Florida Chapter of the American Academy of Pediatrics, Inc. 1400 Village Square Blvd. #3-87786 Tallahassee, FL 32312 (P) 850/224-3939 (F) 912/452-9050 (E) info@fcaap.org Via E-mail Only Governor Ron DeSantis Office of Governor Ron DeSantis  State of Florida  The Capitol  400 S. Monroe St.  Tallahassee, FL 32399-0001  GovernorRon.Desantis@eog.myflorida.com July 29, 2020 FCAAP Executive Board RE: FCAAP Recommendations Regarding School Reopening President D. Paul Robinson, MD, FAAP Dear Governor DeSantis, Immediate Past President Madeline Matar Joseph, MD, FAAP Vice President Lisa Gwynn, DO, FAAP Secretary Toni Richards-Rowley, MD, FAAP As indicated in my letter to you dated July 16, 2020, I advised that FCAAP was drafting a “white paper” to be shared with those superintendents who want to see it as they prepare their school districts to reopen. Enclosed is that white paper – FCAAP Recommendations Regarding School Reopening. We hope this document proves useful to you and the school districts. FCAAP remains available to give guidance to superintendents if they are interested. Sincerely, Treasurer Patricia Emmanuel, MD, FAAP D. Paul Robinson, MD, FAAP President Florida Chapter of the American Academy of Pediatrics CC: Commissioner Richard Corcoran, Florida Department of Education The Honorable Bill Montford, The Florida Senate Dr. Scott Rivkees, Florida Surgeon and Secretary of Health Florida Chapter of the American Academy of Pediatrics FCAAP Recommendations Regarding School Reopening July 28, 2020 2 FCAAP RECOMMENDATIONS REGARDING SCHOOL REOPENING JULY 28, 2020 The Florida Chapter of the American Academy of Pediatrics (FCAAP) believes it is important for children to return to school as soon as possible. The FCAAP also agrees with many of the recommendations of the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) regarding the significant benefits to children in going back into the classroom on school campus for face-to-face education and the provision of other school services. 1,2 While it is clearly in a child’s best interest that he/she attend classes on-campus, the benefits must outweigh the medical risks to the children, teachers, school staff, and families. This goal must be the most important factor. We are learning more about the coronavirus nearly every day, and these recommendations are subject to change as new information becomes available. Therefore, this is a living document and will be changed on an ongoing basis as new information is discovered. Please check back on this site (https://fcaap.org/parents/covid-19/) frequently for updates. At the time of this writing viral positivity rates are extremely high in Florida. The World Health Organization (WHO) has recommended that the new positive test rate for SARS-CoV-2 which causes COVID-19 should be <5% averaged over a 14-day before states (and, hence, schools) can safely open. 3 Therefore, the FCAAP recommends that school districts in locales with higher positive test rates (≥5%) that do not meet the 14-day criteria delay the start date for school until positive testing rates are lower. In many areas of the state coronavirus prevalence will not decrease enough in the next 4-6 weeks to make the benefits of school attendance outweigh the risks. There are recent studies showing children do not become as ill as older age groups with SARS-CoV-2, and they do not spread it as efficiently as adults do. The data are relatively limited to make definite conclusions about these contentions. However, if children, as a group, do not become as ill as adults, it does not mean every child with COVID-19 does not become ill. In one of the papers cited 12% of cases in children were severe. 4 There is great concern about children with special healthcare needs infected with SARS-CoV-2 (asthma, obesity, diabetes, congenital heart disease, cystic fibrosis, and immune deficiencies, to name a few). Furthermore, children have become critically ill due to a rare multisystem inflammatory syndrome (MIS-C) related to COVID-19. In addition, lower spread rates from younger children to adults does not mean that children cannot spread the virus to adults. Adults, as we all know, have the potential to become very ill or die at a higher rate. Of note, some studies have noted that the risk of the Multi-System Inflammatory Syndrome in children (MIS-C), which can cause a 1 American Academy of Pediatrics. AAP, education groups stress the importance of safety in school reopening. https://www.aappublications.org/news/2020/07/10/schoolreentrysafety071020. Accessed July 28, 2020. 2 Centers for Disease Control and Prevention. The Importance of Reopening America’s Schools this Fall. