After the COVID-19 pandemic struck in spring 2020, all but five states had closed schools as of the end of March, colleges and universities were sending students home, and child care all but disappeared. Understanding that the economy cannot reopen until child care and schools reopen, it is essential to have timely, accurate, and authoritative federal guidance and information for states, tribes, and cities and for educational settings, which house nearly 90 million students and staff. Every educational setting must have a functional infection prevention and control plan for operating its facilities and managing occupants and the flexible funding to carry it out. There is a need for research on the SARS-CoV-2 virus and its impacts on children as well as adults. Only through uniform infection prevention and control guidance will we reduce the risk of significant COVID-19 infections in educational settings, which also provide food and mental health services to students and in some cases housing. Such outbreaks not only would be potentially catastrophic for the lives of students, teachers, and other workers but would have dire consequences for educational programs and, because education is a social determinant of health, the future health of the U.S. population. The tragedy is that the poorest communities hit hardest by COVID-19 — Black, Latinx, and Native American — will send their children back to the poorest schools, facilities with a lack of ventilation and sanitation. A healthy operating environment is essential to ensuring a safe learning environment for all occupants of our child-care centers, schools, and higher education institutions.
Relationship to Existing APHA Policy Statements
- APHA Policy Statement 200010: Creating Healthier School Facilities
- APHA Policy Statement 200011: The Precautionary Principle and Children’s Health
- APHA Policy Statement 20131: Endorsing Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Early Care and Education Programs, Third Edition
- APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States
- APHA Policy Statement 20158: Preventing Occupational Transmission of Globally Emerging Infectious Disease Threats
- APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
- APHA Policy Statement 201713: Establishing Environmental Public Health Systems for Children at Risk or with Environmental Exposures in Schools
The COVID-19 pandemic has had an outsized impact on the U.S. economy and on children of all ages. Younger children and those with disabilities may not recover quickly or fully from the loss of school days.
- Child Care: More than 12 million children younger than 5 years, or about two thirds of all children in that age group, are in regular child care, making it a $47.2 billion industry engaging 1.5 million providers. Access to child care is an essential service in some areas, yet frontline workers and working families still have challenges finding accessible, affordable, and reliable slots. It is a fragmented industry with piecemeal approaches. In a pandemic, more public health support, food and nutrition support, and research on children and SARS-CoV-2 infections and transmission are needed. A new study showed that within the context of considerable infection mitigation efforts in U.S. child-care programs, exposure to child care during the early months of the U.S. pandemic was not associated with an elevated risk of COVID-19 transmission among providers.
- Prekindergarten through 12th-grade (PK–12) public and private schools: Every U.S. state has compulsory education laws, resulting in approximately 56 million children enrolled in more than 125,000 public and private PK–12 schools and over 7 million employees. The nation’s taxpayers spent close to $649 billion on U.S. K–12 schools in 2015 according to a survey from the National Center for Education Statistics. Public school students are well characterized in federal data: more than half are children of color (53%), 29.9 million use subsidized meal programs, 7.1 million are in special education, and 25% have chronic health conditions.
- Higher education: Approximately 16.6 million students are enrolled in higher education institutions, including 2-year and 4-year colleges and universities. Adult learners may also be enrolled in postsecondary trade schools.
Child-care organizations and schools, at both the PK–12 and postsecondary levels, are important institutions to families and communities. In addition to the education provided through these institutions, licensed child-care centers and K–12 schools provide a range of social and health support services to their students and families. Many of the services provided are difficult to access outside of educational settings, so many families rely on child care and PK–12 public and private schools to help their children maintain and improve their physical and emotional health and development. Educational institutions also have a critical impact on our economy and the productivity of our workforce, with many families relying on child care and schools to provide a safe place for their young children during the workday. Many college and university communities rely on the economic activity of the campus and students to support the larger economy; a substantial number provide housing and food service to enrolled students.
