Save our Schools: A Health Initiative

As concerned physicians, epidemiologists, medical professionals, and public health servants, we embrace our duty to protect the health and well being of the most vulnerable in society- our children. We must strengthen confidence in our public health and medical institutions by providing evidence-based recommendations and timely updates, so that policy makers are equipped to make well informed decisions supported by science. Bound by the principle of nonmaleficence, to do no harm, this effort begins in the most elementary location- our schools.

• Schools are essential and must open for full-time in person learning without restrictions.
• We must model rational risk assessment for our children and allow them to return to their normal lives this summer and in the upcoming school year.
• No mask mandates for children.
• Eliminate unproven restrictions.
• Adult vaccination is the path out of the pandemic.
• COVID-19 vaccine mandates for children are not warranted and would further undermine the trust in public health.
• Discontinue asymptomatic testing in schools at this time.
• For those with a confirmed history of COVID-19, shared decision making in regards to vaccination is most appropriate.

Schools are essential and must open for full-time in person learning without restrictions.

We must consider that children are more at risk from collateral damage from restrictions than from COVID-19 infection. The detrimental consequences of pandemic restrictions include negative impacts on diet, sleep, physical activity, unreported abuse, food insecurity, and rising obesity rates among children. During the pandemic, ED visits for suspected suicide attempts were 50.6% higher among females compared with the same period in 2019. Children’s Hospital of Colorado declared a state of emergency over children’s mental health, and there has been a dramatic increase in suicidal ideation, depression, anxiety, substance abuse and deaths of despair in our youth. During periods of highest COVID-19 prevalence this past year, even without the benefit of an efficacious vaccine, there were successful districts that demonstrated schools can stay open safely. Fortunately, the data reassures us that schools that have continued in person learning are not super spreaders or a driver of community spread. Overall, the risk to children is too low to ethically justify the remaining restrictions they face in lieu of the adverse effects.

We must model rational risk assessment for our children and allow them to return to their normal lives this summer and in the upcoming school year.

For unvaccinated children, recovery is 99.997%. The documented hospitalization rate of 0.1–1.9% of children diagnosed with COVID-19 has been inflated, given that recent studies suggest approximately 40% of pediatric COVID-19 admissions were mischaracterized. The reported hospitalization rates greatly overestimate the true burden of COVID-19 disease in children. The risk of a child developing MIS-C, a serious inflammatory condition with effective treatments, is rare per CDC, and generally followed by recovery. Of all the tragic COVID-19 deaths in the country, only 0.06% were in children aged 0–17. “Long covid” in children is also rarer than previously thought, with less than 2 percent of children experiencing any symptoms two months after infection. And multiple reassuring studies have found little evidence of the disease affecting children’s hearts. This low risk for children nearly vanishes as cases plummet and as vaccination rates across all demographics rise.

No mask mandates for children.

As our healthcare system battled the strain of the COVID-19 pandemic, we supported the implementation of multiple mitigation strategies, including masks for children, in an effort to lessen disease burden. Over the past year, and even in the past month, the burden of disease on the community has evolved, and our approach must reflect this knowledge. The U.S. 7-day COVID-19 death average has fallen by nearly 90% from it’s peak in January, and the average 7-day hospitalization has plummeted. As of June 2, total hospitalizations fell below 20,000 for the first time since June 24, 2020, and the vast majority of these patients are unvaccinated. At this time, 64% of adult Americans have received at least one dose, and of those that are unvaccinated, we can estimate a significant proportion have the protection of natural immunity due to previous infection. Recent data from more than 1.5 million students and staff at K-12 schools- before adult vaccination- found that mask mandates were NOT associated with student or teacher infection rates when adjusted for spread within the community. A study compiling data from Nov-Dec 2020, prior to vaccine availability and during higher case prevalence, found “lower incidence in schools that required mask use among students was NOT statistically significant compared with schools where mask use was optional.” For children, at our current vaccination, prevalence, hospitalization and death rates, there is insufficient evidence that continued mask mandates for children would provide a benefit that outweighs the potential harm. It is past time to prudently adjust course and lift mask mandates for our children.

