To cope with diminishing resources during the state’s spike in COVID cases, the South Carolina Department of Health and Environmental Control and the State Board of Nursing have issued a temporary order permitting graduate nurses to treat patients during the crisis.
At Medical University of South Carolina’s Florence Medical Center, Chief Nursing Officer Costa Cockfield stated, “This is a win-win situation, the nursing students have a pathway to work while waiting to take the licensure exam. Likewise, the hospital benefits by getting the new graduate oriented and into clinical practice much faster.”
With NCLEX testing sites closed due to the pandemic, the state has been suffering from critical nursing shortages that have been unrelieved by any inflow of new RNs. Under the new order, graduate nurses who have not been able to take the NCLEX can temporarily fill staffing gaps despite lacking a license. The new rules apply to graduate nurses who have registered for the NCLEX and have graduated from an accredited nursing program. The grads are required to work under the supervision of an RN at all times.
Tony Derrick, Chief Nursing Officer at McLeod Medical Center, said, “There is certainly a place where… [these graduate nurses] could fit in to assist as a resource, and while they’re doing that, they’re learning, so I think it’s a positive win for both the student nurse for resource allocation as this pandemic continues and I don’t think it hurts to have this as a good resource.”
South Carolina is one of the few states to issue an order to temporarily admit graduate nurses into the workforce. In March, Ohio governor Mike DeWine signed a bill allowing newly graduated nurses to obtain a temporary license prior to passing the NCLEX, but so far few states have followed suit. Prior to the state’s surge in COVID cases, the Texas Nurses Association, the Texas Board of Nursing, and the Texas Organization for Nursing Leadership issued a joint statement advising that “Prelicensure RN students from diploma, associate degree and baccalaureate degree nursing programs and PN/VN students from certificate nursing programs could augment and support nursing services in health care facilities.” The American Organization for Nursing Leadership released a policy brief recommending similar measures, but such proposals have not gained traction among officials and legislators.
Dr. Geoffrey Watson, an internal medicine specialist and a leader in managed care in Oakland, California, is the founder of The James A. Watson Wellness Center, an African-American health care center focusing on disparities in disease within the African-American community. Dr. Watson also helped to facilitate the formation of an African American Primary Care Group to serve the needs of African Americans in San Francisco’s East Bay, including the development of preventive care programs focused on hypertension, asthma, diabetes, heart disease, substance abuse, and weight control. One of his areas of concern is the treatment of foot problems associated with diabetes. Below, Dr. Watson answers some questions about diabetics as an at-risk group for COVID-19 and describes a new over-the-counter transdermal device for patients with foot issues.
1. What should patients with diabetes know about COVID-19 and how it may affect them?
Those people who are at the highest risks of contracting COVID-19, are those over the age 65, have heart disease, liver disorders, diabetes and other underlying health issues. Because it effects the immune system and compromises the body’s natural defenses fight off infections, it is critical for a person with diabetes to have good blood flow circulation, reducing the chance of infection, ulcers and in worst-case scenarios, amputations.
2. How does Circularity’s over-the-counter (OTC) transdermal device help patients with foot issues?
D’OXYVA® (deoxyhemoglobin vasodilator) is validated to significantly improve macro- and micro-circulation of blood flow and certain nerve activities in the body, which together are widely reported to form an effective non-invasive, pain-free solution option for many conditions. It provides accelerated and comprehensive wound care — plus infection protection — in a painless, affordable non-prescription solution available in a clinical setting, or in the comfort and privacy of your own home.
D’OXYVA has shown significant promise for severe cases of diabetic foot ulcers. Its therapeutic effects have circulatory and neurological benefits as well.
3. Tell us about CO2, microcirculation, and its effects on the body.
D’OXYVA uses ultra-purified carbon dioxide, which has been shown to produce higher oxygen unloading by hemoglobin, thereby increasing oxygen-rich blood flow in the local microcirculatory system. This improved dermal microcirculation leads, in turn, to enhanced wound healing.