The decisions at the state level to recommend closing educational settings at the beginning of the pandemic in the United States, especially public schools, cut across all communities. School closures were recommended by the Centers for Disease Control and Prevention (CDC) and carried out by states, districts, and public and private entities, yet the White House message was that the virus would go away and the pandemic was a hoax. Inconsistent messaging over the effectiveness of different preventive measures (e.g., social distancing and wearing a mask) resulted in inconsistent use of such measures in the community and skepticism of such requirements in educational settings. This established a chain of confusion that persists today and that has compounded the challenges of caring for and educating the next generation.
While educational leaders could have benefited from faster, more complete information on the SARS-CoV-2 virus that causes COVID-19 and how it impacts all children and adults, including longer-term post-infection effects as well as how the virus is transmitted, by whom, and at what stage of exposure and infection, this information was not available in the early stages of the pandemic.
Although new findings on this virus and its transmission are published every day, the data that have been published have not been sufficiently timely or detailed to meet the needs of education and public health policymakers for specific information on how and under what conditions to reopen educational facilities and keep them open. Because many child-care programs, PK–12 schools, and colleges and universities were closed at the beginning of the pandemic and have only recently reopened, data are just emerging in fall 2020 about the risks of transmission in educational settings. We do not yet have sufficient information on how to ensure safe long-term functioning of educational settings in a way that will minimize risks to children, students, teachers, and other personnel, creating additional stress for communities, cities, and states. An unexpected challenge is how political pressure has influenced the guidance or findings published by the CDC and other agencies.
However, epidemiological surveillance of SARS-CoV-2 cases consistently shows that those younger than 20 years are at the lowest risk for experiencing symptoms serious enough to require hospitalization. While there have been few cases of deaths among youth attributed to SARS-CoV-2, very little is known about factors that lead to serious cases in youth and how to protect those most at risk. Published research to date seems to show that youth 10 years or younger are both less likely to experience symptoms as a result of infection and to transmit the disease to others. There is also evidence that minority youth and youth with preexisting health conditions are more likely to experience severe outcomes due to infection. However, among older youth and young adults (10–20 years), their risk of contracting serious disease and transmitting the disease to others is higher and more closely resembles that among other adult age groups. Furthermore, there is some evidence that older youth and young adults are heavily influenced by social media and their peers to not adhere to preventive measures, including wearing a mask and social distancing, raising questions about how likely they are to be infective and the potential risk of transmission by this age group in educational settings.
Schools and child-care settings are densely occupied, more so than offices or nursing homes, and are thus potential locations for high rates of transmission of the COVID-19 virus. The nature of educational settings requires multiple close interactions among individuals every day in their classrooms, as they move among different classrooms, and when they are being transported to and from their buildings. For this reason, limiting the number of students in a space at one time to achieve social distancing has been a recommendation for controlling the spread of the virus, and many PK–12 schools and higher education institutions have moved to full-time or part-time online learning. Unfortunately, there is limited evidence on the effectiveness of online learning for students of varying ages and educational abilities, so questions remain regarding the long-term educational impact of school closures.
Moreover, about 40% of all public school students have been found to lack Internet access or a device to go online, making distance learning an out-of-reach alternative accessible only to students in well-resourced schools or with well-heeled parents. But the challenge does not stop there: if both parents work, and pre-pandemic many did, then who stays at home or works at home in order to monitor online devices and classes? Furthermore, children with disabilities have also been left behind.
While there are insufficient data about specific physical conditions in child-care and higher education settings, it is well documented that the nation’s PK–12 public schools, enrolling 50 million children, are generally in poor condition, including a lack of ventilation and sanitation. They are not required to have infection control plans, and only one state has a nurse in every school (personal communication, National Association of School Nurses, July 2020). It has also been documented that the poorest children in the poorest communities hit hardest will return their children to the schools in the worst physical condition.