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html. Accessed July 28, 2020. 3 World Health Organization. Public health criteria to adjust public health and social measures in the context of COVID-19. https://www.who.int/publications/i/item/public-health-criteria-to-adjust-public-health-and-social-measures-in-thecontext-of-covid-19. Accessed July 28, 2020. 4 medRxiv. Children are unlikely to have been the primary source of household SARS-CoV-2 infections. https://www.medrxiv.org/content/10.1101/2020.03.26.20044826v1. Accessed July 28, 2020. 3 child to become very ill and involves multiple organ systems, appears to peak approximately 4-6 weeks after the rates of COVID-19 itself peaks in a population.5,6 Therefore, children who present ill with fever several weeks after a peak in community COVID infections need to be sent to their physician as soon as possible for evaluation. Recent data suggest that children and young adults 10-19 years of age can spread COVID-19 to adults and others at rates similar to those in the adult age ranges. This new data has implications for junior high and high school settings. 7 Schools should strongly consider mandatory masks and distancing as well as on-line and hybrid learning plans to lessen potential exposures during local disease spikes and increasing positive case testing rates. The exact plan should be developed by each local school district in consultation with local pediatricians, family physicians, epidemiologists, and infectious disease specialists. As in our organization’s recent letter to Florida Governor Ron DeSantis8 expressing concern about opening schools in August, we now ask that the state and school systems help lower the risk to our children as much as possible once in-person school does begin, based on sound and proven epidemiological principle of preventing respiratory virus spread. In the absence of robust and rapid diagnostic testing for schools, the major tools for disease mitigation are personal (social) distancing, mask usage, strict hand hygiene, fomite prevention on surfaces (enhanced cleaning measures), and proper room ventilation. A robust staff and student education program on the mitigation measures is important to the success of prevention. Schools should identify education “champions” to present and monitor compliance with recommended measures. Schools should work closely with their school board and administrators on how best to teach, implement, and monitor preventative measures like those recommended by the FCAAP. FCAAP RECOMMENDATIONS 1. Children must be up to date on vaccinations at the time school starts. Vaccine completion currently stands at approximately 70% for 4-year-old children, and completion of Tdap is at approximately only 23% for 11-year-olds (Florida DOH data). Physicians, medical plans, the state DOH, hospital systems, and medical societies must continue working together in order 5 Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31094-1/fulltext. Accessed July 28, 2020. 6 Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicenter of the SARSCoV-2 epidemic: an observational cohort study. Lancet 2020. https://www.thelancet.com/journals/lancet/article/PIIS01406736(20)31103-X/fulltext. Accessed July 28, 2020. 7 Centers for Disease Control and Prevention. Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020. https://wwwnc.cdc.gov/eid/article/26/10/20-1315_article. Accessed July 28, 2020. 8 Florida Chapter of the American Academy of Pediatrics. FCAAP Letter to Governor DeSantis RE: Re-Opening Schools 7.16.20. https://custom.cvent.com/EDE603C5145F48C8BBC5477DB676A0EB/files/3cd3c981b7134f9d996393a6fafe2a8e.pdf. Accessed July 28, 2020. 4 that as many students as possible are up to date on immunizations. In addition, the state should implement a rule that children going to school receive the influenza vaccine as well as the meningococcal vaccine (if age/condition appropriate). Many other vaccines are already on the school-required vaccine schedule, but influenza illness will raise alarms, because symptoms of influenza are similar to those of COVID-19. Thus, many will mistakenly fear their child/student has COVID-19. Meningococcus, while much less common, is a deadly disease that can cause overwhelming infection and death in hours. The initial symptoms of meningitis can mimic influenza or COVID-19. Teachers and staff should also receive the influenza vaccine. 