Good blood circulation has many important health benefits. Among the most prominent is the optimal oxygenation of bodily tissues and organs, which allows for efficient functioning of the heart, lungs and muscles. Active blood circulation also improves the immune response against disease by allowing the better transportation of white blood cells throughout the body. Furthermore, proper blood circulation improves cellular detoxification, while waste removal becomes more efficient. Among its other health benefits, D’OXYVA® has been also validated as a successful means of improving the autonomic nervous system.
4. What have clinical trials shown about how this device helps patients, especially diabetics with foot problems?
Studies with D’OXYVA have shown increased oxygen concentration and lower carbon dioxide concentration in the blood just 30 minutes after treatment that can last upto 60 minutes. Over two dozen studies demonstrated convincing results at clinics and at home with no adverse events.
Many treatments make bold online claims to help cure various conditions and restore you to health — pills, shots, creams, procedures, and devices. But only science-backed, one-of-a-kind D’OXYVA stands alone, delivering the remarkable physical, mental, and emotionally rejuvenating results.
5. As an Internist focused on prevention, what do you want diabetics to know about making their foot health a priority?
The heart is the engine that makes the body function. The foot though a far distance from the heart requires consistent blood flow. It requires open pathways. If those pathways are constricted, which is fairly normal occurrence with diabetic patients, those areas have a tendency to die off, because of the poor blood circulation. That is why it is key to some type of vasodilation to promote microcirculatory blood flow to supply adequate oxygenation the the feet. There by likely helping to prevent infections, ulcers and wounds.
A native and resident of Oakland, California, Geoffrey Watson obtained a Bachelor of Science in Health Care Administration from the University of California at Davis and a medical degree from Vanderbilt University in Nashville, Tennessee. Dr. Watson completed two years of his medical residency at the Vanderbilt Medical Center with his final year of medical residency completed at the University of California Medical Center in San Francisco. In 1985, Dr. Watson started his medical career in Oakland as a specialist in the art of Internal Medicine working as a staff physician at the Arlington Medical Center alongside his father, Dr. James A. Watson.
Dr. Watson has a special interest in education and has earned the position of Director of Continuing Medical Education at Fairmont Hospital in San Leandro and Alameda County Medical Center of the East Bay. In 1992, as a Board Certified Internist, his love for teaching and medical education has earned him a position as Assistant Clinical Professor of Medicine at the U.C.S.F. Medical Center. Also in 1992, as the Co-Medical Director of the Arlington Medical Center, Dr. Watson became a key player in the Oakland community as a leader in managed care and positioned himself as a Founding Member of the Alta Bates Medical Associates. He developed medical groups, leading the way in managed care, and helped to organize a merger of prominent physicians resulting in a powerful African American Primary Care Group geared towards serving the needs of African Americans in the East Bay, including the development of preventive care programs focused in the areas of hypertension, asthma, diabetes, heart disease, substance abuse and weight control.
Dr. Watson served as the Secretary for the Sinkler Miller Medical and the Golden State Medical Associations during 1994. In May, 1997, he was inaugurated into office as President of the Golden State Medical Association and served through 1998. From 1996 through 1997 he has been honored with serving as the President of the Sinkler Miller Medical Association of the East Bay. On March 1, 1997, Dr. Watson established a new medical facility, The James A. Watson Wellness Center, a legacy of his father, moving his practice to Pill Hill and continuing to provide high quality and sensitive care to patients by treating the physical, socioeconomic, spiritual and psychological ailments and employing medical and practical solutions with hopes of resulting in complete wellness.
Shawn Hayes was thankful to be holed up at a city-run hotel for people with COVID-19.
The 20-year-old wasn’t in jail. He wasn’t on the streets chasing drugs. Methadone to treat his opioid addiction was delivered to his door.
Hayes was staying at the hotel because of a coronavirus outbreak at the 270-bed Kirkbride Center addiction treatment center in Philadelphia, where he had been seeking help.
From early April to early May, 46 patients at Kirkbride tested positive for the virus and were isolated. The facility is now operating at about half-capacity because of the pandemic.
Drug rehabs around the country — including in Pennsylvania, Illinois, Indiana, Minnesota and Florida — have experienced flare-ups of the coronavirus or COVID-related financial difficulties that have forced them to close or limit operations. Centers that serve the poor have been hit particularly hard.