Inconsistencies in guidance between the CDC and the U.S. Environmental Protection Agency (for example, on indoor air and ventilation and on cleaning and disinfecting), as well as differences with individual state departments of health regarding various topics, have led to many questions and uncertainties around controlling the risks of transmission in child-care, school, and higher education settings. As noted, an unexpected challenge is that there are questions about the extent to which federal political pressure has influenced the guidance and findings published by the CDC and other agencies.
In addition, there are serious questions about whether the many U.S. educational facilities that lack ventilation and sanitary conditions are even prepared to house quality education and other services in a manner that minimizes the risk of SARS-CoV-2 transmission. Also in question is whether they have adequate stockpiles of masks and personal protective equipment (PPE) or the capacity to test, trace, isolate, and report new cases to local public health agencies or even to reopen closed drinking water systems that accumulate lead and bacteria during prolonged closures.
- Cleaning: Although educational organizations are familiar with cleaning processes and have the supplies necessary to manage ordinary occupancy issues, this virus requires them to secure additional cleaning and disinfecting supplies and personal protective equipment.
- Air quality and ventilation: While the Environmental Protection Agency and independent researchers knew that the virus was airborne and potentially infective and that schools generally had poor or no ventilation, it was not until early October 2020 that the National Academies of Sciences, Engineering, and Medicine published its final report on reopening schools and the CDC announced that the virus could be transmitted through the air, meaning that many child-care programs, schools, and colleges had already opened without enhanced ventilation.[14,15]
The current models for child-care and education funding have created challenges not anticipated before the pandemic. First, most PK–12 facilities in which education takes place are not federally funded or monitored, and states have adopted different models for funding their public schools using state and local funds. Second, public funding for educational program services from all levels of government is highly regulated, restricting the ability of local educational leaders to shift line-item funding to meet critical needs during a time of crisis. Educational settings rely on a mix of private (i.e., tuition) and public funding sources, and all of these sources were negatively affected by the economic slowdown caused by the pandemic, resulting in both decreases in funding for services and limited flexibility to move remaining funds to cover essential services. This includes the ability to provide support for distance learning or for students who do not have access to technology or the Internet at home, as well as the ability to provide auxiliary services normally received in an educational setting, such as mental health services and free and reduced-price meal services. Most egregiously, many children with special education needs guaranteed under federal law could not receive services remotely. Many PK–12 and higher education institutions have transitioned to using online learning to minimize possible exposures of students and staff while still meeting the educational needs of their students. However, there is little research on the effectiveness of online learning for PK–12 and higher education students and even less on the impact of this learning model on the social and emotional well-being of youth and young adults. In addition, many households do not have equitable access to the technology and Internet service necessary for participating in school from home, potentially exacerbating existing disparities and requiring educational institutions to provide the needed technology to students without further funding or the opportunity to move funding from different sources to cover such costs.
During the pandemic, school food operators around the country have stepped up to ensure that students have access to meals while schools are closed, and varying learning models are being implemented. School meals are a vital lifeline for millions of students around the country, with almost 15 million students eating school breakfast and almost 30 million eating school lunch every day before the pandemic. More than three fourths of those students were from low-income households and received free or reduced-price meals.[16,17] These school meals provide nutritional benefits while supporting and improving the physical and mental health of those who participate in the program. Studies have also shown linkages between school meals and improved learning outcomes. Many teachers can attest that a child who is hungry has a difficult time focusing, which can lead to reduced learning capabilities.
Unfortunately, initial reports show that these school meal programs are not reaching the number of students as in the past. Even with reduced participation, school meal programs are affected by rising costs including PPE, packaging products, transportation and holding equipment, and labor adjustments. Many school food operators are struggling to offer their normal scratch-made meals and fresh fruits and vegetables due to the challenges of varying meal service models and initial concerns about COVID-19 transmission via food, which led to a reliance on prepackaged processed meals. Although waivers were introduced by the U.S. Department of Agriculture (USDA) to create flexibility within meal programs, the time-consuming process to have waivers improved and implemented requires action at both the state and local levels. Furthermore, the waivers were initially extended incrementally, leading to much uncertainty around reimbursement and the ability of local programs to provide food. Congress recently acted to allow the USDA to extend waivers through June 30, 2021, but there is still a great deal of uncertainty regarding the future of this program.[20,21]
Without clear and consistent federal leadership and guidance during a pandemic, coordinated across federal, state, and local public health authorities, those responsible for child-care settings, public and private schools, and higher education campuses are left with attempting individually to determine how to provide education and other necessary services to their students while also protecting their health and the health of communities by minimizing the risk of transmission.
