Is There an Off-Ramp for That? K-12 Schools and COVID-19

Start [MUSIC] We are very excited to have Naomi Bardach tonight as our presenter. Dr. Bardach is a professor of pediatrics and policy in the Department of Pediatrics and at the Institute for Health Policy Studies at UCSF. She is the Vice Chair of Health Services Research in the Department of Pediatrics. In recognition of her passion and her capacity for mentoring, she received the UCSF academic senate distinction in mentoring award for associate professors in 2020. Her research program is focused on improving the quality of inpatient and outpatient pediatric care with a foundation in implementation and dissemination science. From December 2020 until September 2021, she served as the lead of the California's Safe Schools for all team, working for the California Department of Public Health to develop plans to ensure public schools could open in fall 2021. Dr. Bardach today is going to talk about what is next for schools in the COVID pandemic. Naomi Bardach, M.D. Main Presentation Thank you so much for the opportunity to come talk to you guys. I have nothing to disclose and also very important acknowledgment, it's a team effort across multiple sectors, the work that I'll be talking about tonight. The overview of the talk is there are couple of different themes I'll be touching on. Theme 1 is pursuing the goal of what we think of as policy-relevant evidence. Meaning evidence is like, what research do we need to pursue and create in order to inform COVID policy for schools. Theme number 2 is then shifting from making the evidence to making evidence-based policy decisions. I started out doing research and then I moved towards helping to support the policy using everything we've learned so far on the evidence. Then theme 3 is reflecting on lessons learned from COVID-19 for public health and then cross agency leadership is a lot of what I did at this date in order to create, share, and support the implementation of K through 12 schools guidance. Because there's one thing to just say, oh, here's the guidance that you should follow. It's another really important part of the job was actually helping people do the implementation work on the ground. Then finally, we'll do a little bit of looking forward based on the lessons learned, where we think schools might be going next. A little bit about the impetus for the work. It was both personal and professional. I had my younger son, who's now 12-years-old, really, really struggled on Zoom, he was in fourth grade and he had an undiagnosed ADHD and just basically dropped out of school completely for the end of his fourth-grade year and for most of the beginning of his fifth grade year. He had some of the mental health effects that you've already heard about depression, anxiety, emotional dysregulation. Then I also work clinically at Zuckerberg San Francisco General Hospital, which serves a population that was disproportionately devastated by the effects of the pandemic, both in health effects and also lack of equal access to remote education. In the beginning of the pandemic in March and April, I was like, how can we get the schools back open? I just said, I have these research skills. I'm an implementation scientist. I'm going to research my way, and my children's way, and my patient's way back to school. My original hypothesis in April of 2020 was that everyone had actually already been infected. I just needed to measure antibodies for the kids and the teachers and everybody with antibodies was going to go back to the classroom. I actually initiated a lot of conversations with names that you might remember or be familiar with, George Rutherford, also people in the San Francisco Department of Public Health as partners to see if we could start testing in the city-run learning hubs. There were these small hubs that kids were coming back and just doing some learning or just actually getting care in the learning hubs. Unfortunately, that was not really how it played out. It turned out that there was not actually a whole lot of antibodies already in the community. I thought maybe I'd run rampant already, which didn't know about it. There was a Unidose en Salud testing in April of 2020. In the mission, they found that very few children were infected. Only about 2.3 percent of 259 4–17-year-olds in that study. Then there was a random sample of eight in Iceland which found zero cases in kids who were less than 10 years old and even in a high-risk sample that had been symptomatic, traveling or had a positive contact. But they still had a very low case rate in the kids compared to adults, seven percent versus 14. There was plenty of similar findings in Spain in April to May of 2020. My idea of just getting everybody tested and back-to-school, didn't really pan out at the time. We did find in summer of 2020 that there was mounting evidence that schools could be safe and that school closures were harmful. There were international experiences of how to do it right. Also, how to do it wrong, that we could learn from. We learned a couple of things that there was limited illness burden in children. But we also knew that families with children bear a large brunt of the economic devastation, which is mediated through school closures. It was starkly deepening existing disparities for low SES students, people from poor backgrounds, low socioeconomic status. There was increased anxiety and depression for both students and adults. There were concern around signs of increased child abuse, domestic and intimate partner violence. Data from prior recessions had shown that that was actually true under financial instability, that that could happen. Our goals were to have schools be able to be open safely and successfully. Successfully, meaning kids in seats, kids being able to attend in-person school. Safely meaning it was not going to be a big driver of infections in the community. That was the ongoing twin goals, whatever we could learn to try and get us towards those. There are a couple of safe practices that emerged. Masking, which you have now heard about ad nauseum. Physical distancing was something that was a big public health measure, particularly in that first year, 2020 and even into the spring of 2021 and even the end of the school year of 2021, people really focusing on physical distancing, stay on one sec screening