someone may not test positive at a subsequent date/time. Testing may be negative in a person with COVID-19 if the test is performed too early [during the incubation period], if the specimen is not collected correctly or if the test that is used is not very sensitive.

Personal Protective Equipment (PPE)

1. Can you recommend PPE for school nurses in an indoor setting?

When interacting with a person in school with symptoms of COVID-19 or who is known to have a positive test result, a face mask and eye protection [goggles or a face shield] should always be worn by the caregiver, who also should wear an isolation gown and gloves whenever physical contact is anticipated. It should be noted that regular glasses are not considered a substitute for goggles/face shield. In general, an N95 respirator mask requires fit-testing which is not usually available to schools; a poor fitting N95 mask may offer less protection than a properly worn face mask. However, arranging for N95 fit-testing for a school nurse or other likely caregiver and then having a supply of the appropriate size N95 masks would be ideal. Regardless of the type, the facemask should cover both the nose and the mouth.

According to the AAP:

“School staff working with students who are unable to wear a cloth face covering and who must be in close proximity to them should ideally wear N95 masks. When access to N95 masks is limited, a surgical mask in combination with a face shield should be used. Face shields or other forms of eye protection should also be used when working with students unable to manage secretions.”

2. What is the difference in wearing a face mask and a face shield? Do you have a preference?

A face mask covers just the mouth and nose while goggles or a face shield protect the eyes. We don’t know how often transmission of SARS-CoV-2 occurs through the eyes and other membranes but we know that it occurs with other similar viruses. Eye protection is considered to be an essential part of PPE for COVID.

3. How often should a face mask be changed?

A face mask should always be changed after interacting with a person with symptoms compatible with COVID or known to be COVID test positive. Without such exposures, it can be worn for several hours, but should always be changed if it becomes damp or soiled.

4. In a classroom setting, if students are 6 feet apart, can they remove their masks?

The combination of distancing and masking is more effective than either used alone. Droplets can be projected more than 6 feet by a forceful cough in older children or adults. Distancing by 6 feet or greater provides protection but that protection will be enhanced by also wearing a face mask.

5. Should a school nurse wear a N95 mask?

Proper use of an N95 mask requires fit-testing to ensure that a mask of the proper size and shape is used to conform to the size and shape of the person’s face. An ill-fitting N95 mask may provide poor protection and give a false sense of security to the wearer. It would be ideal for school to arrange for a school nurse or other likely caregiver to a person at school who develops COVID symptoms or tests positive to undergo fit-testing and then to supply that person with the proper N95 mask. An appropriately fitted N95 mask should be considered only if the school nurse is performing an aerosolizing generating procedure, such as a nebulizer treatment.

6. Should teachers wear a N95 mask?

It is not recommended for teachers to wear an N95 mask during usual activities. Distancing and a face mask should provide adequate protection and more comfort.

Students with Underlying Health Conditions

1. Should children with underlying health conditions return to school in person?

The decision for children with underlying health conditions to return to school in person depends on a variety of factors including the overall physical and emotional health of the child, presence of high risk underlying medical conditions, ability to learn virtually (and access to virtual learning environment at home), extent of community spread, the family structure and finances, and parental/child’s comfort level. Consultation with a health care professional regarding the child’s specific underlying condition and risk/benefits of going to school should be sought.

2. Are there extra precautions required for students with inhalers with or without spacers? Can students use their own inhalers in the classroom?

Students can use their inhalers with or without a spacer at school and self-carry their inhalers. Attention should be paid to proper hand washing before and after use. As an extra precaution, they should use the inhaler outside of the classroom where other students are present. Asthma treatments using inhalers with spacers are preferred and recommended over nebulizer treatments whenever possible to decrease possible airborne spread.

3. Is an N95 mask required for nebulization treatment in school? How would you clean the room after nebulization if needed?

The CDC recommends that nebulizer treatments at school should be used only in an emergency, reserved for children who are unable to use or do not have access to an inhaler and only used if no alternative option is available. Nebulization treatment is an aerosol-generating procedure and should be the last resort on school premises. According to the AAP guidance:

“[S]chool health staff should wear gloves, an N95 facemask, and eye protection. Staff should be trained on proper donning and doffing procedures and follow the CDC guidance regarding precautions when performing aerosol-generating procedures. Nebulizer treatments should be performed in a space that limits exposure to others and with minimal staff present. Rooms should be well ventilated or treatments should be performed outside. After the use of the nebulizer, the room should undergo routine cleaning and disinfection.”

