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The question of when and how to open schools for full in-person learning in the midst of the COVID-19 pandemic is one of the most consequential the U.S. currently faces. A\u00a0wealth of evidence<\/a>\u00a0suggests that schools can provide in-person instruction with a very\u00a0low level of risk<\/a>\u00a0when\u00a0safety protocols<\/a>\u00a0are\u00a0successfully implemented<\/a>.<\/p>\n So, what do school districts, teachers, families and students need to know? As an infectious disease epidemiologist with more than\u00a015 years of research experience<\/a>\u00a0\u2013 and as co-editor of the\u00a0COVID-19 Literature Situation Report<\/a>, which produces a daily summary of the most relevant newly published and pre-print literature related to COVID-19 – I offer answers to some of the most urgent questions about how schools can safely resume in-person instruction. Some of this evidence is gleaned from preprint studies that may change after they are peer-reviewed.<\/p>\n Infection with the COVID-19 virus has been less common in school-age children, especially those in elementary school, than among other age groups. Evidence from\u00a0Florida<\/a>,\u00a0Utah<\/a>,\u00a0Missouri<\/a>\u00a0and elsewhere indicates that less than 1% of school-age children have had COVID-19, despite\u00a0most being in school in person<\/a>.\u00a0Most cases<\/a>\u00a0have not been linked to school exposures.<\/p>\n While school\u00a0outbreaks<\/a>\u00a0have occurred, most have been\u00a0small<\/a>\u00a0in scale.\u00a0Transmission<\/a>\u00a0from an infected student to others in the household or community has been\u00a0rare<\/a>.<\/p>\n While not definitively proved by scientific studies, indications are that elementary school-age children are less likely than older children and adults to\u00a0transmit<\/a>\u00a0the COVID-19 virus to others.<\/p>\n Spread of COVID-19 through in-person K-12 schooling has been\u00a0limited<\/a>, even without vaccinations. Teachers are now\u00a0eligible<\/a>\u00a0to be vaccinated in all states in the U.S., which means that the risk to teachers and staff who are vaccinated, as well as to students and others who may not be willing or able to be vaccinated, is greatly reduced. No studies give us a magic number for the proportion of teachers and staff who need to be vaccinated before in-person learning can be implemented. In fact, the Centers for Disease Control and Prevention advises that in-person learning can start\u00a0safely<\/a>\u00a0as long as other mitigation protocols like mask-wearing and adequate ventilation are in place. Vaccines offer an added level of protection.<\/p>\n The vaccines currently approved for use in the U.S. under emergency use authorization are all highly effective at preventing mild, moderate and severe COVID-19 disease, and they also\u00a0prevent infections<\/a>.<\/p>\n This means that these vaccines both protect the vaccinated person and\u00a0reduce the risk of transmission<\/a>\u00a0from a vaccinated to an unvaccinated person. This is critical, because at this time there are no vaccines approved for use in those under the age of 16 in the U.S.<\/p>\n Pfizer and Moderna have trials underway in adolescents<\/a>\u00a0and hope to have results by late spring or early summer. In the meantime, to protect students from infection, it will help to vaccinate as many adults as possible in schools.<\/p>\n Transmission is far more common from\u00a0teacher to student<\/a>\u00a0and\u00a0teacher to teacher<\/a>\u00a0than from student to teacher. So far, research that has not yet been peer-reviewed shows that the vaccines approved for use in the U.S. have\u00a0similar efficacy<\/a>\u00a0against the newly emerging\u00a0variants of concern<\/a>, especially in terms of preventing severe disease.<\/p>\n Students enter a Bronx school in February 2021. Lev Radin\/Pacific Press\/LightRocket via Getty Images<\/p><\/div>\n So long as people are wearing masks, there is no evidence that 6-foot physical distancing between students is more effective than\u00a03-foot distancing<\/a>. This led the CDC to shift its guidance to\u00a0recommend a physical distancing of only 3 feet<\/a>\u00a0in classrooms. Three-foot distancing allows for much more flexibility in terms of classroom size and layout. Face masks are\u00a0highly effective<\/a>\u00a0in reducing infection and transmission risk and are therefore a critical mitigation measure.