And that has left people who have another potentially deadly disease — addiction — with fewer opportunities for treatment, while threatening to reverse their recovery gains.
“It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” said Dr. Caleb Alexander, a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic has profoundly disrupted the drug markets. Normally that would drive more people to treatment. Yet treatment is harder to come by.”
Keeping Clients Safe
Drug rehabs aren’t as much of a COVID “tinderbox” as nursing homes, Alexander said, but both are communal settings where social distancing can be difficult.
Shared spaces, double-occupancy bedrooms and group therapy are common in rehabs. People struggling with addiction are generally younger than nursing home residents, but both populations are vulnerable because they’re more likely to suffer from other health conditions, such as diabetes or cardiovascular disease, that leave them at risk of succumbing to COVID-19.
To keep clients safe, some addiction treatment centers employ safety precautions similar to hospitals, like testing all incoming patients for COVID-19, noted Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security. But drug rehabs must avoid some strategies, such as keeping potentially intoxicating hand sanitizer on the premises.
Adalja said he hopes safety measures make people feel more comfortable about seeking addiction help.
“There’s not going to be anything that’s zero risk, in the absence of a vaccine,” he said. “But this is in a different category than going to a birthday party. You don’t want to postpone needed medical care.”
Still, some people requiring drug or alcohol rehab have stayed away for fear of contracting COVID-19. Marvin Ventrell, CEO of the National Association of Addiction Treatment Providers, said many of its roughly 1,000 members saw their patient numbers down by much as 40% to 50% in March and April before bouncing back to 80%.
Unlike many other centers, Recovery Works, a 42-bed treatment center in Merrillville, Indiana, has seen more clients than normal during the pandemic. The facility had to close for a few days early on after a suspected COVID-19 case, but reopened after the person tested negative. It has since split its therapy sessions into three groups, staggered mealtimes and banned visitors, CEO Thomas Delegatto said. It then had an influx of patients.
“I think there are a variety of reasons why,” Delegatto said. “A person who was struggling with a substance use disorder, and who was laid off and a nonessential worker, might have seen this as an opportunity to go to treatment without having to explain to their employer why they’re taking two, three, four weeks off.”
He also noted that alcohol sales went up at the beginning of the pandemic as anxiety and isolation rose, and sheltering in place may have made some families realize that a loved one needed help for an addiction.
Centers Serving The Poor Hit Hard
Homeless and poor Americans, because they often live in close quarters, have been particularly prone to catching COVID-19 — leaving drug rehabs dedicated to this population especially vulnerable.
Haymarket Center, a 380-bed treatment and sober living facility in Chicago’s West Loop that serves many people who are homeless, recently had an outbreak of 55 coronavirus cases among clients and staff members.
Two employees there tested positive for COVID-19 in late February, but testing was available then only for people showing symptoms, said Haymarket president and CEO Dan Lustig.
Haymarket worked with nearby Rush University Medical Center to test its clients. Twenty-six men, though asymptomatic, were found to be positive for COVID-19.
The center isolated those patients and eventually went from double- to single-occupancy rooms, improved its air filtration system and changed the way it served food. It now tests all new admissions.
“What we found was by doing serial testing we could tamp down the epidemic, not just at Haymarket but the whole city,” said Dr. David Ansell, senior vice president for community health equity at Rush, which partnered with the city and other health systems on a COVID-19 response for Chicago’s homeless population.
The pandemic’s economic fallout has also forced some facilities to scale back. The Salvation Army is shuttering a handful of its roughly 100 adult rehabilitation centers nationwide due to COVID-related revenue losses. Those rehabs were funded by the organization’s resale shops, which were forced to close during stay-at-home orders.
“A lot of what we do relies on donations or items that were donated and then sold in our stores,” said Alberto Rapley, who oversees business development for the Salvation Army’s rehab facilities in the Midwest. “When financially we struggle, that is then felt on the other side.”
For instance, the Salvation Army drug rehab in Gary, Indiana, which is set to close in September, treated as many as 80 men at a time in its free, abstinence-based program. The next closest facility will be in Chicago, more than 30 miles away.