4. Why is obesity such a big risk factor for COVID-19?

According to the American Heart Association, there are multiple pathways by which obesity and excess ectopic fat increase the risk of COVID-19 complications. Obesity in general reduces cardiovascular fitness, increases the risk of blood clots, reduces respiratory reserve, impairs many metabolic responses, and can cause impaired immunity. The impaired immunity can reduce the body’s ability to fight COVID-19 infection, and also can help cause an immune response that actually makes the effects of the COVID-19 infection worse.

5. If we have medically-complex students who are not able to wear a mask, how should we help keep them and the other students stay safe?

Medically complex students are generally at a higher risk of severe infection but also at high risk of being negatively affected by virtual learning. Smaller class sizes, meticulous hand hygiene, physical distancing (especially if unable to wear a mask), wearing of masks (if feasible) and cohorting them from other students as feasible are especially important to reduce their risk of infection.

According to the AAP:

“School staff working with students who are unable to wear a cloth face covering and who must be in close proximity to them should ideally wear N95 masks. When access to N95 masks is limited, a surgical mask in combination with a face shield should be used. Face shields or other forms of eye protection should also be used when working with students unable to manage secretions.”

Fit-testing for N95 masks is recommended prior to its use.

6. Should students with asthma wear a mask?

Yes, students with asthma should be able to wear a mask.

Miscellaneous Questions

1) What’s the best way to disinfect the room once a student, teacher or staff member with suspected COVID-19 infection leaves the room?

Outdoor areas generally require normal routine cleaning and do not require disinfection. Indoor areas or rooms should be cleaned with an EPA-approved disinfectant that is effective against COVID-19, which may include ready-to-use sprays, concentrates, and wipes. Proper PPE (face mask, goggles, and gowns) should be worn when cleaning and disinfecting. Outside doors and windows should be opened if possible to increase air circulation in the area. It is recommended to wait 24 hours before cleaning and disinfecting the area if possible; if 24 hours is not feasible, waiting as long as possible is acceptable. 

CDC – Cleaning and Disinfecting Your Facility

2) What is MIS-C?

Multisystem inflammatory syndrome in children (MIS-C) is an inflammatory condition that has been seen in children infected with SARS-CoV-2, when different organ systems (heart, kidneys, brain, skin, eyes, and gastrointestinal tract) become inflamed. The exact cause of MIS-C has not been determined. Children who have been diagnosed with MIS-C either have been diagnosed of having the virus or exposed to someone with the virus. The onset of MIS-C can be several weeks after the initial COVID-19 infection, and that initial infection can cause typical symptoms or be asymptomatic. Children with MIS-C often present with some combination of fever, chills, fatigue, vomiting, diarrhea, abdominal pain, red eyes and rash. Any child who experiences these symptoms after having been diagnosed with COVID-19 should be brought to medical attention immediately.

3) What is considered an outbreak and when does schools need to shut down?

Any positive case(s) of COVID in a school should be promptly reported to the school community. There is no clear definition for a COVID outbreak. According to the CDC, the decision to close schools should be made together by school administrators and public health officials. The decision also needs to be communicated appropriately to students, staff, parents, caregivers and guardians, and all community members. There will almost certainly be situations that will necessitate quarantine of specific classes or even temporary school closure due to positive COVID-19 cases in schools. Parents, educators, and school administrators should be prepared for this in the event that it occurs, while actively working to prevent it through prevention and mitigation practices. 

Texas Education Agency – Public Health Guidance for School Year 2020 -2021

4) What do “well-ventilated” and good “air circulation” mean?

The term “ventilation” refers to the amount and direction of airflow – or “air circulation” – within a room or space. This can actually be measured in closed rooms and spaces by facilities personnel. Inside of a building, the ventilation is determined simply by the amount of air that is pumped into and leaves the room; the more air that moves, the better the ventilation. Normally, this is determined by the settings for fans, air conditioners and heating of a room. However, ventilation often can be increased by the opening of doors and windows, especially if they are positioned across from each other to create directional airflow.

5) What is benchmark for high or low community transmission?

Unfortunately, this question has not yet been answered in the context of determining the level of community transmission at which it is safe to reopen in-person school. Countries in Europe and Asia that have successfully reopened schools with little increase in infection rates had previously established COVID-19 case rates in the community of less than 5 per 100,000 persons, a rate that is much lower than the current (as of September 20, 2020) rate in some parts of the U.S. To be truthful, this question will be answered as schools reopen in various parts of the USA and community and school rates of infection are subsequently measured.

Dr. Starke is a Professor of Pediatrics at Baylor College of Medicine and works at Texas Children’s Hospital in Houston, Texas. He lives in Bellaire, Texas.