JEFFERSON CITY, Mo. — Missouri has released more guidelines for schools that plan to return to in-person learning.
The Department of Health and Senior Services and Department of Elementary and Secondary Education released a list of frequently asked questions in July to help schools prepare.
Updated guidance was released Monday and included both proactive and reactive strategies schools can use to help reduce the spread of COVID-19.
Proactive strategies
Screening
How should K-12 schools screen students for COVID-19?
K-12 schools should use a process for daily screening for symptoms of and exposure to COVID-19 and parents should also screen children at home.
Parents should also be provided with a checklist that includes these symptoms:
- Fever or chills
- Cough
- Headache
- Muscle aches
- Nausea, vomiting or diarrhea
- New loss of taste or smell
- New runny nose or congestion
- Shortness of breath or difficulty breathing
- Sore throat
- Close contact with a person with COVID-19 in the last 14 days
Students with symptoms should not attend school and parents should consult their health care provider and follow CDC guidelines regarding returning to school.
For students who test positive for the virus, return to school is permissible when the student is at least 10 days from symptom onset, has had three days with no fever and has improving symptoms.
Students with known close contact with COVID-19 should stay home for 14 days from their last contact and until return to school is approved by the local health department.
Schools should “broadly communicate” the importance of keeping students home when they feel sick.
Should schools screen students for COVID-19 onsite?
Students should be visually inspected for symptoms of the virus as they enter the school.
School leaders may choose to perform additional symptom or temperature screening at school but should ensure students can maintain a safe social distance during those procedures.
How should K-12 schools screen staff members for COVID-19?
School staff members should self-screen at home, following the same protocol for families screening students at home. Schools should also screen staff members as they enter the building each day and that screening should include a temperature check.
How should K-12 schools screen visitors for COVID-19?
Schools should limit visitors inside the building. Schools should look into conducting meetings with families remotely (conference call) so parents can continue to engage with teachers.
If visitors are unable to join a remote meeting, schools should screen the visitor for the virus and then limit the visitor’s movement throughout the building.
Schools may also consider a designated visitor space where social distancing measures are enforced. A record of visitors in the building should be kept.
Physical Distancing
What physical distancing measures should K-12 schools have in place to protect against the spread of COVID-19?
Schools should assign students to cohorts and limit their exposure to other cohorts within the building – meaning students should stay with the same group throughout the day.
If classes need to rotate, schools should consider rotating teachers instead of moving groups of students throughout the building.
Schools should implement assigned seating and keep records of seating charts to help identify close contacts if a member of the school is diagnosed with the virus.
Cohorting may not be feasible for middle and high school students so assigned seating is encouraged.
Other physical distancing measures:
- Students should be spaced as far apart as possible.
- Six feet apart is best; when that’s not possible, schools should make efforts to ensure a minimum of 3 feet of space between students.
- Desks should be placed facing forward in the same direction so students do not sit face-to-face.
- Schools should place physical distancing markers and cues throughout the building
- Schools should require hand hygiene before and after students move from one space to another within the building
How should physical distancing take place on a school bus?
School bus transportation may not allow for social distancing but here are some strategies to reduce contact on buses:
- Screening of COVID-19 symptoms at home prior to getting on the bus.
- Encouraging hand hygiene upon boarding the bus.
- Assigning students to seats so contacts are stable.
- Seating siblings together.
- Loading the bus from back to front.
- Encouraging the use of face masks during transport.
- Having windows open when safe and weather-permitting.
- Providing bus drivers and monitors onboard with personal protective equipment, such as face masks and face shields and/or eye protection, as long as these do not impair driving.
- Installing physical barriers such as Plexiglass between the driver and students, if feasible.
Schools may also ask families who are able to take their children to and from school or arrange for carpools to reduce the number of students riding buses.
How should physical distancing take place during meal times?
Keep students in cohorts during mealtimes and have students eat in their classrooms instead of moving throughout the building. Schools may consider bringing meals directly to classrooms but should make efforts to ensure nutritional value and appealing menu choices are not sacrificed.