Outbreak Contained, But Beds Still Limited
Philadelphia’s Kirkbride Center also serves a mostly homeless and low-income population. Dr. Fred Baurer, the facility’s medical director, said Kirkbride was “flying blind” early in the pandemic, with little testing capacity and personal protective equipment.
On April 8, the first COVID-19 case appeared on Kirkbride’s long-term men’s wing. Over the next week, six more men on the unit showed symptoms and tested positive, as did 12 of the remaining 22. All quarantined at a local Holiday Inn Express.
Kirkbride started requiring face masks, testing all new clients for COVID-19 and prohibiting people in its various units from mingling.
The rehab has been about half-full lately — it’s usually closer to 90% occupied — partly because it stopped taking walk-in clients and confined new admissions to single rooms.
“I’m starting to feel more confident we’re past the worst of this, at least for now,” Baurer said.
Hayes, who has recovered from COVID-19 without experiencing any symptoms, was discharged from the facility June 15 to a sober living house. He plans to attend 12-step meetings regularly. He hopes to get his GED and eventually enter the mental health field.
He recognizes the need to stay vigilant about his recovery now, at a time of increased anxiety and despair.
“Regardless of the coronavirus or not, the addiction crisis is still there,” Hayes said. “It’s bad. It’s really bad.”
Published courtesy of KHN (Kaiser Health News), a nonprofit news service covering health issues. KHN is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Students at the University of California Irvine Gross School of Nursing made good use of their downtime by paying virtual visits to non-COVID patients at the UCI Medical Center. Between May 4 and their June 13 commencement, 45 iPad-wielding undergrads and graduates took part in the UCI Health Virtual Visitor Project, working in pairs to make bedside Zoom visits.
Virtual visits from sympathetic nursing students brought real-life comfort to isolated patients. One non-COVID patient, Cristian Lopez, was being treated for injuries in a devastating motorcycle accident. Facing the prospect of a year of recovery and physical therapy after five surgeries, he was feeling alone and vulnerable when the Virtual Visitors reached out: “I got a little emotional because I’m still undergoing a lot of trauma, but they made me feel that I had good energy, that I’m on the right path. They were very kind. They just allowed me to talk, which made me feel good.… There’s something special about this place. They really take care of people.” He was deeply moved by his visitors. “I don’t remember anything about the accident. But I’ll always remember them.”
The emotional response of Lopez was not unique, according to Daniel Bernstein, nursing manager in UCI Medical Center’s orthopedics unit: “I had a spinal surgery patient tell me after a session, ‘That was the highlight of my day.’ Then he started crying. The value of the service is that it makes patients feel better and makes [nursing students] feel as if they’re doing something important.”
The students were quick to appreciate the value of the project. In their virtual visits, they were able to connect with abilities at the very heart of the nursing profession. Student Araceli Melchor Cruz reflected: “This project reinforced how important it is to have good communication with our patients, to listen to them and to provide care not only physically but also emotionally. Personally, it was very rewarding to know that even though we were not actually at the hospital, we were able to do something for the patients.” Sahra Kakwani, another Virtual Visitor, added, “In our nursing program, one thing that we learned can be very useful for both the nurses and the patients is to talk to them about anything. I think this program had so many positive results, especially in preventing patients from feeling socially isolated.”
For the full story on the UCI Health Virtual Visitor Project, click here.
Ohio printer Walter Ruiz could not quite recognize her features under all of her PPE, but the voice of Nurse of the Week Lisa Lane quickly became familiar to him during his struggle with COVID-19.
Hospitalized with COVID after passing out at his business, Ruiz was “scared; really, really scared,” and being cut off from his family left him feeling terribly alone: “When you don’t have anybody around you…no members of your family…it’s really hard.” Fortunately, Lane, an RN on the COVID unit at Cincinnati’s Mercy-Fairfield Hospital supported him at his bedside. She held his hand, offered him constant words of encouragement and hope, and urged Ruiz to keep fighting the virus so he could once again see his grandchildren. She told me, “You can make it; you can do it,” Ruiz recalled.