for symptoms, ventilation. We knew that aerosol was part of the picture. Ventilation is going to be important, symptomatic and asymptomatic testing and then small stable groups. Those were the other ideas. If you had a small group of students who only mixed with each other, they were less likely then to pass it along, across lots and lots of different kids in one school environment. For me, I'm all about the successful piece. This is how to do it safely. There's all these layers, but I was saying the limitations of success and success being defined as many kids as possible and being able to go back to in-person learning, was going to be limited in part by the physical distancing, as well as the small stable cohort. Operationally, those are the things that were going to be extraordinarily challenging to schools. This is all stuff that was happening and things we're thinking about in the summer of 2020. For me, I started to think, okay, let's see if we can do research. My antibody study it's not going to solve this for any of us. How can we help on the safe and successful peace? How can we figure out how to do that successful peace? Well, let's try and do some research around it. Step number 1 was defining a policy relevant question. Let's figure out can we peel back the physical distancing? Can we peel back the stable cohorts? Step number 2, involving a lot of stakeholders in order to refine the question and design the study. Thinking particularly about like, what are those potential changes in policy that might result? Can we peel back those things? Does public health feel comfortable with that? Are the teachers comfortable with that? Are the families comfortable with that? The other key part of this was timeliness. Make sure we try to get this done quickly in order to be able to get the information out and to help change policy or inform policy at least. Then sharing the results, interpreting them in the context of what was going on during the pandemic and sharing the policy implications to a broad community. People call that the last mile of implementation science, meaning you've got all the evidence, but how are you actually going to disseminate it? Actually as you're doing key step number 1, you actually have to think about key step number 4. I'm thinking about how your question and how you ask it is going to actually inform the policy. This is a picture of the study we designed in trying to say how might we answer these questions. What you can see here is that this is weeks along the bottom, and then this is school clusters, meaning you can have a couple of schools and a cluster or one school in each cluster. As the weeks go by, all the schools start with a certain set number of policies. Whatever the school opening policies ask, and then you start in your Step 1, in this green section, in one school cluster, you peel back one set of policies. For instance, if we're going to peel back the physical distancing limitation, that would be the only thing that anybody peeled back in the entire section of the green section, week after week after week. First, they would just be one school cluster, then two, then three, etc. Then Step 2 would be peeling back another one of those policies, so eliminating stable cohorts. This is the design and what you do is you actually do testing every single week as you are feeling bad policies. That was the idea that you do some analysis along the way to try and see what are your rates looking like actually as you're peeling back those policies. You began to understand, are there lots of new infections? If the policy is not making a huge difference than when you peel back, it shouldn't make a big difference and this particular design helps us to understand that. As you get controls because you're moving each school cluster one at a time, it controls for whatever random variation is happening across those clusters. It's called a stepped wedge trial. In order to try and do some of this work, and that was the idea we design a study, and then we got to talk to all the people because we had to figure out, first of all, what are the stages going to be? What are Step 1 policies going to look like? What does Step 2 policies going to look like? The questions that drove that or what are the pain points for people? What are the hardest things? I hypothesize there's going to be stable groups and social distancing or physical distancing. But we need to talk to people and see whether or not that's true, then what is feasible, both logistically, emotionally because there's a lot of fear in the pandemic. Then what could the public health leadership tolerate in terms of risk of having this study happening. We talked to a bunch of key stakeholders, and talked to a ton of scientific collaborators. I like to say, COVID-19 and particularly schools and COVID-19 takes unprecedented levels of collaboration. That's really what we saw. I had never hung out with a virologist before, I've done a little bit with infectious disease but like there were so many people who had to get together and share their brainpower and their expertise in order to try and get these things answered and understood. I just listed here the names, I'm not going to go through all of them, but you can see it's a lot of people in virology, you might have heard of Joe Derisi, very famous fantastic work that he's doing. Carina Marquez, actually just won a wonderful prize at UCSF for mentorship, and the Chan Zuckerberg Biohub, pediatrics and preventive medicine, tons of people there in across the chair of the department and also George Rutherford who's in preventive medicine as a pediatrician, Ted Ruel's infectious disease, etc. I'm sorry Bob Harrison is another person to call out. He actually had worked very closely with teachers. His perspective was also very helpful as somebody who thought a lot about occupational health from a teacher perspective. Then San Francisco Department of Public Health, Tomas Aragon, who actually is a leader, he's the Director of the California Department Public Health, now at the state. He was in San Francisco at the time and many other people. School administrators, we were talking to Oakland USD, San Francisco USD, San Mateo County superintendents, Alameda County superintendent, the Department for Children, Youth, and Family leadership. Here we talked to teachers at the CTA. The