For older students, multiple separate lunch periods may be created and alternate locations, like outdoors or large indoor spaces, may be used for lunches.
How should physical distancing take place during recess and physical education?
Students should engage in physical activities with their primary cohorts (groups) to reduce the number of contacts. Multiple cohorts could have recess at the same time, as long as they are playing in separate areas of the playground.
Individual equipment used during recess could be separated by cohort to reduce the need for disinfecting between uses but if that’s not possible – individual equipment should be cleaned between uses.
Stationary playground equipment doesn’t need to be cleaned with the exception of handrails and other high touch surfaces, which should be cleaned in accordance with CDC guidelines.
Schools should require hand hygiene before and after recess and physical education.
Are there other creative ways schools can arrange for physical distancing?
Large spaces, like multi-purpose rooms and auditoriums, could be marked and utilized to account for appropriate physical distancing. Schools may also consider using outdoor learning spaces more often.
How should physical distancing take place during music class, given the conversation around the higher rate of COVID-19 transmission during singing?
When considering music classes, schools should ensure students remain in cohorts (groups) and are maintaining social distancing. Holding these classes outdoors would be a safe alternative.
When classes are not able to social distance, schools could consider alternative classes such as virtual instruction, music technology, music theory and music appreciation.
Masks/Face Coverings
Should K-12 students and staff wear face coverings?
Face coverings are important in reducing the spread of the virus. Young children may have difficulty complying with the proper use of face coverings and may have increased face touching, mask chewing, mask trading and other behaviors that could increase the risk of infection.
For those reasons, continuous usage of face covering is not recommended for young children.
Older children, such as those in middle and high school, are encouraged to wear face coverings during periods when students are not in cohorts (groups) or can’t maintain a safe social distance. Students are also encouraged to wear face coverings while on the school bus.
Schools should also consider how to deliver training to students on the safe and proper use of masks.
Should K-12 staff members wear face coverings?
It is recommended that school leaders require school staff members to wear face coverings. Face coverings should be worn by staff members at all times when they are in close proximity to students or other staff members.
In lecture formats where the teacher is stationary and appropriately distanced from students, face coverings may not be necessary. In situations when working with young or deaf children and the need to convey facial expressions and mouth movements is important, the use of a clear face shield is preferred to no face covering at all.
Bus drivers and monitors onboard a school bus should wear personal protective equipment.
Any teacher or staff member working closely with symptomatic children must wear medical-grade masks and eye protections to ensure that staff are protected.
Reactive strategies
Symptomatic at school
What should K-12 school leaders do when a student or staff member presents with COVID-19 symptoms while at school?
All students and staff members with a fever of at least 100.4° or other symptoms consistent with COVID-19 should seek medical care for further evaluation and instructions. All students and staff members who become symptomatic while at school require immediate isolation and should wear a medical-grade mask until they are no longer in the building. Students who are sick should be walked out of the building to their parent/guardian. The School Nurse Algorithm can be used by local school leaders and Local Public Health Agencies (LPHAs) to further inform the management of symptomatic students and staff members.
It is recommended that each school have a room or space, separate from the nurse’s office, where students or staff members who are feeling sick or appear ill can be evaluated and/or wait to be picked up by a parent/guardian. These rooms/spaces should be set up in such a way as to prevent cross infection among students/staff who may be experiencing different symptoms. For example, in the case that multiple symptomatic students must be in the same room, shower curtain-type barriers should be installed to separate potentially infected students or staff. The room should be disinfected immediately after any individual exhibiting symptoms of illness has exited.
Strict physical distancing should be required and a record should be kept of all persons who entered the room. Staff members entering the room should wear appropriate personal protective equipment, including goggles or face shields, gloves and medical-grade masks and gowns.
