There are no right answers
I can see the level of anxiety about school reopening has reached it's peak. I am grappling with the same choices. *Spoiler alert* There is no right answer here, only lots of choices. I do believe that if children return to school in any area, that the decision should be based off of facts and careful risk vs. benefit analysis. Many other states have already discussed their plans for returning to school based off of health metrics and I believe we should do the same. I do think that some children and staff can return to school if we are all willing to work together to protect the health of one another.
I have put together some careful public health considerations regarding the reopening of schools but would like to note that this is just my perspective. I am not a teacher or school administrator or even a pediatric nurse, this is written purely from the my perspective and experience with COVID-19 as a public health nurse. The purpose of me sharing this is to gain insight on how else the Hopkinton Health department can assist our schools possibly reopening and better understand concerns that relate specifically to the Health department.
Districts across Massachusetts are preparing for the upcoming school year and it is important that the planning process is guided by the same public health principles that have protected our community. It will be a challenge to navigate through the safe reopening of schools, as this is the largest scale of gathering and interaction of individuals since the initial lockdown in March.
Implementation of this guidance will depend on the local public health conditions which are released by the state each Wednesday. Our community will be able to provide education in a phased manner based off of these health metrics. The guidelines and considerations in this document do not reflect the full scope of issues that school communities will need to address and are subject to change.
Establish start and stop procedures that prioritize the health of students but allows for continuity for education.
Establish testing protocol and procedures for staff/students should the health department identify a cluster event.
Clearly define symptoms or other reasons that a child may need to be excluded from attending in person learning.
Implement the HealthTrac application to assist with collection of attestations, provide a streamlined system for contact tracing cohorts and potentially limit the exposure to students and staff while in-person learning.
Clearly communicate and educate students and staff on new protocols and expectations prior to school reopening. This would include education for donning and doffing PPE, FIT testing all school nurses and clearly outlining isolation and quarantine requirements.
Considerations for the reopening of schools should be based on the transmission risk in Hopkinton and the state of Massachusetts. The state reports weekly the health metrics regarding count and rate of confirmed COVID-19 tests.
If the percent positivity rate for the town of Hopkinton were to raise above 5%, schools may consult with the health department and consider closing.
If the percent positivity rate for the state of Massachusetts were to rise above 8%, schools may consult with the health department and consider closing.
If there is evidence of community spread within the schools, or multiple cases in multiple cohorts at a school or when at least 5% of the total number of teachers/students/staff are cases within a 14-day period depending on the size and layout of the school, schools may consult with the health department and consider closing.
School closure may also be warranted for other reasons, including results from public health investigations and for contact tracing.
If there was a cluster event at the school, it would need to close but would be allowed to reopen after 14 days and the following have occurred:
Deep cleaning and disinfection
Public health investigation
Health data indicates it is safe to do so
If all of the above mentioned health metrics indicate that it is safe to reopen the schools and all of the CDC and DPH guidelines for the safe reopening of schools can be met then then Hopkinton Public schools should open. The school must be prepared to meet all of the standards that have been established by the state. The staff must be comfortable implementing new standard operating procedures. Students and their families must also be prepared to abide by the new standards that are designed to protect the community.
Students/staff must not come to school if they are sick
Students/staff must abide by mask/shield wearing, physical distancing and frequent handwashing and cleaning of surfaces.
The current recommendations are that children ages 2- 1st grade would be strongly encouraged to wear a facial covering. Adults and students grade 2 to high school would be required to wear a facial covering unless they are medically exempt. In the event that an individual is medically exempt from wearing a facial covering, a facial shield would be an appropriate substitute.
Students would be expected to provide their own facial covering and to always have a spare facial covering in their backpacks. The school would need a limited number of masks should a child or staff member need to replace theirs for any reason.
All staff would be required to wear a facial covering. It would be acceptable for a staff member to wear a facial shield instead of a facial covering while in their classroom provided that they can maintain the minimum physical distance of 6ft from students.
