Preparing Public Schools in the United States for the Next Public Health Emergency: Lessons Learned from COVID-19

Abstract
Along with child-care and higher education institutions, public kindergarten through 12th-grade (K–12) schools, including prekindergarten programs, were among the first institutions impacted by the COVID-19 pandemic. K–12 schools have since experienced frequent changes in their operations, and many students and their families have experienced uncertainty in their home and educational environments. It is essential that public health and educational leaders have timely and accurate data and federal guidance specific to these settings to make decisions regarding how and whether to open buildings. Every K–12 school must be prepared to protect the health and safety of students and staff by implementing comprehensive infection prevention and control plans and disease surveillance systems, mitigating the risk of community spread during outbreaks, and carrying out plans for alternate learning models. Public K–12 schools must be a priority during public health emergency and preparedness activities given their impact on the economy and critical role in providing educational, social, and health services. Failure to prepare schools for infectious disease outbreaks could be catastrophic for the lives of all working in and served by these institutions. Particularly for Black, Latinx, and Native American communities experiencing high levels of economic and health disparities, it is necessary that students and staff return to schools that have the resources to improve their physical, educational, and emotional environment to mitigate disruptions and continue to provide critical services. A healthful and prepared learning environment is essential to ensuring the success of all K–12 schools.

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
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

Problem Statement
Public kindergarten through 12th-grade (K–12) schools are a critical part of every U.S. community. Every state has compulsory education laws, and the United States spent more than $752 billion on its public K–12 schools in 2019.[1] This funding supported approximately 49 million children and more than 7 million professionals in approximately 100,000 public K–12 schools.[2] More than half of children attending public schools are children of color (52.4%), and over 40% of students have at least one chronic health condition.[3,4] In addition to instruction, U.S. public K–12 schools spend an average of $743 per pupil for a range of services supporting the health, development, and welfare of children, their families, and the community at large, including guidance and mental health support, health services, and speech pathology interventions.[5] Schools are also critical in meeting the food needs of students and families, and almost 30 million children use subsidized school meal programs.[3] Mental and physical health and wellness services are particularly important in communities with limited access to such services, especially for the 7.1 million children receiving special education services.[3]

Even before the pandemic, many K–12 districts were unable to meet the needs of their communities. Particularly in minority communities, districts struggled to address the physical and environmental conditions of their buildings, including poor indoor air quality, ventilation, drinking water, and sanitation.[6] Many schools did not have the health professionals needed to support the physical and mental health of their students, including school nurses and mental health professionals.[7,8] There were disparities among districts on attributes such as availability of technology for student and staff use, ability to recruit and retain staff, and class size.[3,9]

The COVID-19 pandemic had a sudden and drastic impact on public K–12 schools and exacerbated the existing challenges and disparities. While there is a growing field of global research focused on education during emergencies, the strain on the U.S. education system during the COVID-19 pandemic was unique in recent history as schools were closed across the country and students and staff had to create new ways of learning.[9] Schools worked to minimize disruptions to support services critical to their communities, although some cannot be provided through virtual platforms.[10] All of this was done in an uncertain environment, as it took over one year for public health authorities to confirm COVID-19 as an airborne virus and schools did not have accurate, timely information on how to safely provide services while minimizing the risk of virus transmission.

The COVID-19 pandemic fell hardest on Black, Latinx, and Native American communities, exacerbating disparities already seen among public K–12 schools nationwide. The National School Lunch Program provided 45 million meals to students in 2019; the loss of these services resulted in an increased risk of food insecurity for millions of households.[11,12] Over 1.5 million K–12 students were homeless before the pandemic; even with action to freeze evictions during the pandemic, millions more students and families faced housing insecurity and income losses as the pandemic continued.[13] School-based health centers strove to remain open given their role in providing services for students with limited access to health care.[14]

The impact of the pandemic on health and wellness services offered through schools is still unclear. Early research on substance use and abuse among K–12 students during the pandemic has yielded mixed results, but studies have shown that the pandemic created conditions similar to those that led to increased substance use among adolescents in the past.[15] Other research on K–12 students has shown increased anxiety and depression during the pandemic, exacerbated by social isolation, lack of physical exercise, and additional family stress.[16] Data on how the pandemic affected the physical safety of children are not yet available, but research shows that the pandemic did create risk factors for child maltreatment.[17] Unfortunately, the full impact of the pandemic on the health, safety, and wellness of K–12 students is not likely to be fully understood for several years.

