The U.S. Centers for Disease Control and Prevention this week issued new guidance on how schools can reopen safely for the 2020-21 school year — and, as it turns out, some of it was edited in the White House. That could help explain why there is little discussion about the risks of returning to school buildings, which President Trump has been demanding for a few weeks.

The new guidelines for school administrators appears to drop specific reference to keeping students six feet apart, a social distancing measure that had been in previous CDC guidelines, and suggests that schools consider closing only if there is “substantial, uncontrolled transmission” of the virus. “Consider” is the key word there; the new guidance doesn’t say schools should definitely close under those circumstances.

This week, Trump himself stepped back a little bit from his call that all schools should fully open, saying that there should probably be flexibility in places that are “hot spots,” which is what the CDC’s director, Robert Redfield, also said Friday. But neither acknowledged the extent of the spread of the virus in many states.

This Washington Post story reported that Redfield did concede that exceptions should be made for places with significant covid-19 infection rates but he underplayed the number of places that would be included. However, the infection rate that Redfield offered as the definition of a “hot spot” existed in 33 states over the past week.

The Post story says: “The mixed messaging was another indication of how public health officials at the CDC have been squeezed between Trump’s demand for a normal school year and an out-of-control virus.”

If you are confused by the CDC’s changing guidance, here are some recommendations from two infectious-disease specialists who have not been pressured by the White House.

The two are Wendy Armstrong, professor of medicine in the Division of Infectious Diseases at Emory University’s School of Medicine, and Tina Tan, professor of pediatrics in the Division of Infectious Diseases at Northwestern University’s Feinberg School of Medicine. Both are board members of the Infectious Disease Society of America.

They participated in a July 16 virtual town hall on how to open schools safely in the fall that was hosted by the National PTA and sponsored by a coalition of education and health care organizations. The town hall was moderated by John B. King Jr., a former U.S. education secretary under President Barack Obama who is currently the president of the nonprofit Education Trust. A video recording of the full town hall along with the slide presentation are available online.

The National Superintendents Roundtable, a nonprofit organization composed of school district superintendents, released a bulletin on the town hall that highlights some key points made by Tan and Armstrong.

It says that among the significant issues that arose during the discussion were “the need for paying attention to equity, for students from low-income families and those challenged with disabilities, as well as making sure immunizations are up to date.”

“Communities of color are especially at risk: Hospitalization rates for native and black Americans are five times that of whites; for Hispanic/Latinx communities, the rate is four times that of whites,” it says. “Meanwhile, amidst the pandemic, immunization rates have declined and a situation in which the virus and influenza flared up at the same time could be disastrous.”

Here, from the Roundtable’s bulletin, are 10 key takeaways from the town hall:

1. Schools cannot be opened safely for in-person instruction if the virus is not contained in the local community. Ideally, local communities are following mitigation strategies including masks, social distancing, hand washing and ventilation protocols. Examples of schools opening safely in Denmark and Finland are drawn from societies in which the virus was under control.

2. The decision to open schools has to be a local decision based on the latest available, local scientific data. The fact is individual communities don’t know where the virus will be in September. Everyone wants all students back in school in traditional brick-and-mortar settings, but that has to happen safely based on local science and data. Some argue that a local daily infection rate of less than 5 percent is an indicator that the community has the virus in check. Armstrong thought in terms of trends: Even with small numbers the disease could be rising. She preferred to see a downward trend of at least a few weeks. (CDC guidance calls for a downward trend for 14 days.)

3. Infection rates for children aged 10 to 19 are similar to infection rates for adults 20 to 49. Although it is often said that children are less likely to contract the coronavirus than adults, the finding breaks down when children are disaggregated by age. Children from 5 to 9 are less likely to be infected, but that is not true of children of 10 or older.