Adults, children over the age of 10
All adults and children over the age of 10 should maintain the minimum physical distancing of 6 ft between one another. If individuals are not able to maintain this distance and they come into contact with a positive case for greater than 15 minutes they would be considered a close contact and would be quarantined for 14 days regardless of symptoms. The close contact should consider being tested after 5 days from their last exposure or if they develop symptoms. It is most important that adults maintain 6ft of social distancing from other adults, as they are the greatest risk for transmitting COVID-19.
Children under the age of 10
All children under the age of 10 should maintain the physical distancing of 6ft between one another. There are some instances in which children may come close to each other than 6ft. It would be ideal to create pods in the classroom so that it allows for potential human errors in their implementation of the 6ft social distancing. The American Association of Pediatrics has reported that among young children, there is little difference between the transmission of COVID-19 between 3ft and 6ft in this age group.
Cleaning and disinfecting should be intensified and more frequent than prior to the COVID-19 pandemic. While the cleaning will continue to focus on the same areas that are targeted during flu season, with COVID-19 it may require different products. The cleaning product should be an EPA approved cleaning product proven to kill the COVID-19 virus.
Here is a sample of potentially what communication could look like between schools, families and the Health Department:
After a confirmed case of COVID-19:
Any areas used by the confirmed case should be closed for 24 hours before the cleaning and disinfection begins. If 24 hours is not feasible, wait as long as possible. Custodians should be equipped with PPE (including gloves, mask, shield, and potentially a gown) prior to entering the room to clean and there should be a sign to signal to others that this particular classroom is NOT to be entered or used. For this reason, it would be ideal if there was limited movement of children/staff throughout the building and if students ate lunch in classrooms or used designated bathrooms. Mask “breaks” should take place outside or in the staff/students main classroom or work area.
Buses, classrooms, shared items(which should be very limited and only shared in a pod), frequently touched surfaces, and any additional areas of the school visited by the COVID-19 positive individual may also need to be closed temporarily for cleaning and disinfection.
Isolation & Quarantine
Close contacts of the confirmed case would be directed to quarantine and then isolate if they develop symptoms. Close contacts are those that have spent greater than 15 minutes with the confirmed case and were closer than 6ft. Close contact may be difficult to establish especially for younger students but should be easy to establish for adults/older children.
Isolation is for symptomatic or asymptomatic confirmed cases of COVID-19. Isolation lasts for 10 days. The test date or the symptom onset day is day 0. Isolation is different from quarantine in that if done correctly the case is separated from the rest of their household and uses a separate bathroom. If this is not feasible, the case and family should wear a facial covering in the home, should avoid close contact (no hugs), should clean things with an EPA approved cleaner and use the highest setting for laundering or dishwashing. If a case is not able to properly Isolate then the household contacts would not be able to start their quarantine requirements until the confirmed case has completed Isolation requirements. The health department would contact these cases once notified either by the individual, the school or the state. Each local health department is responsible for their town residents, therefore the health department would not be notified of a teacher that lives in Milford that tested positive and would rely on that individual to report this information.
Quarantine is for asymptomatic individuals that have been designated as close contacts of a confirmed COVID-19 case. The last date of contact would be day 0 and the individual would be able to return to school/work on day 15. If a quarantined individual were to become symptomatic they should seek testing and immediately begin to isolate from their household. The health department would need to contact these individuals, confirm their exposure, establish dates of quarantine and would be available for any questions.
There will be reasons that a child or staff should not report to school. Some of these reasons might be because of symptoms of illness, travel or contact with a confirmed or suspected case of COVID-19.
Consistent with the Governor's travel order, any student or staff that travels to an area of high transmission would be required to self quarantine or obtain testing within 72 hours upon arrival from that area. They would be excluded from reporting to work or school until they are able to meet these requirements. If a child or staff member has a household member that has traveled to one of these same areas the child should be excluded from school until the above requirements are met.
If a child or staff member has been identified as a close contact of a confirmed or suspected case of COVID-19 they should be excluded from school for 14 days from their last contact. If a child or staff member has someone living in their household that is experiencing symptoms consistent with COVID-19 or is being tested for COVID-19 they should be excluded from school until they have results.
