Opinion
Operational Considerations on the American Academy
VIEWPOINT
of Pediatrics Guidance for K-12 School Reentry
C. Jason Wang, There is general consensus among experts that K-12
MD, PhD schools should aim to reopen for in-person classes dur-
Center for Policy, ing the 2020-2021 school year.1,2 Globally, children con-
Outcomes and
stitute a low proportion of coronavirus disease 2019
Prevention, Division of
General Pediatrics, (COVID-19) cases and are far less likely than adults to ex-
Department of perience serious illness. 3,4 Yet, prolonged school
Pediatrics, Stanford closure can exacerbate socioeconomic disparities, am-
University School of
Medicine, Stanford,
plify existing educational inequalities, and aggravate food
California; and Center insecurity, domestic violence, and mental health
for Health Policy, disorders.5 The American Academy of Pediatrics (AAP)
Freeman Spogli
recently published its guidance on K-12 school reentry.1
Institute for
International Studies, However, as many school districts face budgetary con-
Stanford, California. straints, schools must evaluate their options and iden-
tify measures that are particularly important and fea-
Henry Bair, BS, BA sible for their communities.
Stanford University
We suggest that school districts engage key stake-
School of Medicine,
Stanford, California. holders to establish a COVID-19 task force, composed of
the superintendent, members of the school board,
teachers, parents, and health care professionals to de-
velop policies and procedures. To implement and evalu-
ate specific measures, the task force should create and
oversee a command center for the school district, com-
posed of data analysts and health experts who can li-
aise with the local health department. Working with the
local health department, school districts can provide
educational materials and training for students, par-
ents, and school staff on the basics of COVID-19 preven-
tion, applicable to both when children are in school and
when they are not in school. School staff will need to be
trained in screening for symptoms of COVID-19. Be-
cause fever and cough are the most commonly re-
ported symptoms in children, 6 staff should be
provided with thermometers and instructed in their
proper use.
The AAP guidance emphasizes the importance of
physical distancing, while acknowledging that strict ad-
herence may limit academic and social learning out-
comes in some cases. Six ft is commonly recom-
mended, but evidence suggests that 3 ft, with face
coverings, may achieve similar benefits as 6 ft.7 School
districts can compute the number of circular zones with
3- to 6-ft radii that may be created in each school and
thus determine whether teaching spaces are sufficient
to allow for proper physical distancing between stu-
dents. If existing indoor spaces are inadequate, tempo-
rary modular buildings may be needed. Costs of these
structures range from $40 to $100 per square foot.
Corresponding
Author: C. Jason Wang,
Physical distancing measures apply to school buses as
MD, PhD, Stanford well. Students should be assigned seats on buses, and
University School of school districts will need to assess the need to expand
Medicine, 117 Encina
their fleet of buses or develop different pickup sched-
Commons, Stanford,
CA 94305 (cjwang1@ ules. Students taking public transportation should use
stanford.edu). face coverings.
jamapediatrics.com
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In terms of protective equipment, schools will need
to have a steady supply of hand sanitizer for students and
staff each day. In districts where families cannot afford
face coverings, schools will need to provide them; they
can take the form of disposable surgical masks, reus-
able cloth masks, or reusable face shields. Disposable
masks cost between $0.50 to $1 each and can be used
over the course of a day. Cloth masks should be regu-
larly washed between uses. Face shields cost between
$5 to $10 and can be used as long as they maintain their
shape and remain intact. The decision of which option
to adopt and stock will depend on the number of stu-
dents and the school’s budget. Transparent barriers
placed on the sides of students’ desks can further limit
the spread of respiratory droplets. Costs of transparent
barriers range from $100 to $200 per desk. As the AAP
guidance suggests, teachers who must work closely with
students with special needs or with students who are un-
able to wear masks should wear N95 masks if possible
or wear face shields in addition to surgical masks.1
Schools will also need to consider the expenditure of in-
creasing disinfection efforts of all teaching spaces, com-
mon areas, and high-touch surfaces such as door-
knobs, computers, and desks.
