As summer comes to an end and the coronavirus continues to rage, North Texas schools are scrambling to make high-stakes decisions: when and how to bring hundreds of thousands of teachers and students back into the classroom.
They must do so without vital information: Only a handful of schools have opened in other states. In other countries, children returned to class when the infection rate was much lower. And there is no good evidence on how easily children transmit the virus.
Complicating these unknowns is state guidance that conflicts with public health advice, The Dallas Morning News found. State recommendations on face coverings and handling students exposed to someone with COVID-19 are both counter to best practices, experts said.
“Unfortunately, this is somewhat of a natural experiment,” said Dr. Cyrus Shahpar, an epidemiologist who used to work for the U.S. Centers for Disease Control and Prevention.
Families have to choose in-person or virtual schooling, while safety procedures are still being created. The uncertainty puts families in agonizing positions.
Parents who can work from home must weigh the risk of infection at school against the risk of social isolation and falling behind in an online environment. Parents who have to leave the house to work might have no choice but to send their children to school — and risk exposing them to COVID-19.
There is also growing evidence that COVID-19 disproportionately affects non-white and low-income communities, particularly Latino neighborhoods, in deaths and infections. For a school district like Dallas, which is 70% Latino and 86% economically disadvantaged, balancing safety and the need for in-person learning is the most difficult part, said Dallas ISD trustee Miguel Solis.
Beatriz Gonzales, a mother of four school-aged children, recently told the Dallas ISD board of trustees that she would stay home to teach her kids, because two are asthmatic and her husband has underlying health conditions.
“When children return back to school, they constantly share tummy bugs, colds, flus, strep throat,” she said. “What is the guarantee that COVID won’t be shared?”
Reopening in a hot zone
National leaders, including President Donald Trump and Education Secretary Betsy DeVos, have pressured states to return to in-person learning on time, saying it’s key to fueling the economy.
“Reopening our schools is also critical to ensuring that parents can go to work and provide for their families,” Trump said during a July 23 news conference. “Schools have to open safely, but they have to open.”
That sentiment has trickled down to states. While pushing for Texas to reopen businesses this spring, Gov. Greg Abbott repeatedly said he wanted students to safely return to campuses this fall.
School administrators, though, wanted guidance. And, until early July, none came.
Parents must decide between in-person or remote instruction. However, each school district can choose to offer only remote instruction for the first four weeks of the school year, followed by a four-week, gradual return to campus that must be approved by the state and a local school board.
A handful of North Texas districts — like Dallas, Cedar Hill, DeSoto and Lancaster — have pushed their first day of school until after Labor Day. The districts hope the delay will allow them to start in-person instruction at a time when infection rates are dropping. Most schools, however, are starting on time in the coming weeks with virtual learning.
Despite recent improvements, North Texas still has a high infection rate. The bigger the school, the more likely someone present on opening day will be carrying the virus. Estimates published recently in the New York Times and based on disease research at UT-Austin predict, for instance, that at a 500-person school in Dallas County, five people would be expected to arrive infected.
“Cases will make it into schools,” said Shahpar. “You obviously are at a higher risk if you open them in a place with a lot of cases outside the school.”
Already, several schools in other states have had to quarantine students and staff, and even close temporarily, within days of opening their doors.
Brandon Guthrie, an epidemiologist at the University of Washington in Seattle who surveyed medical and news articles about schools from around the world, said he found no other countries that reopened schools with transmission as high as it is in Texas.
“There are no models that we identified that really tell you what would happen,” he said.
Some states have set thresholds to meet before reopening. In New York, the rate of positive coronavirus tests must be below 5% before schools can reopen, a benchmark recently echoed by Dr. Robert Redfield, director of the CDC.
Texas, which averaged a rate of about 13% last week, has no such measure. Dallas County’s rate is not available because of limitations in testing data.
A team of Harvard researchers that has been issuing advice for reopening the economy and schools recommends that at the current level of infection in Dallas, Tarrant, Denton and Collin counties, schools could open for students up to fifth grade, with precautions in place.