2. Screening for symptoms is recommended at the beginning of every school day for each student, teacher, and staff member prior to entering school facilities. Please note that the FCAAP does NOT recommend temperature checks at the school. It is expensive, time-consuming, and not sensitive for early infection. Our organization does recommend that parents check their child’s temperature at home before school, however. Those children who have fever should not go to school. As recommended by the Policy Lab at Children’s Hospital of Philadelphia 9 symptoms for which school staff should screen are listed below. Students should not attend school if they meet these criteria: Two or more of the following • fever at home (>100.4°) or subjective fever at school • chills • muscle aches • headache • sore throat • new decrease in smell or taste OR one of the following • cough • shortness of breath • difficulty breathing Students meeting the above screening criteria and who arrive at school should be sent to a designated room separate from the school clinic and staffed for the student’s safety and reassurance. There they can await pick up and transport home with their parent/guardian, including, when appropriate, referral for further medical evaluation. Recommended criteria for return to school are listed in Recommendation 13, below. 9 Children’s Hospital of Philadelphia Policy Lab. Policy Review: Evidence and Considerations for School Reopenings. https://policylab.chop.edu/reports-and-tools/policy-review-evidence-and-considerations-school-reopenings. Accessed July 28, 2020. 5 Some institutions and businesses have developed on-line screening check-in tools where individuals can report symptoms or lack thereof to an on-line portal. The results can be checked before, or as, individuals arrive to enter the building(s). Surveillance should also attempt to identify students, teachers, and staff who were exposed to household or family members with COVID-19. Those who were exposed should be considered for quarantine away from schools themselves (and distance education for the students during that period). Note that web-based reporting has been helpful in some daycare centers in the country, identifying potential outbreaks early. 3. Students should be in cohorts, as much as possible, throughout the school day with as little interaction with other groups of children as possible, including during lunchtime and recess. This should be true throughout the pre-K-12 system. There can be classroom cohorts within grade level-based cohorts. Since an exposure will inevitably occur, keeping students in cohorts would be important for subsequent testing, tracing, and isolation/quarantine if an exposure occurs. 4. Children and teachers should maintain a distance of 6 feet from each other in classrooms and should not be in groups in which they are facing each other. In outdoor activities, the recommended distance between students and staff is also 6 feet, but with a minimum of 3 feet. Students above the age of 5 years, teachers, and school staff should wear masks while in school. Personal Protective Equipment (PPE), including supplies for hand hygiene and extra cleaning supplies, must be made available to the schools (though stored in a setting that is safe for younger children). The CDC recommendations state: “Have adequate supplies to support healthy hygiene behaviors, including soap, hand sanitizer with at least 60 percent isopropyl alcohol (for staff and older children who can safely use hand sanitizer), paper towels, tissues, and no-touch trash cans.” 10 5. Staggering times for school starting and ending would decrease the number of children in school hallways and help with social distancing to limit close contact with parents or caregivers as much as possible. Lunches and other meals (from home or school-provided) are best eaten or provided in classrooms. 6. Use of bathrooms and water fountains need to be regulated. Strict handwashing requirements should be in place for use of such facilities. Classroom surfaces should be thoroughly cleaned with approved disinfectants11 after every school day and between classroom cohorts as they change over throughout the school day. Ventilation systems for classrooms should be checked to assure they are in optimal working order. In poorly ventilated rooms with windows, opening the windows with supervision might be considered. 10 Centers for Disease Control and Prevention. Considerations for K-12 Schools: Readiness and Planning Tool. https://www.cdc.gov/coronavirus/2019-ncov/downloads/community/School-Admin-K12-readiness-and-planning-tool.pdf. Accessed July 28, 2020. 11 United States Environmental Protection Agency. List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19). https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Accessed July 28, 2020. 