4. Schools need well-developed protocols for reopening and for steps to follow if the virus appears in a school. Schools need to be transparent about their procedures for taking students in each day — temperature checks, hand washing, sanitation procedures and the like — as well as procedures to be followed in the event the virus strikes a student or staff member. Protocols for both intake and treatment need to be agreed on in advance, not invented amid a crisis.

5. Schools should consider strategies that encourage cocooning, staggered drop-off and pickup times, social distancing on buses and making best use of ventilation. If children can be “cocooned” during the school day into small groups of 6 to 10 students, it is easier to quarantine the “cocooned” group than the entire school if an infection appears. Staggered times of arrival and departure and staggered days for students in different grades might make sense. Everyone on school buses must wear a mask while students are socially distanced.

Ventilation is another important consideration. Improving HVAC (heating, ventilation and air conditioning) filtering, opening windows if needed and even holding classes outside (in playgrounds inside tents) are all sensible precautions, if possible.

6. Is a vaccine likely to bail us out? The issue of a vaccine needs to be off the table right now. There is no possibility of a vaccine appearing in the next 6-8 weeks.

7. Teachers in schools need protection but so do nonteaching staff. All adults in the school need to focus on masks, hand washing and social distancing. Cafeteria workers, counselors and administrative staff might not have extended interactions with students, but they require protection, perhaps in the form of face guards and Plexiglass barriers. Break rooms, where teachers and staff remove masks and perhaps eat together in confined spaces, need attention.

8. Extracurricular activities are going to be an extremely challenging area for school safety. We have already seen community outbreaks in choral groups and choirs, activities involving expelling a lot of air. We may need to put a hold on them. Band and orchestra don’t present the same problem, but frequently instruments are exchanged, so that may be a challenge. A golf team doesn’t have the same risks as basketball, football or soccer, where players are exerting themselves in close proximity to each other. These teams will be major concerns.

9. The costs of attending to all this are astronomical, at a time when state and local revenues will decline due to the crippling unemployment and recession accompanying the pandemic. The Council of Chief State School Officers has estimated that schools will need between $150 billion and $250 billion to ensure that schools can do what is required to open safely. Congress and the federal government need to step up. Fully 98 percent of those following the town hall agreed that Congress should provide additional emergency covid-19 relief funding for K-12 public schools.

10. The town hall audience was skeptical that it would be safe for students and educators if all schools fully reopened at the beginning of the 2020-21 school year. The question, of course, was loaded, but nearly half of the hundreds of viewers (47 percent) were “very unconfident” about safety, with another quarter “somewhat unconfident.” Just 2 percent were “very confident.” On the assumption that most of the viewers were educational or health care professionals, that’s hardly a vote of confidence on where we stand.

A final word: King noted that Finnish schools reopened successfully, building on national commitments to masks, extensive testing and contact tracing, as well as support for the kinds of public health strategies outlined by Tan and Armstrong. We don’t, he said, have the same level of commitment here. His panelists agreed. Tan: “If we don’t do the measures that Dr. Armstrong and I spoke about, you’re not going to be able to attend school at all. Everything is going to have to be virtual.”

Meanwhile, at a hearing of a House education subcommittee on Thursday held to discuss how to overcome obstacles to reopening schools, Sean O’Leary, an infectious-disease pediatrician and vice chair of the American Academy of Pediatrics’ Committee on Infectious Diseases, delivered the following testimony.

O’Leary was part of the team that authored the organization’s guidance on school reentry, which initially gained attention after the Trump administration used it to bolster its push to force public schools to open fully for the 2020-21 academic year.

The guidance said that school districts should have as their goal getting students back to campuses this fall for their health but was not an endorsement of Trump’s call for all schools to fully reopen — and the American Academy of Pediatrics recently joined with three other education groups in issuing a statement saying that only health concerns should dictate when schools open, not politicians.