The closure of schools in 2020 made sense to reduce disease transmission but exposed challenges that K–12 teachers and students face in virtual learning environments. Many students and teachers were not prepared to learn in a virtual environment. About 40% of all public school students lacked Internet access or a device to go online prior to the pandemic, and studies show differences in students’ access to technology based on multiple factors.[3,18] Some studies published during the pandemic attempted to model possible learning loss and exacerbation of learning disparities, but questions remain as to the degree to which virtual learning may have exacerbated existing educational and social disparities.[3,18,19] Although very little has been published to date showing the effectiveness or impact of online learning with respect to educational outcomes and student well-being, this evidence is important as school districts grapple with how to direct their resources to support students faced with learning loss and deficits in social and emotional learning.

Many educators were not prepared to teach effectively online, nor were they prepared to support their students using technology. Research on online learning strategies for students, particularly those with physical and learning disabilities and English language learners, is limited, and many educators had not been trained on how to best support students in a virtual learning environment. Degree of educator readiness to teach online was related to the availability of professional development and technology training, and this varied greatly between wealthier and poorer districts.[9,20] Education is a key social determinant of health and is critical to future economic opportunities; therefore, the potential for long-term impacts of these disparities in access to learning in online environments is significant.[18]

It is unknown how many public K–12 schools had the infrastructure needed to mitigate the environmental risks of in-person education. Thousands of school buildings were in need of updated or new heating, ventilation, and air conditioning systems before the pandemic.[21] These conditions are even more concerning in schools in poor districts and districts with an older education infrastructure, where buildings are in worse condition and may be overcrowded.[3] Although billions of federal dollars were made available to assist schools during the pandemic, early rounds of COVID relief funds did not prioritize indoor air or ventilation infrastructure in K–12 schools.[22] Schools needed to secure personal protective equipment for staff, additional or different cleaning and disinfecting products effective against the virus, equipment and staff for their buildings, and temporary barriers to help keep students distanced from each other so that in-person learning could be resumed safely. In May 2021, guidance from the Centers for Disease Control and Prevention (CDC) was updated to prioritize improved ventilation along with other mitigation measures such as mask wearing, vaccination, and physical distancing (disinfecting was dropped as a top priority).[23] To date, there are no reports or research focused on how public K–12 schools, particularly in poorer districts, have used pandemic funding to address environmental conditions related to mitigation of COVID-19 and healthier school environments overall.

Educational leaders and policymakers were challenged early on by the paucity of timely and relevant data on the COVID-19 virus. Although the CDC established a case definition for confirmed and probable cases, states reported data differently. Of relevance to schools, states reported only limited data on the number of positive cases among children and used different age ranges, making it difficult to compare and collate data to gain a greater understanding of the impact on children.[24] Since testing in most states was prioritized in the early months of the pandemic for individuals exhibiting symptoms and children were most likely to have asymptomatic cases, children were likely undertested and the number of reported positive cases among school-aged children was underreported.