Students who do not display symptoms of illness can be seen and treated in the nurse’s office. This would include students who are injured during the school day or students with special health care needs. Use of nebulizers and other aerosol generating procedures should be avoided in the school setting when possible. When these are necessary and/or when contact with respiratory secretions cannot be avoided, such as when suctioning is required, medical grade PPE including eye protection, a fit tested N95 respirator, gloves and a gown should be worn during care.
Additional information about PPE can be found in the National Association of School Nurses’ Guidance for Healthcare Personnel on the Use of Personal Protective Equipment (PPE) in Schools During COVID-19.
DHSS also is working to develop PPE guidance at the state level for school nurses in Missouri.
Positive cases
Are public health officials allowed to share health information about a student or staff member with district/school officials to allow necessary contact tracing to take place?
The Family Education Rights and Privacy Act (FERPA) has a provision that allows Local Education Agencies (LEAs) to share student records, which include student health information, with Local Public Health Agencies (LPHAs). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has a provision that allows personal health information (PHI) to be shared by DHSS and LPHAs to LEAs if the disclosure is necessary to protect public health. Some public health authorities may be considered “covered entities” or “hybrid entities” under HIPAA, meaning the law applies to them. HIPAA specifically states that covered entities that disclose PHI in the interests of protecting public health are presumed to have “acted in good faith” if the disclosure:
- Is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; and
- Is to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
In a February 2020 bulletin, the U.S. Department Health and Human Services, Office for Civil Rights stated that “a covered entity must make reasonable efforts to limit the information disclosed to that which is the ‘minimum necessary’ to accomplish the purpose.”
In the case of COVID-19, the “minimum necessary” information to disclose to protect public health (e.g. to support case investigations and contact tracing) may include the name of the student/staff member who has contracted COVID-19 and the probable date of onset. This information should only be disclosed to the necessary staff members (e.g. the school or district COVID-19 point-of-contact) to inform and conduct the steps of the LPHA or school/district. The individual who tested positive should not be identified in communications to the school community at large.
LPHAs may develop written policies to govern routine and recurring disclosures of PHI to schools and districts for the purposes of containing COVID-19. Policies and protocols should address what type of information will be disclosed to support contact tracing and disease mitigation and what will not be disclosed.
LPHAs and LEAs can find additional information on this topic from the following resources:
It is also important to note that federal law typically limits the type of medical inquiries that can be made by LEAs, but given the nature of the pandemic, more leeway has been given to districts and schools in this circumstance to make additional medical inquiries of staff and students than would otherwise be allowed.
- If a parent/guardian tells the school their child is sick, the school may ask the parent/guardian whether the student is exhibiting any symptoms of COVID-19 or has a positive COVID-19 test.
- If an employee calls in sick or appears ill, the district/school can inquire as to whether the employee is experiencing any COVID-19 symptoms or has been tested.
- If a person is obviously ill, the district/school may make additional inquiries and may exclude the person from school property.
LPHAs and LEAs should direct legal questions to their organization’s legal counsel.
What communication will take place between LPHAs and school leaders when a member of the school community tests positive for COVID-19, and what role will each entity play in that communication process?
It is the responsibility of the LPHA to contact the person confirmed with COVID-19, inform direct contacts of their possible exposure and give instructions to those involved with the confirmed case, including siblings and other household members, regarding self-quarantine and testing, as indicated. LPHAs should proactively communicate to the school or district the existence of a positive case among its students or staff.
Schools and districts should designate a point of contact at both the school and district levels with whom LPHAs will coordinate regarding COVID-19 exposures, case investigations and contact tracing. Schools and districts should report any known COVID-19 cases or exposures to the LPHA where the student resides. When there is confirmation that a person infected with COVID-19 was on school property, the district/school should contact the LPHA immediately and follow the directions of the LPHA where the school is located. Schools and districts should track information regarding cases and exposures to ensure that no staff member or student returns to school before released to do so by the LPHA of record. LPHAs should provide clear guidance and direction to schools and districts on the next steps for contact tracing and potential quarantine.