After his recovery, a grateful Ruiz was determined to thank the nurse who had kept his spirits up during his ordeal, but the disguising effects of PPE made it hard for him to identify her. With help from the hospital, he intently perused photos of the unit nurses and finally made a tentative choice. Ruiz’s uncertainties immediately fell away, though, when he once again heard Lane’s voice. To share his gratitude with all of the nurses on the Mercy-Fairfield COVID unit, when Ruiz was well enough to return to his printing business, he created a large sign reading, “THANKS to all Mercy Staff for Being Everyday Heroes in Our Lives.”
Lane was delighted to meet with such enthusiastic appreciation, but remarked, “I don’t do anything more than any nurse on the planet does…that’s just what we do.”
As school officials debate whether to reopen this fall, physicians, teachers, and a prominent ethicist markedly disagreed on whether sending children back into the classroom is safe for their communities.
Some pediatricians are driving the push to reopen, while infectious disease specialists, family physicians, and teachers appear more wary, concerned that schools could become “new hotspots for the virus.”
At the heart of the debate are many unanswered questions, with arguably the most important being: How often are children infected, and how contagious are their infections?
The American Academy of Pediatrics (AAP) issued guidance in late June that strongly recommends children resume in-person classes in the fall.
While acknowledging that “many questions remain,” the AAP was confident in reopening given “the preponderance of evidence” that children “may be less likely to become infected and to spread infection,” as well as less likely to become symptomatic or develop severe illness when they do contract the virus.
However, NIAID Director Anthony Fauci, MD, has cautioned that there aren’t enough data to make a definitive statement about transmission in children. His colleague on the White House Coronavirus Task Force, Deborah Birx, MD, acknowledged on July 8 that children are the least tested population.
The AAP guidance does emphasize the importance of responding quickly to “new information,” but drives home its message that “all policy considerations for the coming school year should start with a goal of having students physically present in school.”
President Trump has made it clear he wants governors to reopen schools, even threatening to withhold funding from states that don’t force these reopenings.
His administration has leveraged the AAP’s own recommendations at every turn.
On July 8, during the Wednesday task force briefing, Education Secretary Betsy DeVos quoted from the academy’s guidance, stating that “keeping schools closed places children and adolescents at considerable risk of morbidity and in some cases mortality.”
At the same briefing, Vice President Mike Pence recommended that “every American” review the AAP’s guidance.
The White House has already shown its influence over these decisions. Following an angry Twitter storm from President Trump over CDC’s “very tough & expensive” recommendations for reopening schools, Pence said the agency would be releasing new guidance next week.
However, in an interview with Good Morning America on July 9, Redfield clarified that the basic CDC guidance would remain in place, but additional reference documents would be included.
The AAP’s statement makes clear it determined that the risk of viral transmission is the lesser danger compared with the social, emotional, and academic consequences of remaining home, and believes the evidence is on its side.
Danielle Dooley, MD, an AAP spokesperson and medical director of community affairs and population health at Children’s National Hospital in Washington, D.C., told MedPage Today that when schools closed in March, many experts assumed the virus would “behave like influenza” which spreads rapidly among children.
“But what we know now … three months later is that it doesn’t behave like influenza. Children do not appear to be ‘super-spreaders,'” Dooley said, noting that only “very limited cases” have shown children passing the virus to adults. A press representative was present during the phone interview with Dooley.
While “tens of thousands of children” of essential workers continued going to daycare centers and emergency childcare facilities throughout the pandemic, Dooley noted “there have not been cases of major outbreaks or spreading events in those areas.”
The YMCA and the New York City department of education cared for a total of 50,000 children during the pandemic, and both organizations told NPRin late June they had had no COVID-19 outbreaks.
The AAP also relied heavily on a May 15 policy brief from the Learning Policy Institute (whose funders include the Sandler Foundation and the Ford Foundation). The report summarized the experience of China, Denmark, Norway, and Singapore in reopening schools in late March or April and also includes the experience of Taiwan, which kept schools open nationally, while implementing mandatory and temporary closures in areas with high infection rates.
All five countries’ strategies were viewed by the policy brief’s authors as successful “to date” in avoiding the spread of COVID-19.
All instituted temperature checks and a range of physical distancing measures. Denmark and China reduced their class sizes and Norway instituted a maximum class size of 15 students for younger grades and 20 for older grades. The five countries also developed quarantine or school closure policies. Taiwan will suspend a particular class for 14 days if one case is discovered and will suspend school for 14 days if two or more cases are identified. In Denmark, anyone who’s sick is required to remain home for 48 hours.