Public K–12 schools had many questions and concerns regarding the safety of their staff as well, particularly older educators and staff with responsibilities that placed them at higher risk of exposure to the virus (e.g., hands-on therapy and special education staff, bus drivers, custodians, and school lunch personnel).[25] Most schools looked to medical and public health experts to help develop plans and balance the risks to their students and staff with the potential harms caused by virtual learning. Many schools required that educational staff return to in-person work prior to the vaccine being available and worked with their state and local health departments to prioritize school staff once vaccines were approved.[26] In the fall of 2021, K–12 schools were considering vaccine mandates for staff at the same time they were faced with difficulty filling all positions and political pressure in opposition to mandates.[27] Unfortunately, financial and political support for local public health agencies and schools to work together on pandemic plans was inconsistent among states and led to additional responsibilities for overworked staff.[28]

With so many questions about in-school virus transmission, the effects of virtual learning on educational and health outcomes, and inconsistent guidance from public health authorities on the risk to students and staff in the school environment, there was much debate over whether schools should reopen beginning in the fall of 2020. The evolution of our understanding of the virus and pressures on public health agencies at all levels to modify guidance resulted in changing and inconsistent guidance to K–12 schools, created confusion, and led some to question the validity of public health recommendations. Organizations such as the American Academy of Pediatrics supported the opening of schools if they could be opened safely.[29] Other organizations, including teacher unions and the National Parent Teacher Association, urged gradually opening schools as supplies and mitigation measures, including adequate personal protection equipment and improvements to school environmental systems, became available.[30,31] The changing communication from public health experts and the politicization of public health actions continue to generate more confusion among state and local education leaders who are ultimately responsible for the health and safety of students and personnel in their facilities.[32,33] They have also created a hostile environment for local and state education and health officials who have implemented mask mandates and other mitigation measures to such an extent that federal, state, and local law enforcement have had to respond.[34,35]

For schools offering an online option to families, resources were needed to support purchasing technology and securing Internet access for students and staff without appropriate Internet service. The demand from families for other support services, such as mental health services and free and reduced meals, increased during the pandemic, placing an additional strain on schools attempting to support their students, families, and staff.[19] For students experiencing homelessness, closure of schools and other public buildings likely meant that they did not have a safe or consistent location from which to learn.[36] School meal programs exemplified the challenges schools faced in attempting to continue important support services. Meal programs were challenged with uncertain funding and rising costs during the pandemic, including with regard to personal protective equipment, packaging of products, transportation and holding equipment, and labor adjustments.[37] Many school food operators struggled to offer their normal scratch-made meals and fresh fruits and vegetables due to the varying meal service models and concerns about COVID-19 transmission via food.[37] Although waivers were introduced to create flexibility within meal programs, this time-consuming process required action at both the state and local levels and reimbursement was uncertain as the waivers were extended incrementally.[38,39] These challenges resulted in school meal programs not reaching the number of students previously reached, even with more community members seeking food assistance from food banks and other community programs.

Relevant case data from K–12 schools began to emerge only in the fall of 2020.[40] Data published since then suggest that K–12 schools have not experienced the spread of the virus seen in congregate living facilities or crowded worksites, although there are examples of school-related outbreaks in the United States.[40] Surges in the pandemic after the start of the 2020–2021 school year were closely tied to younger and unvaccinated populations, including many younger adults and education professionals, demonstrating the risk to all working in K–12 schools.[41]

Increases in both cases and outbreaks in schools in fall 2021 were connected to a more contagious variant and the lack of implementation of evidence-based mitigation measures by schools, including ventilation.[42] By early September 2021, more than 1,800 schools had closed due to COVID. Nationwide data on how many school staff became infected or ill or experienced symptoms associated with COVID-19 were unavailable, including data on how many were at higher risk as a result of age, underlying medical conditions, or likelihood of workplace exposure.[43] There is no system to collect standardized data on disease transmission and infection in schools, illnesses due to environmental conditions in schools, or the health of school staff beyond the annual reporting of the Occupational Safety and Health Administration (OSHA). Without standardized disease and illness surveillance of K–12 students and staff at the local, state, and national levels, policymakers cannot make evidence-informed decisions regarding school outbreaks or environmental health problems that might require remote learning.

