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How Can We Continue to Keep Schools Relatively Safe from the Coronavirus?

In late March, New York’s public high schools reopened for in-person instruction. Elementary schools have been offering some in-person instruction since December, middle schools since February. The country’s largest school district has managed to provide more in-school hours than many other districts that might have seemed better equipped for the task. But, nearly three months after vaccines became available to teachers, fewer than half—around sixty-five thousand, out of approximately a hundred and forty-seven thousand Department of Education employees—have received at least a first shot of the vaccine.

For much of the past year, in-school transmission of the coronavirus has not been of particular concern to infectious-disease specialists. Data seemed to show that children become infected at a relatively low rate. That may be changing, however, with the advent of more infectious variants of the virus, as Peter Hotez, a pediatric microbiologist and vaccine specialist at the Baylor College of Medicine, told me. The B.1.1.7—or U.K.—variant, for example, appears to cause more severe illness in young people than the original version of the virus, and has an over-all higher risk of transmission. Not much age-based data exist on the more recent B.1.526 variant, which is now the single most widespread variant in New York. The positivity rate at schools stayed low through the fall, even as cases spiked citywide, and although it has been inching up it still remains below one per cent. (In mid-March, my nine-year-old son, my partner, and I all tested positive for the coronavirus, with my son the first to show symptoms.)

One way to lower COVID-related risks in schools would be to insure that as many people as possible inside school buildings are vaccinated. With vaccines not yet approved for children and adolescents, it’s up to the grownups who work in school buildings to make them as safe as they can be. “That needs to be transmitted to staff and teachers—your luck may run out,” Hotez said. Michael Mulgrew, the president of the United Federation of Teachers, told me that union representatives in New York City have been educating teachers about the vaccine and helping set up appointments since January. But the city, state, and federal governments have not undertaken a campaign to persuade school personnel to be vaccinated.

Saad B. Omer, an epidemiologist who heads the Yale Institute for Global Health, told me that refusal rates among some of the groups that have had access to vaccines the longest—some health-care workers, members of the military, and nursing-home staff—are high. “They may be the canary in the coal mine,” Omer said; vaccination rates in these groups may predict rates among others, including teachers. Apparent hesitancy among some health-care workers is especially troubling, as members of this group are the most trusted sources of vaccine-related information. Reluctance among their ranks, Omer said, signals a danger of a “vaccination plateau.”

Schools occupy a peculiar place in the pandemic conversation. For many children and parents, the lack of in-person school has been one of the biggest losses of the pandemic. For those of us lucky enough to have access to some in-person instruction, it’s been a lifeline. I’ve lost track of the number of times that my son’s school partially or fully closed for ten or fourteen days, owing to a case in his classroom or two unrelated cases in the school, but the weeks that he has been able to attend in person have been the easiest and sanest of the past few months. (On Monday, Mayor Bill de Blasio announced that the city would end its policy mandating a ten-day closure of any school with two unrelated cases.) For many families, school has been their most frequent and sustained contact with people outside their households. Schools have also been safer than almost any other public space.

But, if vaccination rates among school staff remain low compared with some other groups, and if more-infectious variants are circulating, schools may lose their status as a relatively safe harbor. And schools are different from other congregate settings, because, unlike nursing-home residents, hospital patients, or college students, young children cannot be vaccinated. They cannot contribute to protecting the group by choosing immunity—only the adults in the building can do that until pediatric vaccines for all age groups are approved.

A possible solution is a vaccine mandate. Omer and other public-health specialists were working on vaccine-requirement frameworks before the pandemic, particularly in connection with outbreaks of measles. In July, 2019, Omer and two of his collaborators—the social scientists Cornelia Betsch, of the University of Erfurt, in Germany, and Julie Leask, of the University of Sydney, both of whom work on medical communication—published an article in Nature urging caution in introducing compulsory vaccination. The authors warned that overly punitive or restrictive vaccine mandates could backfire. For example, when California eliminated nonmedical exemptions from childhood-vaccination requirements, many parents either secured medical exemptions or opted to homeschool their children. Omer told me that he thinks vaccine mandates should be an option in the fight against COVID-19, but only following a concerted campaign for voluntary vaccination. “Mandates don’t get you from fifty-per-cent uptake to a hundred,” he said. “But they can be helpful in getting from seventy to ninety.”

Hotez is vaccine developer (he has a COVID-19 vaccine currently in clinical trials) and also a longtime activist against vaccine disinformation. Last year, research to which he contributed showed that two groups without much overlap exhibited the highest levels of vaccine hesitancy: Black Americans and conservative Republicans. (Hesitancy among Black Americans has since lowered.) In response to these findings, Hotez became a regular on radio talk shows that would reach people least likely to trust the vaccines. What he discovered, he told me, was that conservative callers assumed that the government would institute a vaccine mandate—they were already in battle with this straw man. Requiring vaccination, Hotez told me, would be, at this stage, “poking the bear.” “Mandates may become necessary, but now I’d say, ‘Don’t push too hard,’ ” he said. “It may be counterproductive.” A mandate, he believes, would affirm the anti-big-government expectations of some of most vocal vaccine resisters, rather than change their minds.

Ultimately, it is the state Department of Health that would impose a vaccination mandate in schools. At present, it requires all children to provide proof of a raft of vaccinations, from polio to hepatitis B—no nonmedical exemptions allowed—but does not require any vaccinations of school-based personnel. Jill Montag, a spokesperson for the D.O.H., told me by e-mail that, as a matter of practice, the state required mainly children, not adults, to receive vaccines. In fact, the state imposes strict vaccination requirements on adult students at post-secondary institutions: anyone born in 1957 or later must show proof of vaccination against measles, mumps, and rubella. (Montag didn’t respond to a follow-up e-mail; in response to a fact-checking query, she referred to her previous statement.) Hotez told me that he expected a plurality of colleges and universities to require students to be vaccinated against COVID-19 before the fall; Rutgers, the state university of New Jersey, announced such a requirement on March 25th.

According to Omer, a major obstacle to effective vaccination is the failure of American state and city governments to use existing expertise on conducting vaccination campaigns. “They don’t realize that you need science for vaccine communication,” he said. Researchers have accumulated a wealth of data on strategies that work, including guidance on messaging, organization, and regulation. A clear and effective campaign would involve creating vaccination locations that are accessible and welcoming. The convoluted online sign-up systems for New York City and the state are neither of those things, and neither are giant, out-of-the-way vaccination sites, such as the Javits Center. It also involves collaborative communication strategies. Studies show, for example, that a pediatrician who says “I’m going to vaccinate Johnny today” or “It’s time for Johnny’s vaccine” is less likely to end up getting a shot into Johnny’s arm than one who asks “What do you think about vaccinating Johnny at this visit?”

“Interestingly, the W.H.O. has been more receptive” to adopting communications strategies recommended by researchers than American officials have been, Omer said. The haphazard approach to vaccination campaigns may be a product of what Omer generously called “a robust public square”—a conversation, largely playing out in the op-ed pages, that juxtaposes expert opinions with those of people who have little or no experience in the epidemiology of infectious diseases. These include Scott Atlas, a radiologist whose contrarian views on the pandemic earned him former President Donald Trump’s ear, and Marty Makary, a surgeon who, less than two months ago, argued in the Wall Street Journal that the United States would attain herd immunity by April.



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