The institute acknowledged that countries that reopened their schools “differ significantly from the experiences so far in the United States” with regard to their capacity “to test and track cases” and to “isolate individuals who have been exposed to infection,” all factors linked to their success in avoiding viral spread. The policy brief further stated that it “has not investigated the health implications of using any of these practices in the United States and does not endorse the safety or effectiveness of these practices or of any medical practices.”
Dooley also cited a systematic review in The Lancet, published in April, which cited data from the 2003 SARS outbreak in mainland China, Hong Kong, and Singapore indicating that closing schools “did not contribute to the control of the epidemic” while recent modelling studies of COVID-19 estimate that closing schools alone “would prevent only 2%-4% of deaths.”
AAP also cited an editorial published in The BMJ in May that leans on studies of widespread community testing in Iceland and South Korea which found children were “significantly underrepresented” in positive cases. The authors also cited a case study of a cluster in the French Alps in which one child with COVID-19 failed to transmit the virus to anyone “despite exposure to more than a hundred children in different schools and a ski resort.”
The AAP recommends that older children in elementary and secondary schools wear face coverings, social distance, and space their desks 3-6 feet apart when feasible. They also suggested that schools eliminate lockers, and transition to a block schedule for older students (where classes run longer each day, but terms are shorter) and when possible, rotate teachers for each new class rather than crowd hallways with students transferring place to place.
For children in pre-kindergarten, the academy did not suggest face-masking and physical distancing, believing both too difficult to implement in that age group. Instead it advocated separating kids into cohorts, using outdoor spaces whenever possible, and limiting unnecessary visitors.
The AAP recommended that students use alternatives to buses when possible, and assign seats in cohorts for those who do take the bus. The guidance also suggested one-way hallways, limiting the number of children on a playground at once, and potentially using classrooms or outdoor spaces for meals.
When asked about children as vectors of the virus, NIAID director Anthony Fauci, MD, said on Thursday during a press conference at the virtual International AIDS Conference that there’s “an assumption that we know for sure that children are poor transmitters when as a matter of fact, we don’t have enough data to make a definitive statement in that regard.”
He noted that there are “some suggestions that they are poor transmitters” and have less chance of an adverse outcome, but the research on transmission is ongoing.
“Right now, we are doing a natural history study on 6,000 families in the United States to determine definitively whether that suggestion … is actually based in actual scientific data,” Fauci said.
At the coronavirus task force briefing on Wednesday, Birx said current infection data are “skewed” to older adults, in part because initial testing protocols sought people with symptoms.
In recent weeks, case counts in children and teens 17 years of age and younger have been creeping up, nationally now at 5.9%, versus less than 2% as of April 2. In California, infection rates in this age group have more than doubled from 3.4% two months ago to 8.2% this week.
In a statement on Friday, the Infectious Diseases Society of America and the HIV Medicine Association suggested that school systems should be concerned about “instances in which children have fallen seriously ill … and in which children have died,” given that dynamics of the virus are unknown, and that teachers and other adults may be vulnerable to disease and death. The groups called for policies on symptom screening of students and staff as well as testing, and a recognition that a substantial proportion may be asymptomatic yet capable of transmitting.
On July 10, the AAP in coordination with the American Federation of Teachers (AFT), National Education Association (NEA) and AASA, The School Superintendents Association, issued a joint statement that looked like a reaction to statements from the White House calling for all schools to reopen.
While continuing to stress that “children learn best when physically present in the classroom” the new statement warned that public health agencies should base their recommendations on “evidence not politics.”
The four stakeholder groups also emphasized that local school leaders, public health experts, teachers and parents should drive decisions regarding “how and when to reopen schools, taking into account the spread of COVID-19 in their communities and the capacities of school districts to adapt safety protocols to make in-person learning safe and feasible.”
The groups also pointedly stated that “schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts.”
Schools’ Role, Beyond Educating Kids
Dooley said evidence has shown that online learning is “not sufficient to meet children’s academic needs.”
“We’re already looking at children being now months behind in their school curricula,” she said.