<\/p>\n In addition, early research suggests that keeping students in groups, or cohorts, and limiting contact among\u00a0cohorts<\/a>\u00a0may reduce the potential for\u00a0widespread transmission<\/a>\u00a0if a case occurs in a school. Cohorting can also minimize the number of students who would need to be quarantined.<\/p>\n Just as in the classroom,\u00a0masks work<\/a>\u00a0when transporting students to and from school.\u00a0Double-masking<\/a>\u00a0is probably best, especially in\u00a0indoor spaces<\/a>, including cars and buses. Ventilation with outside air \u2013 either by opening windows or avoiding ventilation that recirculates air \u2013 may help to reduce the risk of transmission in\u00a0buses<\/a>. Students should space out as much as possible, given the elevated risk of transmission seen among passengers sitting close to an infected individual on\u00a0airplanes<\/a>, although universal mask usage is likely to reduce the importance of physical spacing.<\/p>\n While droplet and airborne transmission of the COVID-19 virus appear to be the\u00a0dominant modes<\/a>\u00a0of transmission, hand-washing and using hand sanitizers before entering buses and upon exit may help reduce the risk of transmission through contact with\u00a0contaminated surfaces<\/a>.<\/p>\n Growing\u00a0evidence<\/a>\u00a0shows that kids can play sports and have recess if they are\u00a0outdoors<\/a>\u00a0and players have no or low contact. Based on studies, including some that have not yet been peer-reviewed, activities such as\u00a0soccer<\/a>,\u00a0tennis<\/a>\u00a0and\u00a0cross-country<\/a>\u00a0are fine.<\/p>\n The\u00a0American Academy of Pediatrics<\/a>\u00a0recommends that athletes participating in indoor sports wear masks, except those participating in swimming and diving, cheerleading, gymnastics and wrestling, to prevent choking or suffocation. Some indoor sports, particularly\u00a0wrestling<\/a>\u00a0and\u00a0hockey<\/a>, have been associated with large outbreaks. Also, outbreaks of COVID-19 have been associated with\u00a0football teams<\/a>.<\/p>\n An important finding from a number of investigations is that many of the cases of transmission, including on football teams, appear to be linked to\u00a0activities<\/a>\u00a0not directly related to the sport itself, such as meetings in\u00a0enclosed spaces without masks<\/a>, eating together and\u00a0parties and social events<\/a>.<\/p>\n Masks are likely to be a critical part of protocols to prevent COVID-19 in schools, at least until vaccines are universally available, including for children. Even then, the potential emergence of new variants that are resistant to existing vaccines may make mask usage a necessity for some time. Schools that have provided in-person instruction during the COVID-19 pandemic, including during periods of high community transmission, have experienced\u00a0few<\/a>\u00a0widespread outbreaks directly related to school transmission when\u00a0masks<\/a>\u00a0are used.<\/p>\n This has been true in\u00a0Florida<\/a>,\u00a0Massachusetts<\/a>,\u00a0Salt Lake City<\/a>,\u00a0England<\/a>\u00a0and elsewhere.<\/p>\n In contrast, not wearing masks was a problem in schools in\u00a0Sweden<\/a>. In this Scandinavian country, younger secondary-school students returned to full-time, in-person learning without masks and with few other mitigation measures. Older secondary-school students continued with remote learning. Students and staff who went to school in person and without masks or other safety measures had a somewhat higher likelihood of having COVID-19 compared with those learning remotely, although the absolute risk was still quite low.<\/p>\n While the coronavirus that causes COVID-19 has been detected on\u00a0surfaces<\/a>, touching those surfaces doesn\u2019t appear to be the dominant route of transmission. Even so, hand-washing and using hand sanitizers are still good ideas. Face masks and physical distancing are more important, though.<\/p>\nWill school make children more likely to transmit COVID-19?<\/strong><\/h4>\n
What about teacher and staff vaccinations?<\/strong><\/h4>\n
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What is the right amount of physical distancing?<\/strong><\/h4>\n
On the bus or other transportation<\/strong><\/h4>\n
The gym, recess and after-school sports<\/strong><\/h4>\n
Are masks still required?<\/strong><\/h4>\n
How critical is soap or hand sanitizer?<\/strong><\/h4>\n