6 7. Children with special health care needs are at higher risk of harm from COVID-19 infection. Their families should strongly consider whether their child’s educational needs can be met through virtual school. Schools should ensure that the goals of each child’s IEP can be met for children attending virtually. For children attending in-person, each child’s Individualized Health Plan (IHP) should include specific Covid-19 instructions. A Back to School Checklist, which has been written in both English (https://bit.ly/ChecklistEnglish) and Spanish (https://bit.ly/ChecklistSpanish), might be helpful for parents in deciding whether to send their children with special healthcare needs back to school. It can help guide their conversation with their healthcare provider. 8. Almost 30% of teachers are above the age of 50. Those teachers who are greater than 50 years of age or have special healthcare needs should work in an area that is lower risk (virtual instruction, for example). Furthermore, these higher risk teachers should receive more enhanced surveillance and have more flexible work schedules. The New York Times recently published an article outlining a very interesting way to decrease risks to older teachers. 12 9. School systems should make every effort to hire school nurses for each school to help manage the recommendations and for symptom surveillance. There was already a marked dearth of school nurses in the Florida primary and secondary school systems before the COVID-19 epidemic, and it is now a critical issue. Even with a school nurse in every school, the position may be inundated by the breadth and volume of responsibilities during this pandemic. Schools can consider creative solutions such as volunteer assistance from healthcare professionals and institutions in the community, including medical education programs (e.g., medical schools, nursing schools). 10. During the school year students will, inevitably, present to the health room with other nonCOVID type complaints. These should be handled as usual, and the nurse should have a signed release under the Family Educational Rights to Privacy Act (FERPA) to allow her/him to call any child’s pediatric/family medicine/healthcare provider office when important. This would be particularly true for children with special healthcare needs. Please note that nebulizers should NOT be used in schools during the coronavirus pandemic. There are limited data on whether they increase the spread of COVID-19. However, out of an abundance of caution nebulizers should not be used. 13 Inhalers used with spacers are thought to be safer. 11. School buses and bus routes need to be set up so as to allow social distancing of children. Extra cleaning will, of course, need to be maintained on the buses, in the same manner as in the schools. 12 The New York Times. How to Re-Open the Economy Without Killing Teachers and Parents. https://www.nytimes.com/2020/07/20/opinion/coronavirus-reopen-schools-economy.html?smid=em-share. Accessed July 28, 2020. 13 Minnesota Department of Health. Aerosol-Generating Procedures and Patients with Suspected or Confirmed COVID-19. https://www.health.state.mn.us/diseases/coronavirus/hcp/aerosol.pdf. Accessed July 28, 2020. 7 12. Contact team sports are not recommended by the FCAAP for at least this fall, as the viral infection rate is too high and sport activities place students in closer contact. Once the viral infection rates decrease, safe involvement in sports might be possible. Please see CDC guidelines (https://bit.ly/CDCSaferSports) for safer sports involvement. Band and music involvement, particularly the playing of wind instruments and singing, will require extra social distancing, and, of course, instruments will need to be cleaned very well. There are some data that the air plumes from brass and woodwind instruments are actually less than that produced from talking. Nonetheless, observers and those not playing instruments should wear masks in addition to social distancing. The safest areas for bands and choruses to perform are outdoors (which may be impractical on many days in Florida) or in large buildings such as a gymnasium. Activities involving singing are not recommend in classroom or tight settings. Projection of infectious material is much greater in magnitude from singers than for wind or brass instruments. 13. The following table has been adapted from the Indiana Department of Health’s original table. It should aid decision-making about when children, teachers, and staff can return to school after a potential COVID exposure. 