On Thursday, O’Leary talked about the importance of opening schools but also the risks in places with high covid-19 infection rates. Here’s O’Leary’s written testimony:

Chairman Sablan and Ranking Member Allen, thank you for the opportunity to testify before you today. It is an honor to be here to talk about how to do the best we can for our children in these challenging times. We support the goal of returning students to school in the fall, but we must do it safely and schools will need appropriate funding to do it.
My name is Dr. Sean O’Leary and I am a practicing infectious disease pediatrician from Denver, Colorado. As a parent of 2 children in Denver public schools, this issue is both professional and personal. I work at Children’s Hospital Colorado and I am testifying today on behalf of the American Academy of Pediatrics (AAP), a nonprofit professional membership organization of 67,000 primary care pediatricians and medical and surgical pediatric subspecialists dedicated to the health and well-being of children.
At the Academy, I am the Vice Chair of the Committee on Infectious Diseases and am part of the team that authored AAP’s Guidance on School Re-entry. The guidance is attached at the end of this testimony. I would like to take this opportunity today to discuss the Academy’s guidance, why and how it is developed, what it does and does not recommend, and what resources will be needed to support school reopening.
The purpose of the Academy’s guidance is to support educators, public health officials, local leadership, and pediatricians collaborating with schools in creating policies for school re-entry that foster the overall health of children and adolescents, while protecting teachers, staff, and communities. Our guidance is based on the evidence currently available. It is important to note that we will be updating our guidance frequently as new evidence comes to light and we learn more about covid-19.
Importance of schools and impact of covid-19 on children
We start from the knowledge that children get much more than an education at school. Schools are fundamental to child and adolescent development and well-being. Students who are in school learn more than just math, reading and science. In addition to academic instruction, schools help students develop social and emotional skills; provide healthy and reliable meals; offer physical, speech and mental health therapy; and provide physical activity through gym, recess, and team sports, among numerous other benefits. Lengthy time away from school deprives students of these benefits, and it also makes it difficult for schools to identify and address important learning deficits as well as child and adolescent physical abuse, substance use, depression, and suicidal ideation.
Being away from peers, teachers and school services has lasting effects for children. As such, it is critical to reflect on the differential impact covid-19 and the associated school closures have had on African American, Native American and Latinx children, as well as children with disabilities and those living at or near poverty. Schools also support parents by providing safe places for their children to be before, during and after school, particularly for parents who work, including essential workers.
Any parent of school aged children can tell you the difficulties we faced when schools shut down in the spring. My own children missed their friends, and they also missed out on learning and physical activity. As working parents, we struggled to find ways to meet their needs and perform our jobs at the same time.
AAP’s guidance on return to school considerations
Because of these considerations, AAP carefully weighed the available evidence and determined that our overall goal should be to have students physically present in school in the fall. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. We have already seen studies documenting rises in mental health problems in children such as depression, anxiety, and suicidality, as well as rises in obesity as a result of school closures in the spring.
Even though this will not be easy, we strongly advocate that all policy considerations for the coming school year should start with this goal in mind. This must happen with careful measures to keep students, teachers, and staff safe, and with flexibility to adapt as needed to the community’s prevalence of covid-19.
This guidance does not mean that we recommend that all schools should open 5-days a week from the start of the school year. A one-size-fit-all approach is not appropriate under the current environment. Many parts of the country are currently experiencing uncontrolled spread of covid-19. While the AAP urges those areas to maintain in-person learning as the goal, our guidance recommends that jurisdictions utilize distance learning strategies until cases decline.
SARS-CoV-2 Infection in Children
It is important that policymakers consider the evidence regarding covid-19 in children and adolescents, including the role they may play in transmission of the infection. SARS-CoV-2 appears to behave differently in children and adolescents than other common respiratory viruses, such as influenza. Although children and adolescents play a major role in amplifying influenza outbreaks, to date, this does not appear to be the case with SARS-CoV-2.