The communication process between LPHAs and schools/districts could take place in a number of ways, including, but not limited to:
- Scenario 1: An LPHA might share that an individual in Mr. Green’s fourth grade class has tested positive to allow for contract tracing. Such information should allow the LPHA to obtain the necessary information from the school to perform contact tracing and notification of exposed individuals.
- Scenario 2: A parent/guardian may inform the school that his/her child tested positive and won’t be attending school. The school should alert the LPHA and immediately provide the necessary information for the LPHA to perform contact tracing.
- Scenario 3: If the LPHA directs a student to isolate or quarantine, but the parents or guardians are not cooperating with the LPHA and causes the LPHA to believe the student plans to attend classes, the LPHA should alert the school for contract tracing purposes and to prevent the student from attending school and exposing others.
- Scenario 4: If the LPHA’s functional ability to begin contact tracing on the same day of notification is constrained by an increase in cases, a decrease in staffing levels, etc., the LPHA may provide the necessary PHI to the school or district, along with instructions, to begin the process of identifying and isolating close contacts that occurred on school or district property.
Should school buildings plan to close for a certain period of time after a positive case within the school community to allow for contact tracing and/or sanitization efforts to be completed?
School districts should consult the LPHA where the school is located for more information about whether a school building or school district closure is required and how long to expect to be closed. In the case of conflicting guidance from multiple LPHAs within the district’s attendance area, the more restrictive guidance should be followed, whenever possible.
If, in the course of contact tracing, a cluster of infections is found in a school community, the LPHA(s) leading the case investigation should provide clear guidance and direction as to whether a classroom or portion of the school building should be closed for cleaning and contact tracing, and provide an estimated timeline as to how long the case investigation may take, so that school leaders and teachers can plan for distance instruction. If the LPHA conducting the case investigation and contact tracing recommends a school building or district closure, it should consult and coordinate with the LPHA where the school is located, which will make the final recommendation.
In the event that a closure is required, LPHAs should, when feasible, default to a closure strategy that disrupts the learning of the fewest students. For example, if a school is properly cohorted, that cohort should be sent home, and that classroom cleaned, before an entire floor or school building is closed. If it becomes clear that a school has not utilized cohorts, or that close contacts of the student or staff member that tested positive have moved beyond the cohort, then school leaders should follow the guidance of local health officials regarding closures.
Schools and districts should prepare distance learning plans for both short- and long-term classroom, building and district closures.
What criteria or indicators should be used to make a decision to increase mitigation strategies, pivot to more frequent or strictly distance learning, etc.? Are there thresholds that trigger certain actions?
Districts should make the decision to shift to distance learning, either intermittently or for a more substantial period of time, in consultation with the LPHAs within their attendance area. At this time, there are no absolute thresholds in place at the state level that trigger certain actions. It will be critical for schools to track cases and clusters in their school community, as this may be the most important factor in determining if a shift to an alternate instructional model for some or all students is necessary. The CDC recommends considering the level of community transmission when determining mitigation strategies for COVID-19, including school closure. For example, school districts should consider the following indicators when determining a school closure, as these data points can help to better inform local leaders of the community spread in their area:
- Percent change in new cases per 100,000 over a 7-14 day period in the county in which the school is located
- Increases in new cases per 100,000 in the county in which the school or district is located over a 7-14 day period
- Increasing percent positivity of tests reported to the LPHAs in the school’s attendance area
- Access to adequate testing to support contact tracing, including turnaround times of 72 hours or less, as reported by the LPHAs in the district’s attendance area
- Increasing rates of hospitalization or death
- Hospital and ICU bed capacity in the region in which the school is located
While Missouri does not have statewide thresholds and criteria to dictate how COVID-19 statistics should impact mitigation strategies and approaches to teaching and learning, there are several national resources school leaders and LPHAs can review collaboratively to develop plans locally.
Click here to view the frequently asked questions page provided by DHSS and DESE. It may continue to evolve as health experts learn more about COVID-19.