14 COVID-19: When a Student, Faculty, or Staff Member Can Return to School Individual Febrile or symptomatic but not tested with alternate explanation (strep, influenza, urinary tract infection, etc., as determined by a provider) Not tested without alternate explanation 14 Symptomatic May return to school after 24 hours resolution of fever without fever-reducing medications. No Symptoms N/A Must remain home for at least 10 days (20 days if significantly ill) from the first day symptoms appeared AND for 24 hours fever free without feverreducing medications and with improvement of symptoms. 15 N/A Indiana Department of Education. IN-CLASS COVID-19 Health and Safety Re-Entry Guidance. https://www.doe.in.gov/sites/default/files/news/june-5-class-document.pdf#page9. Accessed July 28, 2020. 15 Centers for Disease Control and Prevention. Discontinuation of Isolation for Persons with COVID-19 Not in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html. Accessed July 28, 2020. 8 Tested and Negative Tested and Positive Close Contact (within 6 feet for more than 15 minutes of someone with confirmed COVID-19) If no alternative explanation, isolate until the COVID test is back. If that test is negative and still having symptoms continue isolation and consider re-testing for COVID. If test is negative and symptoms have resolved, isolate for 24 hours fever free without fever-reducing medicine AND with improvement of symptoms. The individual may return to school if tested negative. Must remain home in isolation for at least 10 days from the date symptoms began AND for 24 hours fever-free without fever-reducing medications and improvement of respiratory symptoms. N/A If an individual becomes symptomatic, refer to the symptomatic scenarios. The individual must quarantine for 14 days after contact with the COVID-19 positive person even if the student has an alternative diagnosis for symptoms. May proceed with attending school. EXCEPTION: A known close contact (within 6 feet of a confirmed case for more than 15 minutes) must complete a 14-day quarantine, even if the test results are negative for COVID-19. Isolate at home for 10 days from the day the test was taken. *If the individual develops symptoms, isolation time starts on day 1 of symptoms as in symptomatic tested and positive (to Left). Quarantine for 14 days before returning to school AND must remain symptom-free. If individual develops symptoms, refer to the symptomatic scenarios. 16 Note: QUARANTINE keeps a close contact with someone who has COVID-19 away from others. ISOLATION keeps someone who is sick or tested positive for COVID-19 without symptoms away from others, even in their own home. 16 Centers for Disease Control and Prevention. Public Health Guidance for Community-Related Exposure. https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html. Accessed July 28, 2020. 9 RESOURCES AAP Site on School Reopening: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid19-planning-considerations-return-to-in-person-education-in-schools/ CDC Guidelines on Reopening Schools 2020_07_23: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html CDC Internal documents warn school reopening high risk: https://www.cnn.com/2020/07/11/politics/cdc-documents-warn-high-risk-schoolsreopening/index.html CDC Consideration for Schools: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html CDC Childcare, Schools and Youth Programs: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/index.html CDC Readiness and Planning Tool: https://www.cdc.gov/coronavirus/2019-ncov/downloads/community/School-Admin-K12-readinessand-planning-tool.pdf COVID-19 Planning Considerations: AAP Guidance for School Re-entry: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid19-planning-considerations-return-to-in-person-education-in-schools/ AAP, education groups stress the importance of safety in school reopening: https://www.aappublications.org/news/2020/07/10/schoolreentrysafety071020 Children’s Hospital of Philadelphia (CHOP) Policy Lab: https://policylab.chop.edu/covid-lab-mapping-covid-19-your-community 10 CONTRIBUTORS D. Paul Robinson, MD, FAAP—Adolescent Medicine Lisa Gwynn, DO, MBA, FAAP—General Pediatrics and School Health Patricia Emmanuel, MD, FAAP—Pediatric Infectious Diseases Madeline Joseph, MD, FAAP—Pediatric Emergency Medicine Toni Richards-Rowley, MD, FAAP—General Pediatrics Michael Muszynski, MD, FAAP—Pediatric Infectious Diseases Mobeen Rathore, MD, FAAP—Pediatric Infectious Diseases Jeffrey Brosco, MD, FAAP—Developmental-Behavioral Pediatrics Tommy Schechtman, MD, FAAP—General Pediatrics Shannon J. Fox-Levine, MD, FAAP—General Pediatrics CONTACTS Alicia E. Adams, Esq. – FCAAP Executive Director aadams@fcaap.org Mrs. Melanie Range – FCAAP Membership & Communications Coordinator mrange@fcaap.org FLORIDA CHAPTER OF THE AMERCIAN ACADEMY OF PEDIATRICS, INC. 1400 Village Square Boulevard, #3-87786, Tallahassee, FL 32312 Call or Text: 850/224-3939 Fax: 912/452-9050 www.fcaap.org