The COVID-19 pandemic has shown that public health, environment, labor, and education agencies must work together at all levels of government to effectively take the actions necessary to protect students, staff, and families during emergencies. The piecemeal approach to public K–12 schools during the pandemic and the lack of research addressing what K–12 schools need to know have created confusion and deepened the disparities experienced by Black, Latinx, Native American, and other underserved students in greater need of the services provided by schools to support them and their families at a time of economic and emotional crisis.

Evidence-Based Strategies to Address the Problem
The COVID-19 pandemic made clear that K–12 schools must be designated as a priority for the federal critical infrastructure and be involved in emergency and disaster planning and recovery at all levels of government. This starts at the federal level, where a structure must be in place to respond to future pandemics that includes all federal agencies funding, regulating, or otherwise supporting programs in public K–12 schools. Examples of such agencies are the Department of Education, the Department of Health and Human Services, the Department of Commerce, the Environmental Protection Agency (EPA), the Department of Labor/OSHA, the Department of the Interior, and the CDC (including the National Institute for Occupational Safety and Health [NIOSH]). These agencies must provide credible and consistent leadership and assist tribal, state, and local authorities in making evidence-based decisions on preventive and mitigation measures for K–12 schools, inclusive of clean air, clean water, and clean facilities as an essential part of infection prevention and control. This federal model must be shared with state and local counterparts so that all levels of government are ready to respond to future emergencies in a coordinated manner.

It is important to use best practices already developed through public health preparedness experiences to inform collaboration between the education and public health sectors. Although schools are described as possible community partners in public health preparedness materials, current preparedness guidance does not address the public health implications of disruptions to educational services or include K–12 students and staff as vulnerable populations during a public health emergency.[44] It is necessary to expand public health preparedness activities to intentionally include K–12 education in all planning activities (e.g., tabletop exercises) and identify liaisons between school districts and local public health, environment, and labor agencies so that educational leaders are part of the public health emergency response infrastructure. Inclusion of K–12 schools will also help to establish a “chain of command” during a response and confirm the legal authority of local and state public health agencies during an emergency.

As vaccines are approved for all school-aged students and staff, K–12 schools and public health authorities must work together to build upon existing policies, including mandatory vaccination laws and regulations, to keep students and staff safe as our nation transitions to endemic COVID. This includes adding COVID vaccines to existing lists of required vaccinations for children to enter and stay in K–12 schools and policies governing required vaccinations for school staff. Such actions must involve collaboration among education and public health authorities, parents, staff (including unions), and students so that questions can be addressed in a transparent and open manner. Collaborations such as this can also facilitate vaccine clinics for students, families, and staff in K–12 facilities, increasing access for underserved populations.

Federal agencies must support research and surveillance on school facilities and environmental conditions, virtual learning, and social and emotional impacts of different learning models on children. A national infectious disease and exposure surveillance database for K–12 schoolchildren would provide public health authorities with standardized and consistent data to make timely decisions about educational services during a public health emergency. Research on the social emotional learning of students in different instructional models and the role of schools in meeting noneducational needs should be prioritized and funded, with a specific emphasis on research in racially and ethnically diverse communities. Such research would help decision makers balance the risks of virus transmission with the mental, social, physical, and emotional needs of students and help schools prepare student and staff support services that can be mobilized during an outbreak.[19]

It is 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 funds to address critical needs in times of crisis. We must also examine how educational funding has been used to drive decisions on implementation of mitigation measures (e.g., withholding funding from schools implementing mask mandates). Failure to critically examine the funding structure of educational services has resulted in disparities in the education and support services available to students, including continued funding for noneducational services. Funding must also be made available to support the time necessary for public K–12 schools to work with their public health colleagues to jointly develop and implement comprehensive infection control plans.