Eliminate unproven restrictions.

Data collected from more than 1.5 million students and staff at K-12 schools — before adult vaccination — found that lower classroom density was associated with higher rates of infection. Closing off playgrounds, restricting use of athletic equipment and masking at recess are not backed by science. Contagion via athletic equipment has proved exceptionally low. Plus, restrictions at recess discourage children from participating in lower-risk, but essential, playtime and exercise. Do away with plexiglass barriers, face shields and deep cleaning. Many of these interventions divert precious resources away from vulnerable and at risk populations, and are not supported by science.

Adult vaccination is the path out of the pandemic.

We champion the use of safe and efficacious vaccines. Available COVID-19 vaccines are 95% efficacious in preventing hospitalization or severe illness. The CDC has stated that those with breakthrough infections after vaccination are likely to be completely asymptomatic or have minimal symptoms with low viral load. Those with autoimmune conditions or immunosuppression may still receive the vaccine, and the majority will have adequate immunogenic response with an acceptable safety profile. New variants have thus far shown promising response to vaccination in a large study by Public Health England. As we saw in Israel and Britain, vaccinating adults indirectly protects children. The same trend is evident here in the United States, as adult vaccination has lowered COVID-19 incidence among children by 50 percent in the past four weeks.

COVID-19 vaccine mandates for children are not warranted and would further undermine the trust in public health.

There is debate in the medical community as to whether the use of emergency use authorization in children is ethically appropriate considering the low risk of severe COVID-19 disease or complications in children. There is also growing unease about rare, but serious, vaccine induced adverse effects particularly in males aged 16–24, as recognized by the CDC’s Advisory Committee on Immunization Practices on 6/23/21. A cautious approach and preservation of patient autonomy is vital to maintain trust, preventing further vaccine hesitancy and resultant decreased childhood vaccination rates. More rigorous safety data and evidence of community necessity will emerge over the next school year.

Discontinue asymptomatic testing in schools at this time.

The value of asymptomatic testing is complicated by pretest probability, community prevalence, and cost-benefit analysis. With testing widely available in the community, the high vaccination rates of teachers and staff, and low community prevalence, we feel indiscriminate asymptomatic testing in schools is of limited value. The high rate of false positives under these conditions would lead to needless quarantining, loss of learning, missed work, absenteeism, and strain on substitute availability. A transition away from the focus on case prevalence and instead to adverse outcomes and hospitalization rate will provide a more accurate picture of disease burden.

For those with a confirmed history of COVID-19, shared decision making in regards to vaccination is most appropriate.

It is important to acknowledge the mounting evidence that natural immunity after COVID-19 infection is protective and likely long-lasting. Reinfections after COVID-19 recovery are rare events and Natural immunity to COVID-19 appears to confer a protective effect for at least a year, which is similar to the protection reported in recent vaccine studies. A large study of 52,238 Cleveland Clinic employees concludes that individuals who have had COVID-19 infection are unlikely to benefit from COVID-19 vaccination, and vaccines can be safely prioritized to those who have not been infected before.” Blanket restrictions and mandates in our schools and communities fail to take into account the protective nature of natural immunity and would potentially lead to unnecessary restrictions or requirements on staff and students.

In closing, we must acknowledge the great burden we have placed on our children while managing the COVID-19 pandemic. The decisions that resulted in that burden were made with the best of intentions, the desire to protect our children from a potentially catastrophic disease. But now, benefitting from plentiful scientific data, along with a historic vaccine development and distribution program, it is abundantly clear that the universal desire to protect our children is achieved not by further masking and restrictions, but by allowing our children the freedom of activity and socialization they knew prior to the pandemic. We must continue to act with beneficence, and let our kids be kids again.

Jill Ackerman, MD