Can Schools Reopen Safely? One Model Says Yes

A modeling study that appeared in the Annals of Internal Medicine found that it was safe to resume in-person education with controlled community transmission and moderate mitigation strategies in place.

Vinay Prasad, MD, MPH, breaks down the study and explains why it shows that much of the damage is done, and says that if schools do not reopen in the fall, we will be in a dire situation in this country.

Following is a transcript of his remarks:

Dr. Vinay Prasad here from University of California San Francisco. I’m back with a new video for MedPage Today, for “Articles You Will Definitely Read (Later).” So we’ve got a new article out today. It’s in the Annals of Internal Medicine, it’s called “Passing the Test: A Model-Based Analysis of Safe School-Reopening Strategies.” And it is an interesting article.

Here’s what the authors did. The authors recognize that right now only 60% of American students are back in school 5 days a week. We did a lot of things in the pandemic that were disruptive to normal life. One of the most disruptive things, with the longest legacy, will be school closure. The authors recognize this. The editorial points out some interesting things. Of course, mental health visits are on the uptick and we may not have yet seen the full repercussions of what school closure has done to this young generation of kids.

The authors of this article wanted to ask, can we safely reopen school for that 40% of kids who aren’t back in school, in person, full time, 5 days a week? And to answer that question, they take part in an elaborate modeling exercise. Basically what they did was they created model households, model schools, and model interactions, and they assumed what would happen to schools, elementary schools or high schools, if you assumed different levels of spread.

They assumed that elementary school kids are a little bit less susceptible to acquiring the virus and less susceptible to transmitting it than adults. And I think that’s a safe assumption. They also assumed that things like masking, distancing, cohorting, and screening students with PCR-based testing might lower the risk of transmission in these schools. And putting these assumptions together, they created a series of models to assume what would happen if a school did all of this very, very well; did some of this kind of well; or did it rather poorly.

And they got a very interesting result. They show that under a broad set of assumptions, schools can reopen safely. Transmission will be very, very low and the benefits to kids will far outweigh that, in my opinion. But they show that — I think is rather the most interesting finding of their study — is they redo their models, thousands of times, 2,000 times, to get a distribution of the cases that might happen, and I think this is the insight of this study, which is that under most of the scenarios they run, transmission is going to occur in very, very few cases in the school. Or it’s not going to occur at all.

But there is some tail. There is some rare set of events where transmission can occur in multiple people. It has sort of a distribution where the big hump of the distribution is over one, two, three, zero — and then the tail of the distribution gets out there into many people affected.

Why is this important? I think this is important in that as we reopen schools, we should not panic if one school out of 100 schools or 500 schools has a bunch of cases in it. That’s actually to be expected, even if things are going really well for the majority of schools. So I think it’s important to know that SARS-CoV-2 spread has this stochastic phenomenon where some individuals in some schools will have worse spread, but that doesn’t mean that opening schools was wrong or bad. The majority of the model scenarios would show that it will be associated with less spread. It’s an inevitable consequence of the way in which the virus spreads. I thought that was the greatest insight of this study.

The tough part about the study was that, in many respects, the study finds what the study puts into it. It’s a model study. You know, models are only as good as the inputs. And here the authors assume that these interventions — masking, distancing, cohorting — are going to exert a large reduction in the spread of the virus. Now, is that true? I wish we had done careful empirical studies during this pandemic to sort out how much of that is true. How much of the effect sizes from each of these different things, so we could know what was important and what isn’t important. But the fact is we don’t know that for sure.

We do have, I think, in addition to this study, many really elegant studies, we have the North Carolina Experience, which is a wonderful study. We have the Wisconsin study, which is a wonderful study, and these are as real-world as it gets, they put kids back in school and they document what happens. And what happens is it’s generally reassuring. The spread of SARS-CoV-2 is very low in schools. Very few people are affected. And if you weigh that against the benefit schools provide in terms of upward mobility, life choices, an improvement in the well-being of kids, both psychologically and physically and mentally, the answer is clear in my mind. It is to reopen schools.

So I will say one thing about this article, I’m often a critic of the editorial. I think it doesn’t usually go far enough. Doesn’t usually say what I want it to say. But this time, Ted Long, MD, writing, “Resuming In-Person Learning: Safe and Imperative,” it is a stellar editorial. It’s an editorial worth your time. It’s an editorial that makes the case that now is the time to be ready for fall reopening, getting all kids back in public schools.

The last thing I will say — when the pandemic first hit in March of 2020, I will admit I didn’t know a lot about schools and I didn’t have a strong opinion about school closures. We learned rather early on by the spring of 2020 that kids were not the prime driver of this virus. We also learned that in Europe they could reopen schools and some countries actually kept schools going even during the pandemic, such as Sweden.

I started to read more in the summer of 2020, and I learned a lot about schools, that schools provide a tremendous opportunity for kids, particularly poor, minority, and vulnerable kids. Schools are the one great ladder of upward mobility left in this country. Schools have a tremendous importance in society, not just for the kids’ wealth, for the upward mobility, but also their health, which is so tied to how much we earn and our wealth and our socioeconomic drivers.

So by the fall of 2020, I became concerned that prolonged school closures was a bad idea. The school closures were not even even. They were more likely to happen in Democratic strongholds than Republican districts. That certainly has nothing to do with the virus. The schools’ closures had nothing to do with the rate of SARS-CoV-2 spread. Some places that open schools had rip-roaring spread. And some places that closed it had very low test positivity rates. It had nothing to do with hospitalizations. It didn’t speak to how overwhelmed healthcare systems were.

And the more I investigated the schools closure issue, I realized the sobering fact that school closure was merely — I believe — a political reaction to the pandemic spread driven by strength of local teachers’ unions and by political realities on the ground. It wasn’t driven by a rational response to the virus.

And we have paid and we will pay the price for this. The consequences of school closure, you have just seen the tip of the iceberg, with the reports of mental health ailments in children. It’s the tip of the iceberg. What’s to come will be the children who have been lost, who have not spoken to people outside of their family, will come forward in the months and years to follow. And I think you will see the full extent of the damage that was done.

Closing schools in this country was a catastrophic intervention. It has profound consequences on kids. In my mind, it would only be justified if it were key and integral to slowing the spread of this virus. Many, many empirical analyses, including this modeling study, show that that is not the case, that schools can reopen safely. I think the price we have paid in school closures is too great. This study is a necessary reminder that schools can and must reopen in the fall. And if we don’t do that, I think we will be in a dire situation going forward in this country.

So that’s it. My take on this article, a model-based analysis of safe school reopenings, I think it’s an important article. I think the most important finding is that there will be some stochasticity to this. There will be some schools that have many, many cases. That doesn’t mean it was wrong to open schools. That is a consequence of the way in which this virus spreads. And I think this reinforces the urgent and pressing need to do this. So, Vinay Prasad for MedPage Today.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Evidence Harm People With Cancer.

Last Updated June 08, 2021