Although many questions remain, the preponderance of evidence indicates that children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection. In addition, children, particularly younger children, may be less likely to become infected and to spread infection. A study that was just published from South Korea showed that children under age 10 were roughly half as likely compared to other age groups to spread covid-19 to others. The same study also suggested that adolescents and teens aged 10-19 may spread the virus at rates similar to adults. With these data in mind, school systems may consider prioritizing the return of younger children and taking additional measures to ensure physical distancing and the wearing of face coverings among older children. Policies to mitigate the spread of covid-19 within schools must still be balanced with the known harms to children, adolescents, families, and the community by keeping children at home.
Policymakers should also acknowledge that covid-19 policies are intended to mitigate, not eliminate, risk. No single action or set of actions will completely eliminate the risk of SARS-CoV-2 transmission, but implementation of several coordinated interventions can greatly reduce that risk.
Returning to school safely
Returning to school must be done safely. It is important to make the school environment safe for all those in the building. Schools will need to follow guidance from public health officials and adhere to health monitoring and cleaning/disinfecting protocols, utilize cloth face coverings as much as possible, and urge frequent hand-washing. The Academy has offered age-specific guidance on the need for physical distancing among students. In addition to these essential needs, schools will also need to have sufficient personal protective equipment (PPE) for teachers and staff, implement new procedures for busing and transporting students to school, before- and after-school child care and enrichment programs, ensure that students competing in athletics and other activities are safe, make physical plant modifications, adjust staffing schedules, and put protocols in place for how a school responds when a student or teacher tests positive for covid-19.
It is also important that children are up to date on all vaccines, and AAP recommends all children are vaccinated for influenza and have had their annual checkups. Existing school immunization requirements should be maintained and not deferred in response to coronavirus. New outbreaks of vaccine-preventable diseases such as measles can cause severe illness or be life-threatening and should not be taken lightly especially in the midst of the covid-19 pandemic. Protecting children, teachers, and staff from influenza through vaccination will be especially important this year.
Decisions to alter the school schedule, such as partial days or alternate attendance days, or to temporarily close schools, must be made in collaboration with local and state officials according to the prevalence of covid-19 in the community and the ability of schools to accommodate safety measures.
Throughout all of this, it is also important to stay focused on considerations and accommodations to account for the diversity of youth. With the goal of safe return in mind, we must pay special attention to vulnerable populations, including those who are medically fragile, live in poverty, have developmental challenges, or have special health care needs or disabilities.
Schools should also anticipate and be prepared to address a wide range of mental health needs of children and staff when schools reopen. The emotional impact of the pandemic, including the loss of family members, financial concerns, social isolation, and growing concerns about systemic racial inequity — coupled with prolonged limited access to critical school-based mental health services and the support and assistance of school professionals — demands careful attention and planning as well. School health centers and school nurses will need to respond to these concerns while dealing with any covid-19 concerns within schools and therefore will need significant new resources.
Robust federal education funding
In order for schools to be able to safely reopen with students in the classroom, Congress must provide sufficient funding to help schools adapt and make necessary changes and accommodations. The AAP is urging Congress to include robust funding for education in the next legislative package in response to the covid-19 pandemic.
Specifically, we urge $175 billion for K-12 education through the Education Stabilization Fund and $25 billion for Individual with Disabilities Education Act (IDEA), Title I and other Every Student Succeeds Act (ESSA) programs that support marginalized students that are most likely to be affected by missing in-person instruction. Money must be available to all schools regardless of their timeline for reopening. Schools in areas with high rates of covid-19 spread may need to consider delaying a return to full-time in-person instruction, and these schools will need the same or greater federal investments, not less.
Additionally, we urge Congress to include $500 million in the Education Stabilization Fund specifically for programs operated by the Bureau of Indian Education (BIE) as Native American populations are facing disproportionately high covid-19 infection and mortality rates. Increased funding for BIE will be important to ensure BIE schools are equipped to implement the necessary safety precautions to provide safe in-school services.

(Clarifying: In an earlier version, there was a hyphen missing in No. 5, and it should have been that there will be no vaccine in the next 6-8 weeks, not 68 weeks.)