local UCSF is United Educators of San Francisco, and then individual teachers with a real shout out to Emily Frank, who is a teacher at USD, but also a pediatrician who trained at UCSF and gave us, again, a lot of perspective about how the teachers were feeling on the ground and then working with families as well. There's a group called decrease the distance, and then there's the CARE's webinar, which is a UESF sponsored group that was also focused on how do we support schools to open. Then there's funding from a lot of different people. Unfortunately, the summer surge really decreased confidence. If you guys remember, March is when the pandemic hit, there's like some cases, and then everybody said, well, maybe we're done. In the summer, people opened up a little bit and there's a big surge. Well, not as big as what we've seen so far, but it was a surge at the time that scared people. My study design went down the drain because everybody got very nervous and nobody was interested in peeling back any layers at all. They all said, nope, just keep everything. If we're lucky we're going to open. We're just not even going to peel back anything. We were still wanting to build on the momentum we had going from all the partnerships and stakeholder discussions we've had. I actually decided to do at least some work on how we might do school-based testing. We did a San Francisco summer camp study. That was a pilot test based way to say, is it feasible and is it acceptable for students to do their own testing? Because if you remember, way back then there was this test that you had to put really far back in the back of your nose. When people were doing it, the people who are collecting the test, it was somebody else who had collect the test. They had to wear full gowns, N95 masks, face shields, gloves. It was a lot of work that people had to do. And if the kids could actually self-collect their swabs from what they call the anterior nares, the front of the nose, then we wouldn't have to have all of that protective equipment, the kids could do it themselves. It's a lower risk situation. It's actually very feasible model for school if we're going to do school-based testing. That was the study that we did. We also observed the camps in action and we saw that kids were actually able to do successful masking, they were able to stay in their stable cohorts, they did physical distancing, hand hygiene, ventilation, they could actually do self-testing very nicely on their own to the youngest age of kindergarten. I joke, but it's not such a joke, but I joke as a pediatrician. It's like picking her nose of the Q-Tip basically, and kids are really good at picking their nose, and so they're really good. They just go to town, they run around there, they've got great samples. We found that there weren't any documented cases by PCR either at the beginning of the camp, we did find that there were some antibody-positive folks because we also did an antibody test using saliva. But a couple of things that we found the implications were that it's possible to follow public health principles in the indoor setting, so schools could do it. Then students' self-collected tests were very feasible and acceptable for kids as young as kindergarten. The other study that I was involved in, but was led much more by other people, was a modeling study that was also trying to get at this question is like, what are the most important interventions? And basically what they looked at is said they modeled what it would look like because they took the day they knew and they surveyed people actually about how they moved around and how much interaction they had, and they modeled how, how the infection might move it throughout a population depending on what intervention you did. I don't know if you can see, but the top one, it says no additional precautions here and the teachers you have in the dark blue, the elementary school students in the lighter blue, middle-school, and the very lightest blue of high school. You can see that actually there's a lot of infection that's going to go on. At the bottom, it says proportion of each group experiencing symptomatic illness over the fall semester, there's a lot of illnesses that can get passed around, particularly in the high schools and also the middle schools. Mostly because of not having stable cohorts in those settings, as well as having a potentially higher rate of infecting each other in the older age groups. The older you get, it looks like at the time and still looks like now you're more likely to pass it along to each other and the older age groups. But then if you add testing, you get monthly testing with teachers, teachers, and students and then weekly testing of teachers and weekly testing as teachers and students. You can see the weekly testing makes a difference. It can help, particularly you're doing weekly testing of teachers and students. But the masks make a huge difference alone, and the stable cohorts made a big difference alone. If you put them all together, you really have moved those numbers back. This was really helpful information to show us what was potentially possible and where people should be focusing their time and energy and attention. It's great if you can do everything, but if you have to focus on one or two things because you're an under-resourced school, it's really helpful for people to know, particularly at that time, because testing was so limited, it was really helpful to know that testing is not the be-all and end-all, it's going to be an incredible layer. It's a great tool, but it's not the be-all and end-all if you have these other interventions in place. A couple of other things, so although we couldn't do that stepped wedge trial that I showed you, this was our next best study design which was basically go observe once reopen some learning hubs in the fall of 2020. We went and we observed how people were interacting and what they actually, what practices they were doing and we tried to see if there was a difference in behavior in those settings. Was there a difference in the transmission level? The thing that we found in those, because people were so locked down still, there are actually still very few infections during that period of time compared to what we've seen since. There's a very little transmission on the school campuses. There, even though there