I have been asked by a number of people to share my thoughts on school openings in the face of the coronavirus pandemic. This is a very challenging and complex subject. Like so much of this trying and unprecedented time, nothing is simple and straightforward. There are no quick fixes or unequivocal paths. Unfortunately, whether we want to admit it or not, we are learning as we go. SARS-CoV2 is a wily and formidable foe. Recriminations and blame are not appropriate at this time. Political leaders can only do so much.
Suffice it to say, I am in the president’s corner. I think he has done many amazing things against this implacable foe. His closure of flights from China early on was heroic and brilliant. His mass production of ventilators was unparalleled. His bipartisan $3-trillion relief package has not received the credit it deserves. I am sure another trillion-dollar relief bill will be produced. He deserves credit for this, too.
When it comes to masks, friends of the president asked me to write my thoughts, and I did long before anyone else. The utility of masks was noted by the administration at that time. Production of N95 masks was put into effect at an incredible clip. I was involved early on with convalescent plasma, and the administration has done a great job in this regard, too. The list goes on and on, including the massive purchase of Remdesivir, and no one has been working harder in making sure a vaccine will be available soon. Even the testing, which might have been problematic early on, has reached a level never thought possible.
So now comes the daunting task of trying to open schools. Obviously, it cannot be a one-size-fits-all approach. Each school district and even each school building has its own set of requirements and hazards. There will be starts and stops. I pushed for Major League Baseball (see my article “We Need Major League Baseball More Than Ever” – 6/7/20) and it is working, albeit with some difficulties.
I believe in the resourcefulness and innovative spirit of the American people. We must try to open up our schools. Remote learning is good for colleges but not for elementary or high school. The CDC has offered important guidelines as to how to do this. I will add some of my thoughts. I am fully cognizant of the Georgia overnight camp experience (MMWR 8/7/20) where 260 out of 597 campers and staff were infected (attack rate of 44%). There are many lessons to be learned from this experience. Unfortunately, campers did not wear masks. Proper ventilation like keeping windows open was not done. Testing was not done close enough to the time both the staff and campers came to the camp (12 days was too long). Proper social distancing was not followed. This experience should alert all schools to the bumps in the road ahead. A number of religious Jewish camps have done much better. Children and teenagers have a much better outcome than adults. Transmission by 12-to-19-year-olds seems to be equal to adult-to-adult transmission. The incidence of Multisystem Inflammatory Syndrome (which has features of Kawasaki Disease) is uncommon, although New York has had over 100 cases). The actual incidence of MIS-C in persons under 21 is 2 per 100,000, as compared to an incidence of COVID-19 infection of 322 per 100,000 (NEJM 7/23/20).
Schools have to try to reopen. I would, however, not do so in an area that is deemed a “hot spot.” The worry by parents, teachers, and staff can be alleviated to some degree by use of the same techniques employed by physicians and nurses working with patients. Teachers and staff who are elderly or have underlying medical conditions should be allowed to opt out. I have been seeing patients during this pandemic and will share my techniques, which can be utilized by schools.
1) Masks. I wear my N95 mask eight hours straight, only taking it off outdoors, for lunch and a coffee break. As I noted above, I am a big believer in the N95 mask. The physics of the N95 makes it 95% efficient in blocking even a virus like COVID-19. This is in contrast to a level 1 surgical mask, which is only 77% efficient. I recommend that all teachers and staff be equipped with an N95 mask and either wear glasses or goggles or a face shield to prevent infection via the mucous membranes of the eyes. Enough N95 masks are being made for every teacher in this country. Students must wear masks, as well, but can use surgical masks. There are surgical masks available that fit children.
2) Ventilation. As mentioned above, one of the problems with the Georgia camp spike was the lack of opening windows. Any class that can be held outside would, of course, be best. All air conditioning and heating systems will have to be re-outfitted so as to not recirculate air, and HEPA filters will have to be eventually attached in a massive scale at some point. I currently use a separate HEPA H13 filter/purifier in each room, which can filter to 0.1 micron. These are relatively inexpensive, and I would not work without them. There are more expensive devices that create negative pressure, which dentists are now employing. Additionally, all of my windows are opened in my office, at least during the summer and fall.
3) UV Light. Many new devices are being developed in this regard. Hospitals are using UV lights to sterilize rooms after procedures on patients. I do the same in my office. Low-level UV lights are being developed for use in stores and restaurants. Its use in schools should be explored. I turn on my UV light for 15 minutes in my facility after every procedure.
4) Cleaning. Rigorous cleaning of surfaces is still important. This includes frequent washing of hands, but it also means sterilizing of cell phones and the soles of shoes. Having an alcohol spray bottle handy makes the latter easy. Obviously, more isopropyl and ethyl alcohol have to be made to accommodate the demand. That is not the case presently.
5) Bathroom Cleaning. At least the shortage of bleach seems to be over. Bathrooms in schools will have to be cleaned frequently. I have written extensively in the early days of this pandemic how viruses are shed in the feces and aerosolized by the flush toilet. Covering the toilet after use is essential.
These are just a few ideas. The CDC guidelines are important to follow. Limiting class size, using cohorts to limit interaction, and frequent testing are also important. Proper mask use is essential.
Where there’s a will, there’s a way to open schools. I believe America can indeed pull it off.
Joseph M. Frager is a physician and lifelong activist.