Detailed and consistent requirements and authoritative public health guidance on how educational settings can operate safely, including template infection prevention and control plans to be adopted by licensed child-care and PK–12 schools and higher education institutions that address appropriate ventilation, cleaning and disinfecting, water system management, and other facility needs, as well as staff and student management addressing screening, masking, distancing, hand hygiene, and appropriate PPE, are lacking, and funding is often not available to implement strategies to make these settings safe. In addition, the need for accommodations for high-risk students and staff who have preexisting conditions or age-related risks, live with first responders, or are homeless must be part of any school reopening plans. Instead, our educational system has experienced a piecemeal approach to restarting educational activities that sows confusion and deepens disparities as wealthier communities and their schools and child-care settings can find and buy what they need while others are unable to provide education and support to their youth.
Evidence-Based Strategies to Address the Problem
To facilitate evidence-based policy-making by local educational leaders, the nation must restore credible federal leadership and a pandemic task force led by qualified public health scientists and improve surveillance of SARS-CoV-2 and its effects on children. The resulting information will help not only parents and families but also policymakers determine what steps are appropriate and essential to reopen and keep open community educational facilities. Education and health agency leaders also need to better understand transmission risks and how to mitigate them in classrooms and other educational spaces as well as during extracurricular activities, including athletics and music. This must be a joint effort between educational organizations and public health experts so that the requirements to be followed for reopening and any research data collected can inform both policy-making and decision making.
In addition, we need more research on the social and emotional benefits of children simply attending school with their peers. This would help balance the risks of COVID-19 transmission with the mental, social, physical, and emotional needs of students. We need a better understanding of the role schools play in meeting these needs and how the closure of educational settings has affected all students (e.g., which students have succeeded, which have not and why), as well as more research on the characteristics of children who do well or do not do well with online learning. This will require both short- and long-term surveillance. We also need continued surveillance that shows the true impact of the virus on younger populations, including the true rates of transmission and infection and longer-term health and learning post-infection impacts. A system should be established for long-term surveillance of health effects on those infected with COVID-19 as children, young adults, and school staff members. Establishing a system for both short- and long-term surveillance of the impact of the pandemic on all school occupants will help schools, communities, and public health agencies plan and prepare for any future pandemics.
It is also necessary to address the funding of educational services at all levels to both allow for a significant investment in the physical and technological infrastructure of our educational facilities and give educational leaders greater flexibility in using available funds to address critical needs in a time of crisis. Failure to critically examine the funding structure of educational services will likely result in increasing disparities in the services available to students based on the resources available to their institution.
Continued research and data are needed to document the varying waivers and local implementation of those waivers relative to effects on school meal participation, meal quality, the social and emotional health of students, and school meal finances. Data are incredibly valuable at this point as we look to address the growing food insecurity crisis and identify avenues through which varying flexibilities could provide opportunities to increase access to meals.
It is difficult to assess the opposition to using public health measures to control the pandemic in the current politicized operating environment. Opponents have chosen politics over public health and opposed changes made to educational institutions during the pandemic, including closing buildings and transitioning to online education. They argue that younger individuals are the least likely to become seriously ill or die from COVID-19. They argue that the risks for those younger than 20 years are minimal and that the risks of isolating youth and young adults are more significant. These arguments ignore what happens to teaching and custodial staff and the spread of take-home viruses to families.