Symptoms of COVID-19 may include the following:
Fever greater than 99.5 degree Fahrenheit
Shortness of breath/chest tightness
New loss of smell or taste
Muscle or Body aches
Dizziness (usually a pediatric symptom)
A child should be automatically excluded from class if they are having a fever, new cough or shortness of breath. If they have any other 2 of the symptoms they should also stay at home until their symptoms have resolved for 24 hours. Staff or parents should consult with their primary care physician or child's pediatrician to determine if testing is appropriate or if they have specific medical questions or concerns.
Testing prior to the start of the school year is not required but all students and families should self- quarantine in Massachusetts 14 days prior to the start of the school year.
There are many testing sites throughout the state of Massachusetts and the health department is available to help anyone locate a site to obtain testing. The health department is trying to obtain a rapid antigen system, that we will use to assist in testing staff/students. The results would take 15 minutes and would allow us to make quick and informed decisions about the potential need to close a classroom.
Contact Tracing & Health Attestation
There currently are no treatments or vaccines available to prevent someone from getting COVID-19, so public health relies heavily on other mitigation strategies aimed to help slow the spread of the virus. Many of these practices are already used during flu season. Because COVID-19 appears to be more contagious than the flu it will be important to be able to quickly identify the original source of COVID-19 and their close contacts. I firmly believe that the best tool we have against the spread of COVID-19 is excellent contact tracing efforts. The HealthTrac app will allow us to perform contact tracing in an efficient manner to avoid as many disruptions to in person learning as possible. Contact tracing and case management would be completed by the public health nurse in Hopkinton with assistance from the school nurses.
The app HealthTrac couild potentially help us to collect daily health attestations from family to verify that the student and their household do not have symptoms of COVID-19, the student or their household members are not being tested for COVID-19, and the student or their household have not had any known contact with a COVID-19 case or traveled from an area of high rates of infection.
If there was a confirmed case of COVID-19 at the school, the app would change that students “pass” to red and their close contact cohorts. Close contact is defined as being within 6ft of another student for longer than 15 minutes. If younger students were grouped into pods it may be easier to identify close contact. Older students that ideally should be more compliant with hand washing, facial covering and maintaining distance would not be considered close contacts as long as they are following this guidance. For example, walking in the hallways in high school by a confirmed case while both individuals are masked and their contact was for less than 15 minutes but possibly less than exactly 6 ft, this would not be considered close contact.
Additionally, the app will allow for the grouping of cohorts so that notifications could be sent immediately to each student/family. Cohorts should be assigned for classmates and children that are riding on the bus together. Should sports be allowed to start in the fall, cohorts would also be assigned for these groups.
The app does not track your location protecting your privacy.
The app collects and stores data in a HIPPA compliant format and any health information would only be shared between the health department and the school.
The app assigns a “green ticket” if you have answered all questions and are cleared to attend school.
The app assigns a “yellow ticket” if you have forgotten to answer the questions and are in school or you require a visual check by the nurse.
The app assigns a “red ticket” if you have symptoms of COVID-19 or have had known exposure or someone in their household is being tested for COVID-19. Children of the same family and cohorts would also flip to red, preventing them from going to school.
The app allows for contact tracing and case notification to happen in minutes rather than days.
The app can be used on Apple or Android devices.
The app could be preloaded onto the tablets that would be required for remote learning.
The cost of the app is 0.60 cents for each user and would be paid for using money from the CARES act. It is a 10 month contract but if at any point the school goes full remote for an extended period of time we are not required to pay for the service.
The app is available in several different languages but can be translated in another language within a matter of days. It would be ideal to have a survey of all languages that would be required. We could have the languages available for the start of the school year.
The app does offer training videos and quick tip reminders about the prevention of COVID-19.
The app relies on the individuals to accurately report their symptoms, travel or exposure. It is not a guarantee that there will never be a case of COVID-19 in the schools.