Opposing Arguments/Evidence
There have been many disagreements among policymakers and scientists over how to respond to the pandemic, with public K–12 schools the focus of many debates. Local education leaders were left to make decisions that required balancing the risk of the virus to students and staff with the risks of social isolation and learning via unproven models. These decisions were complicated by disparities within communities and public K–12 schools; disparities in access to technology, child care, and health and supportive services; and school buildings in disrepair. Most education leaders do not have the expertise to make such public health decisions, and data are not available to inform their deliberations. Inconsistent guidance from public health authorities has created further disruptions and uncertainty in K–12 school plans.

Opponents of changes made to K–12 public schools during the pandemic, including closing of buildings and transitioning to online education, argued that younger children were the least likely to become seriously ill or die from the virus, that these children were more likely to suffer learning loss, and that overall the risks to students were minimal.[45] Studies conducted during the 2020–2021 school year suggested that schools are not “super spreader” locations as long as they adhere to mitigation measures; however, these studies were not representative of students or school buildings across the United States.[40] Similarly, early international studies showed limited effects of school closures on COVID-19 transmission.[46] Others have opposed mitigation measures in K–12 schools and argued that interventions, including mask mandates, have done more harm to the physical and mental health of children than the virus itself.[47] There have been credible questions from opponents as to whether students eligible for special education services have received all of the support required by state and federal laws. Research on the effect of mitigation measures on preventing outbreaks in schools is ongoing, but the debate continues as to whether the “costs” of school closures were too high or were necessary given the risk of furthering community transmission of the virus; better research and surveillance are necessary to answer these questions for future public health emergencies.[48]

Arguments were made that schools needed to open to support their local economies. Schools provide child-care and nutrition services to low-income and working families, and proponents of reopening schools argued that full access to these services was critical in helping community members experiencing economic hardships, including loss of income and employment and increased food insecurity. Research has shown that the risk of experiencing hardships was higher in populations already experiencing disparities based on race or ethnicity.[49] By staying closed and limiting access to services, schools risked further harming students and families already struggling.[49]

It was not clear initially how the virus spread, and federal agencies did not officially acknowledge that the virus was airborne and did not update guidance until May 7, 2021, which led to questions about the need to address environmental conditions in schools as a condition of in-person learning.[50] Questions about transmission and the effectiveness of mitigation measures in schools continued into the 2021–2022 school year, even as new variants became dominant and more was learned about how the virus spreads through indoor spaces. Without continued research on the transmission and mitigation of variants among children and staff in school settings, questions about risks at school remain.

K–12 public education is inherently a local issue, with locally elected school boards and superintendents responsible for the education and services received through schools in compliance with state and federal laws, funding requirements, and regulations. COVID-19 mandates imposed on schools by other local, state, and federal agencies created questions as to who is responsible for decisions impacting K–12 schools in a public health emergency. Opponents of K–12 mandates have argued for the primacy of local decision making, stating that local leaders are best positioned to make decisions appropriate for their community needs, even though this has placed local public health and education leaders at risk of harassment, threats, and violence by community members. The balance between federal and state agencies and the traditional role of local leadership in K–12 public education has been a constant tension throughout the pandemic.[51] This debate continued through the fall of 2021, including debates over mask mandates and the role of federal, state, and local authorities in making such decisions for K–12 schools.

Finally, many have argued that schools “just need to get back to normal” and that there is no need to invest in long-term changes when there are more critical needs that should be addressed with the funding made available to schools. However, providing clean air and water and a healthy learning environment is necessary to successful learning. In addition, the need to improve environmental conditions in schools existed before the pandemic. Furthermore, given the emergence of new and dangerous viruses before the current pandemic, including SARS, MERS, and H1N1, and the likely emergencies resulting from climate change, we must consider the questions raised by this pandemic and reexamine whether current policies and practices help all students and staff stay healthy and safe during “normal” times as well as during emergency events that disrupt normal K–12 operations.