The AAP also recommends creating fixed cohorts of
students and teachers to limit exposure of students to
teachers and students to each other. Fixed cohorts can
use the same classrooms consistently and stagger their
lunch periods to reduce density of students in the caf-
eteria. Moreover, if a school’s available teaching spaces
are inadequate to accommodate physical distancing for
every student, fixed cohorts can facilitate alternate
scheduling plans, for example, having different cohorts
come on alternate days or alternate times of the day.
These scheduling strategies may call for modifications
in teaching methods to include more home learning com-
ponents (such as flipped classroom approaches). How-
ever, fixed student-teacher cohorts may require addi-
tional teaching staff.
The AAP guidance states the importance of identi-
fying symptoms and signs concerning for COVID-19 but
does not discuss operational approaches in depth. To ad-
dress this, we recommend that schools implement mul-
tilevel screening for students and staff. Each morning,
parents should report (via an online interface or by an
automated telephone-based program) any fever or
symptoms concerning for COVID-19 to the school or
school district; students with symptoms should stay
home. When students arrive at school each day, school
staff should also record their temperatures and any
alarming symptoms. We urge school districts to link stu-
dent and staff identification numbers with a central da-
tabase for rapid identification of individuals in need of
(Reprinted) JAMA Pediatrics Published online August 11, 2020 E1
 Opinion Viewpoint

monitoring. Students who develop symptoms at school are to be im-
mediately isolated until an authorized adult can transport them home
or to a health care facility for testing and/or treatment. We also rec-
ommend that schools limit the access to school grounds to 1 or 2 en-
try points. Schools may consider expanding the role of a school nurse
or hiring additional personnel to screen and brief school visitors on
disease precautions while on school grounds.
The AAP guidance does not include how schools can approach
testing for the virus. To this end, we recommend a 3-pronged testing
approach, which can be carried out in collaboration with local hospi-
tals.(1)Allstudentswithsymptomsshouldbetested.(2)Schoolsshould
devise a schedule to randomly select a proportion of students and staff
for COVID-19 testing to identify asymptomatic individuals; a pooled
testing strategy can significantly reduce costs.8 (3) Students from high-
risk households (eg, those residing in zip codes with socioeconomic
challenges) should be offered more frequent testing. Costs for indi-
vidual tests currently vary between $50 to $200 per person.
Even with all the precautions in place, COVID-19 outbreaks within
schools are still likely. Therefore, schools will need to remain flex-
ible and consider temporary closures if there is an outbreak involv-
ing multiple students and/or staff and be ready to transition to on-
line education. As such, school districts need to invest in developing
or acquiring online education platforms and train teaching staff in
switching seamlessly from in-person teaching to online education
platforms. Schools will need to ensure equitable implementation of
online education among students, especially those with limited
knowledge of or access to technological resources and consider sub-
sidizing educational technologies for these students. Additional chal-
lenges faced by students with learning disabilities can be assessed
on an individualized basis, and schools should attempt to provide
special education services when appropriate (and in-person, if
necessary).
Finally, schools should consider hiring additional nurses, psy-
chologists, or social workers (or sourcing them through partner-
ships with local health care facilities) not only to assist with screen-
ing and managing potential COVID-19 cases but also to provide more
support for students and any staff members with emotional or psy-
chiatric concerns.
In summary, to maximize health and educational outcomes,
school districts should adopt some or all of the measures on the AAP
guidance and prioritize them after considering local COVID-19 inci-
dence, key stakeholder input, and budgetary constraints. Given the
increased costs of preparing and operating schools, public schools
will require additional funding from the state or the federal govern-
ment, whereas private schools may need to temporarily increase tu-
ition or seek some assistance from the government. If these are not
attainable, schools will need more time to prepare to ensure the
safety of students and staff.

ARTICLE INFORMATION
Published Online: August 11, 2020.
doi:10.1001/jamapediatrics.2020.3871
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Paul H. Wise,
MD, MPH (Stanford University School of Medicine),
for his suggestions on improving the manuscript.
Dr Wise was not compensated.
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