While there is evidence that youth and young adults are effective at spreading the virus, opponents of restrictions for educational settings point out that many outbreaks occur at locations without protective measures in place, including requiring all participants to wear a mask and requiring adequate social distancing. Opponents also argue that many child-care centers, schools, higher education institutions, and summer camps were able to bring together youth and young adults safely without an outbreak. In addition, they argue that many non-educational businesses and organizations have opened safely and that educational organizations should be able to do the same. This seems to ignore the resurgence of infections taking place now in more than 30 states and ignores that colleges and overnight camps can control occupants, whereas children moving in and out of schools and child-care programs have more opportunities for community exposures. At this writing, it is too soon to determine how colleges and universities have fared, particularly those that required all incoming students to self-quarantine for 2 weeks and/or required routine testing on campus.
Some argue that it would be more effective to open all parts of the economy, including the education sector, to develop herd immunity. They point to countries such as Sweden, which had more limited restrictions than other parts of Europe and the United States. However, Sweden has since been revealed to have had high death rates and tough impacts on its economy.
There are also arguments against the effectiveness and quality of online schooling, especially for younger students and students with additional educational and social support needs. Concerns are expressed by opponents as to whether students are receiving all of the support required by state and federal laws. Many also are concerned about the impact to the mental and emotional health of youth and young adults who are isolated from their peers.
- The administration should restore the White House Pandemic Task Force and restore its scientific public health leadership as the designated source of federal communications about the pandemic with the U.S. public. Consistent and evidence-driven leadership will help educational authorities make decisions regarding appropriate COVID prevention strategies.
- The administration should invoke the War Powers Act to drive private production of needed supplies and equipment, including distribution of supplies to licensed child-care centers, PK–12 schools, and institutions of higher education.
- The administration should activate the Strategic National Stockpile to ensure that supplies needed in educational settings are readily accessible and affordable.
- Congress must provide COVID-19 bailout funding for child-care programs, PK–12 schools, and higher educational facilities to improve ventilation and fresh air, install hand-hygiene stations, ensure safe drinking water, repair lavatories and vent them to the outside, vent nurses’ suites to the outside, ensure that every classroom space has at least one window that opens, and hire the additional educational, health services, and facilities staff necessary to provide a safe and nurturing educational environment.
- The CDC and state and local public health entities must scale up testing, tracing, and isolating of individuals to ensure that community outbreaks and outbreaks occurring at educational sites can be quickly identified and controlled.
- The CDC must develop and disseminate authoritative public health guidance to state public health agencies on infection prevention and control measures, including a template infection prevention and control plan for educational settings to adopt as part of their “all-hazard emergency plan,” describing how each educational facility will work to reduce the facility viral load and risks of infections through facility and occupancy management and appropriate accommodations for high-risk/high-needs individuals.
- The CDC, in partnership with local, state, and federal departments of education, must develop and implement a surveillance system documenting the short- and long-term mental and physical health impacts of the pandemic on children, young adults, and adults working in education to provide an evidence base for future decisions.
- Congressional and state emergency appropriations must allow for flexible use of education funding so that child-care programs and schools can safely reopen.
- Congress and the U.S. Department of Agriculture must continue to allow waivers for school meal programs. Waivers such as noncongregate meals, meal service times, and allowing parents and guardians to pick up meals would provide more opportunities for children to access meals. Simplifying the authorization and implementation of waivers for the entire 2020–2021 school year is a crucial first step. Offering meals to all students at no cost during and beyond the pandemic is a critical step to ensuring that students’ nutritional needs are met, giving them the opportunity to focus on learning while addressing the growing food insecurity crisis that has been exacerbated by the pandemic.
- Federal, state, and city governments should invest in state and local public health agency capacity to assist child-care programs, schools, and higher education entities with infection control issues; testing, tracing, and isolating; reopening water systems; and reporting new infections.
- The National Institutes of Health must make funding available to study the health impacts on children in child care, students and educational staff in schools, and those in higher education, including the success of various preventive interventions and the social-emotional well-being of students and staff. Funding for research on the effectiveness of distance-learning environments (e.g., in terms of emotional health) should also be provided.
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