At a June 10 hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee, ranking member Patty Murray (D-Wash.) said she worried school closures could exacerbate inequities in education.
Researchers project that “Black children could lose over 10 months of learning, Latino students could lose over 9 months of learning, compared to white students who are projected to lose 6 months of learning,” she said.
She also cited the story of a mother in Yakima, Washington, whose children are sharing one iPhone for distance learning and who’s not certain she can continue to pay the phone bill.
Despite these challenges, Murray underscored the importance of school districts following the advice of public health officials and letting “science drive decision-making.”
Dimitri Christakis, MD, MPH, a pediatrician at Seattle Children’s and editor-in-chief of JAMA Pediatrics, agreed that distance learning for young children simply doesn’t work.
“No one thinks you can teach a kindergartner, a first-grader, or second-grader entirely over Zoom,” he said.
In cases where it has worked, a parent has been present and helping, but that isn’t sustainable in the long-term, particularly for parents who work outside of their homes, Christakis said.
“I think we have to confront the reality that for primary school kids, not having the schools open means that a sizeable percentage of children are not learning at all,” he said.
If a child isn’t reading at grade level in the third grade, he or she is 3 to 4 times less likely to graduate high school, Christakis said, and even less likely if the student comes from a low-income family.
“We’re going to see the impact of this years from now, in terms of high school graduation rates,” he predicted.
But Dooley emphasized that beyond academics, schools are “absolutely critical” for children’s social and emotional well-being, providing free or reduced price meals and health services including mental health programs.
“Schools are also critically important for socialization for children,” she said.
In her practice, she’s seeing children and families “every single week” struggling with anxiety and depression, as a result of not being in school, not having contact with peers, and being socially isolated.
She’s also seeing challenges with food insecurity — 30 million children receive free and reduced price lunch in schools — and children who’ve gained weight because they aren’t involved in physical education classes, she said.
Howard Taras, MD, a pediatrician at the University of California San Diego Center for Community Health and the district physician for the San Diego Unified School District, also sees the importance of in-person learning for children.
“At every stage of development, children learn how to make friends, and learn how to deal with bullies, and they learn how to test their personalities, and try different ones on,” Taras told MedPage Today. “There’s just all these things going on that are also part of the normal, natural education of children aside from formal education of children.”
That in-person contact with supportive adults is also important, Taras said.
“Abuse is often detected by school personnel,” and while child abuse rates appear to have plummeted, it’s possible that abuse has actually increased but simply isn’t being reported, he said in an email.
If the AAP is full throttle on reopening, the American Academy of Family Physicians is perhaps in first gear.
Gary LeRoy, MD, president of the AAFP, told MedPage Today in an email that family physicians “understand the importance of in-person learning for children.”
“They also understand the potential health risks of sending children back to school during a national pandemic,” he added.
Looking ahead to the 2020 school year, LeRoy stressed the need to carefully monitor COVID-19 cases in individual cities and communities “to help signal if and when the risks of attending school begin to outweigh the benefits.”
Any guidelines on returning to school should be “evidence-based and flexible” because the science concerning the spread of COVID-19 is still evolving and we “cannot predict where the next outbreak will appear.”
Asked whether the AAP’s own guidance would apply in states where cases are currently climbing, Dooley explained that the academy “would hope that even in areas that are seeing a surge in cases, that school systems are still working towards an opening of schools in some format, in-person for children, because this is really vital for their survival.”
Kris Bryant, MD, president of the Pediatric Infectious Diseases Society (PIDS), said it’s important to consider all sides of this discussion.
PIDS currently does not have an official position on schools reopening; she emphasized that she was giving her personal opinion.
Bryant echoed many of the concerns mentioned by other pediatricians around the danger of isolation for children’s development and mental health and the “variable” benefits of distance learning depending on how well-resourced a family is or isn’t.
While she described data from Iceland, for instance, showing no transmission among children as “encouraging,” she remained skeptical.
“When everything is said and done. I’m not convinced though that we will see zero transmission from children to adults or zero transmission from child to child,” Bryant said.
She stressed the need to “look at the experience of other countries that have already gone down this path … [and to] try to identify models that are similar to our situation in the U.S.”
