The Things You Need to Think About Before You Reopen Schools

I’d like to start off this blog post by telling you that I am in no way advocating for or against reopening schools. This is currently a hot-button issue, and many policymakers are scratching their heads on how to do school reopening correctly. I am also not telling any one person or group how schools should reopen. I just want to tell you a few things that you need to know as we move toward that moment when they do reopen.

In 2009, when the H1N1 influenza pandemic happened, we were lucky because we had the tests for the virus rather quickly. Even if we couldn’t identify the H1N1 novel influenza virus itself, PCR analyzers could tell us that they detected an influenza virus but couldn’t tell what subtype it was. With coronavirus, things are different. PCR analyzers spat out a negative-to-all-known-viruses result early in the epidemic, so it was hard to identify cases.

Now, we are going into a phase of unintended consequences of laboratory testing. It’s not that we have enough tests; we probably don’t. It’s that we have many different types of tests. There are the PCR tests that detect the virus’ genetic material. There are the rapid antigen tests that detect the virus’ antigens (those little bits of protein on the virus surface). There are antibody tests that require blood. There are viral cultures that grow the virus. Currently, only the PCR test is good enough to be the “gold standard,” but it is not available everywhere.

So we need to be cognizant of the laboratory testing that children will go through before, during and after school is back in session. Is it the gold standard or something else? Is it accurate? Is it sensitive, thus giving us good confidence that a positive is positive? Is it specific, thus giving us good confidence that a negative is a negative? Is it easy to do? Is it cheap enough that children of all socioeconomic strata will be able to have access to it?

Another thing that helped us in 2009 was that a vaccine was available in less than one year. In fact, it was available the same year that the virus made its appearance. This is because the technique for making influenza vaccines was already available. All that vaccine manufacturers had to do was replace one strain in the vaccine with the novel pandemic one. That is not the case today. Today, there are many laboratories around the world working on a vaccine that will be brand new.

So we need to be cognizant that a small proportion of the population will have been exposed to the virus if the schools open in September. This means that a huge proportion of the population will not have been exposed, and, thus, there will be many susceptible students congregating in schools. Even if they have been exposed and have antibodies, the jury is still out on whether they are immune or susceptible after an initial infection. Both school officials and public health officials will need to have a sense of what level of immunity there exists to understand any possible school-based epidemics.

Then there is what happened in 2009 when the children did return to school. Look at this graph from CDC:

As you can see, there was the initial wave of H1N1 influenza in week 20 (May) of 2009. Then the massive wave hit around week 35 (September). If you were to look at the second wave on a state-by-state basis, you would have seen it happen first in the South, where states like Georgia started school in late August. The wave then marched its way up the Eastern Seaboard and then toward the Midwest and the western half of the country. It lasted well into December, and it was the time when the most people died from it.

Of course, many people who know a lot about viruses and epidemiology will fight me on this and say that influenza is one thing and coronavirus is another. This is, of course, true. But they both are viruses where hand hygiene and clustering of people are critical to its transmission. So I’m not convinced that the coronavirus will behave differently when schools go back in session. Not only that, but the level of asymptomatic people who are infected and still pass it on is a big, huge concern that we need to be aware about.

You can also kind of see the effect of the fall vaccine campaign in the graph above. Notice how the second peak collapses in a matter of about four weeks while the one in May to July seemed to last for about eight weeks after that peak. And then see how it all ends by week 15 of 2010, with virtually nothing after that. In 2010 to 2011, we had an “average” flu season in which H3N2 influenza prevailed.

How do we detect asymptomatic infections? What kind of testing scheme do we need to put in place? And, going back to my previous point about testing, which tests are admissible to detect cases and which ones are not? Which ones do we trust?

Then there are the issues of the inequities and inequalities that the pandemic has brought out of the darkness. Latinos and Blacks are more likely to catch the disease or be part of localized epidemics. Latinos may not be as likely to die (as they are relatively younger as a population), but Blacks are (as they are more likely to have serious comorbidities)… All when compared to Whites and Asians of similar socioeconomic status. Then, when it comes to socioeconomic status, poorer people are more likely to get sick and be hospitalized and die from coronavirus than wealthier folks.

What does this mean for poor schools and poor children going to those schools? What does it mean for wealthy schools? You get the idea…

At the end of the day the decision on opening schools is going to be a policy one decried or supported by politicians, parents, teachers and school administrators. Sure, it will have some input by public health, but — as we have seen lately — many public health recommendations can be overridden by governors and mayors and others. Even individuals can choose to ignore public health recommendations.

But I would be irresponsible to the profession if I didn’t point out all these things… And others that are a little more complex than what can be hashed out in a blog post. I just hope we all have the time to hash it out.

I really do.