are 36 cases, there's only one transmissions adulthood, adult. The implications were that you can implement layers very feasibly in high-risk situations. Meaning these learning curves were actually very like, people were worried that the kids who didn't have a stable at home or less socially regulated or socially able to follow along with those instructions, that there is a worry that in those learning hubs there'll be a lot of transmission, and we said no, absolutely not. Those kids are great. They're totally able to like, go along. School is a great environment for teaching people how to do what their peers do and so there was no student transmissions in those layers were quite feasible. Then the last study is sort about one other piece of the puzzle, which for many of us is still actually something that we have to think about, which is if you have symptoms, when should you go get testing, and how can we inform national and state recommendations for symptom screening in order to limit the missed school days for testing because particularly in this past year we've been having people, they have to go home and they get tested if they're symptomatic. We basically looked at symptom screening results, meaning when you came into Benioff Children's Hospital, Oakland, not Zion and the Palo Alto Medical Group, anybody who came in and got screened for symptoms and then a test, we actually were able to say, well, what symptoms are associated with a positive test. Interestingly enough, we found that the highest likelihood of you actually having a positive test had to do with being exposed prior, which is not that surprising, and loss of taste or smell also not that surprising. Although to be clear, this is actually an earlier variant of COVID. Now, loss of taste and smell is not as common. It would still probably predict it pretty well, but it's not going to show up as frequently in anybody who has it. The things that were very, very common, not surprisingly, nasal congestion and rhinorrhea, meaning runny nose. Sore throat, were really common, but we're not as likely to be associated with COVID because those are symptoms of so many other viruses that children have. Having every kid with a running nose leave and go take a test might actually not be the best use of resources and would be an unfortunate loss of missed school days. That's the last finding we calculated how many missed school days there were and there was a high number of missed school days associated with exclusion and testing to find one case of COVID-19. Particularly if those non-specific symptoms, the runny nose, the cough, the sore throat. The findings from that paper is that probably would lead to excessive missed school days. This particular finding has not impacted policy as much as I think might be helpful. It'll continue to be a conversation, I think for people. As we continue to go through the pandemic and it becomes hopefully closer to being endemic. A couple of limitations, as I mentioned before about this particular study was the original strain and maybe a little bit of the Alpha variant, but we need to basically repeat the study actually, I think in order to make it more relevant, the option now to consider based on what we found is to allow for a rapid test to clear symptomatic students if they have non-specific symptoms, meaning on school site, schools can do it, and some schools actually implemented this throughout California. They doing a rapid test right there and say you should go back to class or considered not excluding kids for very common non-specific symptoms. Now I'm going to transition to the next phase of the talk, which is talking a little bit about the public health leadership stories and lessons learned, which is different from the evidence generation. You remember theme one is, how do you create information research to answer these questions? And now I'm going to talk about high moved into a leadership role, thinking about the policy and how to create policy, and what are the lessons learned. Part 2 making evidence-based policy decisions. How do we put what we know into practice? As I mentioned before, it's called the last mile problem. Sharing and interpreting the science and doing thought leadership is another piece that I ended up starting to do, mostly because I was so obsessed with how we can get schools open so I was reading everything. I got invited to do medicine grand rounds at UCSF in July 2020, then they established the CARES group, which it was a group of UCSF doctors who were all getting tapped by their school communities to help figure out how to re-open schools. We actually started to get together and share resources and figure out what is the advice that we think is the right advice to give to schools. I had immediate collaboration. I did a New York Times op-ed and then I ended up consulting with the Chicago Public Schools around testing, mostly based on all the experience I had doing the testing study and then I started to work with San Francisco Department of Public Health as part of my service. I got deployed to support the design of the school testing strategy for schools in San Francisco and then I got invited to go and serve the state of California and the Department of Public Health and Health and Human Services to lead a multi-agency Safe Schools Team, which basically was a cross-disciplinary team where they said, the public health piece, but public health cannot do this in a vacuum. They have to be partnering with Department of Education. So I partner very closely with Department of Education, State Board of Education, the office of the State Architect because of the ventilation questions, the office of State Health Planning and Development for also thinking about how to do the implementation on the ground of all those different layers that we talked about. Extraordinarily interesting and complicated work to get everybody thinking about it and communicating well together. I put this slide up basically just to give a reminder of the timeline of schools and thinking about schools in context of how you think about how that policy unfolded. There's a policy analysis in helping you and everybody makes sense of how the whole thing played out. If you remember, first we shut down since we thought that schools would drive transmission and children would get COVID and would be a place where