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With cases of COVID-19 spiking in many areas of the United States, and a greater resurgence expected in the fall, whether and how to reopen schools is the subject of strong national interest. In an article published in JAMA Health Forum, Weill Cornell Medicine and NewYork-Presbyterian researchers highlight the significant consequences of keeping schools physically closed, and recommend strategies used by countries that reopened and mostly managed to contain the spread of the virus.

A “one-size-fits-all” solution is not likely in the U.S., where there is not a unified federal response to the pandemic and where geographic diversity and resources among school districts are varied, the authors write in the June 30 piece. But other countries in Europe and East Asia offer important strategies schools can learn from, like increased testing of students and staff, staggering days or times students come to school, using spacing that encourages physical distancing, and making accommodations for vulnerable students and staff.

“School reopening decisions need to be informed by the current infection rate of a given community,” said senior author Dr. Rainu Kaushal, senior associate dean for clinical research, chair of the Department of Population Health Sciences, the Nanette Laitman Distinguished Professor of Healthcare Policy and Research at Weill Cornell Medicine, and physician-in-chief of population health sciences at NewYork-Presbyterian/Weill Cornell Medical Center. “In New York State, reopening can happen if a region meets Phase IV requirements and the daily infection rate remains below 5 percent.”

“We acknowledge that the U.S. is not the same as any other country. Many of the countries whose school plans we examined have COVID-19 transmission under control, and we don’t. But the takeaway is in terms of strategy—what techniques schools in other countries are using,” said lead author Lala Tanmoy Das, a second year student in the Tri-Institutional MD-PhD program at Weill Cornell Medicine, The Rockefeller University and Memorial-Sloan Kettering Cancer Institute.

Keeping schools closed has “profound” consequences on children, including regressions in academic gains, increases in rates of depression and anxiety, greater digital dependence, and reduced likelihood that children vulnerable to abuse, food insecurity, or who have disabilities are identified, according to the authors.

“As a society we can’t lose sight of the fact that children have tremendous needs that have to be met in this complex time, and school plays a critical role,” said Dr. Erika Abramson, a professor of pediatrics and population health sciences at Weill Cornell Medicine and assistant attending pediatrician in the Division of General Academic Pediatrics at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

Additionally, 27 million U.S. parents depend on school for childcare, and are limited in going back to work if their children are learning from home.

The authors note that based on available data to date, children appear three times less susceptible than adults to infection from SARS-CoV-2, are more likely to be asymptomatic, and less likely to be hospitalized and die than adults. The multi-inflammatory pediatric syndrome that is a potential risk to children who are infected with the virus needs to be monitored, the authors write. So far it has been seen in only a small number of children and is usually treatable, according to the authors.

While the Centers for Disease Control and Prevention released guidelines on reopening schools, implementing them falls to states and school districts. Health officials must start working with teachers, parents, superintendents, and local governments, according to the authors.

Strategies for reopening schools

The authors share six “buckets” of strategies, which have been implemented in other countries.

A “child-friendly national infrastructure” should make it possible to do widespread testing, including saliva testing, they write. Some schools in Germany are providing self-administered viral tests with overnight results, and China, Taiwan, Vietnam, and Japan are doing daily temperature checks.

Officials should consider private transportation and limiting the number of passengers on school buses, according to the piece. Families should use private transportation whenever possible, the authors write. Otherwise, schools can increase the number of bus routes, as they have done in China, and limit the number of children per bus to maintain physical distancing measures in transit.

Schools can also reconfigure the physical environment of schools. To enforce distancing, schools in other countries have limited the number of children per classroom, spaced desks six feet apart, installed plastic tabletop partitions, had children eat lunch at their desks, closed shared spaces like gyms, and used outdoor space for activities.

American school officials can implement schedule changes that promote physical distancing, as well. Many schools in other countries have staggered attendance to limit students’ interactions, and reopened schools in phases. In Germany, some schools have alternated between having students attend class and learn remotely, and schools in Japan and Israel have staggered arrival times. Denmark and Norway reopened elementary schools first, while Germany opened their schools to graduating high school seniors. Other proposals U.S. schools can consider from these countries include prioritizing children of essential workers.

American education leaders can also require behavioral changes in the daily life of classrooms. Most countries that have reopened schools encourage students to wear masks there, have alcohol-based rubs inside classrooms, and enforce periodic hand-washing. They also clean and disinfect facilities at least once a day, “with a particular focus on door handles, light switches, and other heavily touched areas” and have increased ventilation.

Finally, teachers and staff members should have adequate personal protective equipment and be encouraged to wash their hands regularly, write the authors. Staff who are vulnerable to infection can be allowed to work remotely, an approach taken in the United Kingdom, Israel and Denmark. Children should also have the choice to opt out of in-person instruction to accommodate their health or their family’s, and paid sick leave for school teachers and staff should be expanded to make it easier to stay home when ill.

Actionizing disease-limiting strategies

Implementing these strategies will take significant funding and resources, the authors acknowledge. They point to the American Academy of Pediatrics’ July 10 statement encouraging Congress to provide the needed federal resources to support the goal of students returning safely to school this fall.

Reopening will also hinge on controlling the spread of SARS-CoV-2 in the community, and require contingency plans if there’s a spike in a community. Though none of the 22 European nations that reopened schools saw an increase in infections, some schools in Japan, Israel and South Korea reverted to virtual learning when new clusters of COVID-19 emerged.

“My suggestion is that schools try to come up with a plan for four to six weeks at the point that their community COVID infection rates can accommodate re-opening, and iteratively refine it and come up with a second plan to be implemented at about six weeks,” said Dr. Kaushal.

While school districts will be independently deciding how to reopen, planning based on the successful strategies from other countries is critical, the authors conclude.

“I think we need to very quickly start applying lessons from other countries that have been able to successfully reopen schools, so that we can move toward the goal of getting students back into the classroom as soon as possible, while appropriately maintaining the safety of children, their family members at home, teachers, and staff,” said Dr. Abramson. “Every school district has to plan for this now.”

This article originally appeared on Weill Cornell Medicine's newsroom