Action Steps
Although K–12 public education is primarily managed at the local level, actions taken at the local level must follow federal and state funding requirements, laws, and regulations. Therefore, federal and state agencies must provide guidance, resources, and structures within which public K–12 schools and health departments can take the actions necessary to protect the health of students and staff. The following action steps should be taken:

1. A White House pandemic task force should be maintained and its scientific public health leadership designated as the sole source of federal communications with the public about pandemics. The task force should include leadership from the Department of Education, the Department of Agriculture, the EPA, the Department of Health and Human Services (including CDC/NIOSH), the Department of Labor (OSHA), and other federal agencies that regulate, provide guidance to, or provide funding and other support to programs and social services offered through educational settings. This will facilitate coordination of recommendations to the educational sector at the state and local levels, communicated according to the CDC’s Crisis and Emergency Risk Communication model. The pandemic task force should serve as a model structure at the state and local levels and disseminate information on best practices. There should be a clear relationship between the task force and its local and state counterparts.
2. During a pandemic, the White House administration should invoke the War Powers Act to drive private production of needed supplies and equipment, including distribution of supplies to K–12 schools, and should activate the Strategic National Stockpile to ensure that the supplies needed are readily accessible and affordable to K–12 schools.
3. K–12 public schools should be designated as critical infrastructure by the Department of Homeland Security and funded appropriately so that they are prepared to successfully respond to public health disasters while sustaining educational and other services for children. K–12 schools and state, tribal, and local health departments must be priorities for funding by Congress and state legislatures during a public health emergency to ensure both a safe and healthy environment and support for systems planning to promote equity in remote learning.
4. The CDC, advised by public and health communications experts, should revisit its own standards for crisis and risk communications (Be First, Be Right, Be Credible; NIOSH Hierarchy of Controls; and Universal and Standard Precautions) to improve its communications with the American public before the next disaster.
5. The CDC, the EPA, OSHA, and the Department of Education, in consultation with other relevant federal agencies, must develop and disseminate guidance to state and local public health and education authorities on joint preparedness activities. These guidelines should build upon current public health preparedness infrastructure and include template infection prevention and control plans; model policies for public schools that address clean air, clean water, and sanitation; and procedures for contact tracing, isolation, and quarantine.
6. The CDC must develop standardized surveillance systems to monitor the physical, environmental, occupational, and mental health of students and staff before, during, and after a public health emergency and make these systems available to state and local health departments at no cost. These surveillance systems should be designed so that researchers can use data collected across jurisdictions to evaluate health outcomes during virtual and remote learning. A similar system is included in the action steps of APHA Policy Statement 201713.
7. The CDC should evaluate and fund model programs for testing and vaccination at educational facilities, with a focus on underserved and disadvantaged communities. Federal appropriations must be made to support implementation of surveillance, testing, vaccination, and research activities, which should focus on prevention and mitigation of disease transmission. 
8. Federal appropriations must be made available to restore, develop, and support CDC, EPA, OSHA, and Department of Education programs focused on healthy K–12 school environments. These agencies will provide consultation and guidance to schools on creating and maintaining healthy mental and physical environments for students and staff.
9. Congress must provide appropriations to states and directly to K–12 school districts to upgrade ventilation systems and make other structural changes to improve environmental health in all facilities. States must require their public schools to update and stay current on ventilation and sanitation and provide funding to do so. Funding should be allocated in an equitable manner at both the federal and state levels.
10. Congress and the Department of Agriculture must continue to allow waivers for school meal programs during public health emergencies to provide more opportunities for children to access meals, including waivers for noncongregate meals and meal service times and waivers allowing parents and guardians to pick up meals.[11] Offering meals to all students at no cost during and beyond the pandemic is a critical step to ensure that nutritional needs are met.
11. OSHA must develop comprehensive guidance for worker safety during a public health emergency, which could be tailored across industry sectors to protect individuals working in K–12 schools.
12. The United States must remain an active member and supporter of the World Health Organization and advocate for continued research on disease transmission and strategies to mitigate risks in educational settings.

References
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