Dallas County’s health department director, Dr. Philip Huang, said he did not rely on just one statistic when he attempted to prohibit in-person schooling until Sept. 8, a decision recently challenged by the Texas attorney general. Huang cited the county’s high numbers of COVID-19 patients in hospitals, including children.
In July, more than 2,050 children tested positive and 52 were hospitalized, including four in ICUs, according to county data. More than 100 staff and children, at 69 day care centers, have also tested positive. Two children in Dallas County — a 5-year-old boy and a 17-year-old Lancaster High School student with no underlying health conditions — have died of COVID-19 since the epidemic began.
Scientific groups have highlighted the benefits of in-person learning.
Closing schools can take a psychological toll, and teachers can miss signs of physical abuse, emotional distress and learning problems, the American Academy of Pediatrics said in July.
A recent report from the National Academies of Sciences, Engineering, and Medicine said the priority should be reopening grades K-to-5 and schools that serve children with special needs. These groups struggle the most with distance learning.
In late July, the CDC also highlighted the importance of in-person classes and said in a statement that “scientific studies suggest that COVID-19 transmission among children in schools may be low.”
In fact, scientists have yet to determine whether children transmit the virus less than adults.
“We do not know that and shouldn’t make that assumption until there is good data one way or the other,” said Dr. Tina Hartert of Vanderbilt University Medical Center. Hartert is leading a national study to determine the rate of COVID-19 infection in children and families.
New research continues to stream out: Just last week, a published study found that kids under 5 carried high amounts of coronavirus in their noses and throats, suggesting they could greatly contribute to the spread of the virus.
Another recent report on 6,000 patients of all ages in South Korea suggested people between 10 and 19 were most likely to transmit in their household.
The science on COVID-19 symptoms in children is more clear. Although multiple studies have found children are less likely than adults to get very sick from the illness, up to 5% of symptomatic children have had severe or critical symptoms, according to the report from the National Academies.
Doctors said biological differences in lung cells may explain why children appear to be less susceptible to COVID-19′s worst effects.
“In kids, even if the virus comes into the mouth or goes into the lungs, our hypothesis is that it’s less likely to enter cells and create problems,” said Matthew Harting, a pediatric surgeon with the UT Health Science Center and Children’s Memorial Hermann Hospital in Houston.
But children can still get very sick.
Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C., has followed 540 children at her hospital since March. About 26 percent were admitted to the hospital, and, of those, one-third required intensive care. Those older than 15 and younger than 1 were most likely to be hospitalized. The older children had symptoms similar to those of adults, including pneumonia, shortness of breath and blood clots.
About 60 percent of children had at least one underlying condition such as cerebral palsy, sickle cell anemia or cancer, said DeBiasi. Asthma, the most common underlying condition, did not appear to be associated with more severe disease.
The long-term effects of COVID-19 infection are still unknown. DeBiasi said none of the children she is following have suffered lingering effects. But after the illness passes, a small number of kids can develop a serious complication that causes inflammation of internal organs; most recover fully, according to the National Academies.
COVID-19 is as serious for children as influenza, she said.
“Most kids do fine with influenza, but a significant number end up in the hospital and even need critical care,” DeBiasi said.
Last month, the Texas Education Agency outlined measures to keep schools safer, yet warned that outbreaks and temporary closures are almost certain. But key elements of the agency’s guidance are ambiguous, or misguided, The News found.
For instance, the document says some safety measures are required for all school systems and others are required in areas with “high levels of community spread.”
But the agency does not define “high levels” and the document doesn’t say which practices are required when community spread is high.
“We don’t have a firm statewide metric, because measurement systems vary by region,” TEA spokesman Frank Ward said in a written statement to The News. “The guidance indicates that school systems should implement every recommendation that they can.”
The News also found problems with those recommendations.
The agency requires that teachers and visitors who came into close contact — within 6 feet for 15 minutes with someone who tested positive for COVID-19 — cannot return to school for 14 days. But the guidance does not require students who spent time near someone known to be infected to stay off campus, contradicting CDC recommendations. Instead, it says parents may “opt” for remote learning in that situation.
