key: cord-0898166-9f8hw915 authors: Long, Ted title: Resuming In-Person Learning: Safe and Imperative date: 2021-06-08 journal: Ann Intern Med DOI: 10.7326/m21-2291 sha: 01829d8529d2148d0011587604b2dadfad78718b doc_id: 898166 cord_uid: 9f8hw915 In their article, Bilinski and colleagues report a model that suggests that schools are not a primary driver of community transmission of SARS-CoV-2 infection and, with appropriate mitigation, it is safe to resume in-person education. The editorialist discusses the model results and his experience with New York City public schools and argues that schools must offer in-person learning to avert a mental health and educational crisis. D uring the darkest days of the COVID-19 pandemic, cities and health care systems focused on managing the highest-risk and critically ill populations. Because children and adolescents were among the least likely to have serious illness, they were not at the forefront of concern early in the pandemic. However, it is becoming increasingly clear that they must be at the center of our recovery. Across the United States, we are beginning to see sharp increases in urgent mental health visits. Between 2019 and 2020, the proportion of emergency department visits for children aged 5 to 11 and 12 to 17 years that were mental health-related increased approximately 24% and 31%, respectively (1). Although we knew that remote learning can adversely affect social development (2), we now know that students learning remotely may have at least the same risk for SARS-CoV-2 infection as students attending school in person (3). One of the most powerful tools we have to support children's and adolescents' mental health is inperson learning. There is no replacement for the opportunities it offers to foster social development and education. The American Academy of Pediatrics advocates that "students [be] physically present in school," and the evidence shows substantial benefit of in-person learning (4) . Unfortunately, as we near the end of May 2021, about 40% of students enrolled in U.S. public schools still have not yet been offered a return to full-time, in-person education (5) . The evidence is now compelling: Our schools can reopen safely. Bilinski and colleagues' model (6) builds on the individual experiences of other cities; the authors conclude that schools are not a primary driver of community transmission and that, with appropriate mitigation, it is safe to resume in-person education. Specifically, they find that rigorous mitigation efforts (masking, cohorting, distancing, and testing) can reduce risk for transmission up to 5fold in elementary schools and up to 10-fold in high schools compared with low mitigation efforts. The model also estimates the effects of such interventions as teacher vaccination and weekly testing, and the results suggest that schools can reopen safely. If schools can reopen for in-person learning, then they must, to avert the mental health and educational crisis that is at our doorstep. New York City reopened public schools to in-person learning in the fall of 2020. Our experience before the vaccine became available is consistent with Bilinski and colleagues' findings. Transmission in schools was uncommon, and COVID-19 incidence among both students and teachers was similar to or less than community incidence (7) . This important point is often underappreciated. Our data showed that for both teachers and students, risk for contracting COVID-19 outside the school setting was equal to if not greater than risk within school. Other studies of the risk for transmission in schools have observed that some cases believed to be linked to school transmission turned out to have different viral genotypes, indicating community rather than school transmission (8) . Transmission may be lower in schools than outside them because preventive measures, such as mask wearing and social distancing, may not be as strictly enforced outside schools. Bilinski and colleagues also examined screening for asymptomatic infection, and our experience in New York City offers lessons that may be applicable for others implementing school screening programs. In New York City, we created a central "situation room" for our public schools that housed data from all of the screening tests done in schools to enable immediate response with rapid implementation of contact tracing and quarantine for teachers and students. We have performed more than 1 million tests in our program, necessitating a central decision-making body. Our experience supports setting up "situation rooms" or the equivalent to ensure rapid and standardized responses to positive test results. Looking ahead, several important factors will affect continued reopening of schools. Two thirds of all cases in the United States are currently the B.1.1.7 variant (9). It is possible, if not inevitable, that other variants will arise, creating additional challenges for any public environment where people will be coming into contact with one another. A key finding from Bilinski and colleagues' model is that preventive measures can allow schools to safely reopen even with moderate community spread. Another important factor in reopening schools is the availability of vaccination not only to school staff and teachers but also to students aged 12 to 15 years as of May 2021 and hopefully to younger children over coming months. Vaccination will provide an additional layer of protection on top of the preventive measures examined in Bilinski and colleagues' model. As we enter the recovery phase of the COVID-19 pandemic, it is crucial to support our children and adolescents who have suffered from lack of educational opportunities and social interaction. Data show that schools can be reopened safely with preventive measures. We must do everything we can to reopen our schools to ensure that young people emerge from this pandemic healthy. Ted Long, MD, MHS New York City Health + Hospitals New York, New York Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic-United States Association of children's mode of school instruction with child and parent experiences and wellbeing during the COVID-19 pandemic-COVID experiences survey Pilot investigation of SARS-CoV-2 secondary transmission in kindergarten through grade 12 schools implementing mitigation strategies COVID-19 guidance for safe schools K-12 school reopening trends Passing the test: a modelbased analysis of safe school-reopening strategies COVID-19 infections among students and staff in New York City public schools Low SARS-CoV-2 transmission in elementary schools -Salt Lake County Disclosures: The author has reported no disclosures of interest. The form can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M21-2291.