Arthur Caplan, PhD, an ethicist and population health expert at NYU Langone Health, called the AAP’s guidance “optimistic.”
“I think we’re reopening schools just like in some ways Texas, Arizona, Florida reopened restaurants, bars, and beaches,” Caplan said. “And I don’t think it’s going to work any better.”
“I’m terrified that what’s going to happen is, kids will go back, they won’t have had their shots for measles, or mumps,” he continued. “The flu will come and COVID will stay, and we will have one viral, toxic stew that will lead to many hospitalizations and deaths, not just from COVID but from these other infectious diseases.”
The CDC identified a year-over-year drop in orders for noninfluenza childhood vaccines and for measles-containing vaccines funded through the Vaccine for Children Program (VFC) from early January through mid-April 2020 compared with roughly the same period in 2019. (The program provides federally purchased vaccines to roughly half of all children 18 or younger in the U.S.)
What About Teachers?
Lily Eskelsen García, president of the National Education Association, told CNN’s Erin Burnett on Tuesday that she worries what school reopenings will mean for teachers.
“I had 39 sixth graders one year in my tiny little classroom with one window,” she said. “My classroom was a germ factory.”
Every year she knew one of her students would pass a cold onto her, García said, adding: “This is different. This is a virus that kills people.”
She acknowledged the argument by pediatricians that “‘we have to consider the mental health of children’ – of course we do – but they didn’t say at the expense of their physical health, and they didn’t say that you should do it under all circumstances. They said when it’s safe and where it’s safe.”
Gov. Greg Abbott (R-Texas) announced last week that public schools in his state will reopen this fall, but without a state-level requirement for testing or masking.
In response, Zeph Capo, president of the state’s AFT affiliate, called on the governor to consider students’ and teachers’ safety.
“We want to see kids return to school in some way, but prudence requires that there be a health and safety plan in place to reduce the chances of spreading the deadly virus,” Capo said in a statement, suggesting that the state require every school district to develop a plan for a safe reopening and submit it to the Texas Education Agency.
National AFT President Randi Weingarten said all schools need plans to ensure they don’t become the “new hot spots of transmission.”
“A no-mask, no-testing, no-worries attitude is exactly what will spread the virus,” Weingarten said.
Bryant said she tells parents asking about their children returning to school that there is no “one-size-fits-all” answer. It depends on the individual child’s health, the school’s protocols, and the level of transmission in the community, she said.
While it isn’t feasible to keep schools closed until the virus “goes away, because that’s likely to be a long time,” Bryant expects a rocky transition.
“[T]here will be cases,” she said. “We need a plan for what to do when cases occur.”
Parents are accustomed to sending a child with a mild illness or a cold to school, she noted, but in this context that decision could have serious consequences: from now on, “sick children need to stay home.”
The Experiment Continues
While a recent Gallup poll suggests 56% of parents of children in grades K-12 support their children returning to school full-time, that leaves another 44% who have qualms.
The Clark County, Indiana school district near Bryant is offering a three-tiered model: all in-person, a hybrid of in-person and online, and an entirely virtual option.
Bryant said the model recognizes that some children may be at risk for infection, have an underlying condition, or live with someone who’s immunocompromised and need that at-home option.
“[W]hen school systems have the capability to do that and transmission in the community suggests that bringing everybody back and resuming school as usual is not the best choice, it’s great,” Bryant said. Her colleagues are also currently developing a white paper focused specifically on schooling challenges for immunocompromised students.
The AAP’s guidelines also emphasize the importance of being flexible and practical, Dooley noted.
“We may have to revise plans as we go along, and as we’re learning what works best … both from our country, but also the experiences of other countries, ” Dooley said.
She also underscored the need for robust research to monitor the return to school and to identify best practices for “mitigating the spread and the risk of the virus.”
Still, Dooley emphasized the need to “start from that starting point of having children physically present in school and then working together between our health system, our public health department, [and] our education system on how we can do that as safely as possible.”
Originally published in MedPage Today.
By Shannon Firth, Washington Correspondent, and Cheryl Clark, Contributing Writer, MedPage Today, with contributions fromAssociate Editor Molly Walker