Asked to explain, the agency did not specify its rationale for not requiring the student to stay away from campus.
The News also found problems with the agency’s guidelines on face coverings.
Initially, the agency said that for schools, face coverings could be masks that cover the nose and mouth, and also full face shields.
The TEA’s rules echo Gov. Abbott’s July order to require face coverings statewide. That applied to anyone over age 10 — unless a medical issue prevents it, or the home county has fewer than 20 active cases.
Abbott’s order doesn’t define the term face covering, and spokesman John Wittman did not respond to repeated requests for a definition.
The TEA’s initial inclusion of shields was out of step with information on the CDC’s website two weeks earlier, which states shields should not substitute for cloth face coverings.
Face shields, which have open bottoms and sides, can’t contain fine particles emitted when infected people breathe, talk or sing, said William Ristenpart, an engineering professor at the University of California, Davis who studies transmission of respiratory viruses.
“If you have a lot of kids in a room, these little droplets accumulate all over,” he said.
In response to questions from The News, Ward, the TEA’s spokesperson, said in a prepared statement that Abbott’s medical advisers had recommended face masks and shields as equally permissible.
The advisers — Texas Department of State Health Services commissioner Dr. John Hellerstedt, Abbott adviser Dr. Mark McClellan, UT-Austin Dell Medical School’s Dr. Parker Hudson, and UT System executive vice-chancellor for health affairs Dr. John Zerwas — either did not respond or did not confirm they had offered that advice.
After The News’ inquiry, the TEA changed its definition. Now the agency requires medical-type or cloth masks that cover the nose and mouth. But face shields are still allowed when masks are “not feasible” or when it’s beneficial to see someone’s full face.
The agency told The News last week it changed its definition to better align with recent CDC guidance. It said it decided to permit face shields to help children with disabilities or taking speech therapy, a distinction not made in the guidance. Health department spokesman Chris Van Deusen said Dr. Hellerstedt discussed masks and face shields with TEA commissioner Mike Morath before the guidance changed.
Masks that closely cover the nose and mouth are best at containing the virus, experts said. And while they’re vital, they’re not perfect at blocking the virus. Keeping people far apart, and hands and surfaces clean, are also a must.
The TEA’s guidance says face coverings are optional during exercise or other extracurricular activities, as long as students are 6 feet apart.
“I don’t like it, especially inside because things don’t disperse as well inside,” said Richard Corsi, a former engineering professor at UT-Austin and now a dean at Portland State University in Oregon.
People breathe out more virus when they exercise while others exercising nearby breathe in more. Even at a 6-foot distance, there’s a risk.
“You’re just basically like a vacuum cleaner, sucking in all those particles that have viruses,” he said.
Singing, cheering or playing musical instruments that require blowing with the mouth are also risky, Corsi said, and should be done outdoors at a safe distance.
The education agency said “while scientific evidence on the virus continues to evolve, TEA guidance is consistent with recommendations from multiple health experts.”
One school’s story
A report published recently by public health officials in Israel describes how quickly the virus could spread in a school setting.
In mid-May, after a two-month shutdown, a high school in Jerusalem opened with safety measures in place — masks, instruction on hygiene and minimal mixing of classes.
Disease prevalence had been low in Israel the week before: According to the Johns Hopkins University COVID tracker, the country had averaged about 19 new cases a day, in a country of about 9 million people. Right now, Dallas County is tallying 100 times that rate.
After the first day, the mask rule requirement at the school was suspended for four days because of a heat wave. Within six days after that, two students fell sick. The school shut down.
By the end of May, 150 students and 25 staff members at the 1,100-student school had tested positive. By the end of June, so had 87 others — siblings who went to other schools, friends, sports and dance classmates, parents and family members of school staff.
The impact of removing masks remains unclear. Crowded classrooms probably also contributed, health officials said in their report.
Similar outbreaks are to be expected in the U.S., experts said, and are more likely when many people in the community are carrying the virus.
“The main problem is that it’s going to happen over and over,” Shahpar said.
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