it spread, everything through the schools. Then we thought, maybe here right before the surge happened, maybe it would be safe to open. We were looking at other countries. They understood how to do safe schools with safety layers and how important it was to do in-person instruction. Then there was a surge that happened here, a winter surge. We'd start to re-open a little bit, but then there was a big surge and then we really shut down. On the other side of the surge, there was a big emphasis of in-person instruction and preparing for that, and I'm going to go through this timeline a little bit more slowly and pull out some pieces that I think are quite policy-relevant and interesting to think about how and why things played out the way they did in California of how schools re-opened. The theme here is actually that there's different branches of government and how they worked together or didn't work together and how they moved policies. If you remember, on March 4th, state of emergency was declared. That's declared by the executive branch. That was Governor Newsome saying and declaring a state of emergency. The schools shut, many of them around March 7th. There were students testing positive with COVID-19 and the state's fifth largest school district announced their closure and many other schools just followed suit almost immediately. Like I mentioned, they thought it would be a source of viral transmission. There's was assumption that kids would be the vectors. There was uncertainty about how to protect students and staff and the schools pivoted very very quickly to distance learning and then trying to support families who needed the support, giving them school nutrition, providing computing devices and other things. SB98 in the summertime was actually a really, really big moment and is a legislative action where the legislature and the governor partnered together to allocate an additional $5.3 billion for schools to respond to COVID-19, including really important safeguards, distance learning, addressing the digital divide. But it also set requirements for distance learning, mental health student re-engagement, and in-person instruction, and it provided a do not harm clause, meaning, if you didn't teach in-person, that your money was going to be fine, schools were going to get paid. It felt totally the right thing to do at the time, but it had implications and ramifications until it sundowned a year later in June of 2021. The next phase of the roller coaster, this is where I usually start screaming. In this particular part, which is around September 2020, we saw the science, but the implementation was really really hard to execute. I don't know if you remember this when California had all those different parts of the blueprint, they call it the blueprint for California and you were in the orange phase or the red phase or the purple or the deep purple, and the reunion negotiations were very very difficult because of that hold harmless clause and the limited power then that people had to do negotiations to basically say, let's re-open schools here, let's show that you can do it safely. Everybody is just trying to figure out how to open and to figure out how to implement what we knew. There were a lot of public schools in more rural counties who went back to in-person instruction but most urban counties stayed remote. Many did learning hubs, those smaller hubs where kids could go in; kids who didn't have digital access at home or who needed childcare at home so families could go back to work. Then mostly private schools marshaled the resources and re-opened for in-person learning. They weren't subject to the whole [inaudible] because that was just for SB98, it was just for public schools. There are a lot of private schools who opened during that time. San Bernardino in the beginning of December or, it might've been actually more middle of December, announced that they were not going to reopen for the entire rest of the school year and the the sense in the governor's office and the State of California government in general was real concerned that many other schools were contemplating similar decisions and they really wanted to figure out how can we get things to a place where people actually feel like they can re-open. We have to reassure people that they can actually consider re-opening because they felt it was such an important emphasis. That's actually when they brought me on and they formed the Safe Schools team, it was in December and we put out guidance in January that created a lot more clarity and a way for it. That guidance, it was a public health order. It's an executive order, so it's executive branch. You're seeing again, how are the levers of government moving in order to try and help support schools in order to be able to re-open both safely and successfully. You've heard about executive orders and then legislative movements or legislative laws that were passed and then now, again, here's an executive branch order. Then in February of 2021, the governor really accelerated vaccines in a huge effort to get vaccines out to the K through 12 school staff, leading to most people actually receiving access by early March. Again, that's an executive branch move. On March 5th, they passed the legislature and the governor partnered to pass something called AB 86, which allocated an additional 6.6 billion to help accelerate reopening and actually incentivize schools to reopen, so they said if you reopen your schools by XYZ date, then you'll get extra money in order to help you support doing that safe school reopening. That actually was relatively effective incentivizing schools and feeling like, we're going to empower you, they also like ramped up a huge testing program for the schools in order to support schools to reopen, so that was helpful. It didn't solve it. There are a lot of schools that remained closed, but it helped in many ways. Then you can see in the summertime SB 98, sundown, so there was no longer a hold harmless clause that meant that there was a lot of emphasis basically saying full in-person instruction is the goal for when we opened in September. Then the CDC and CDPH guidance came out around the middle of the summer, so the CDC released their guidance and then shortly thereafter, California Department of Public Health Guidance was released. You may remember there was a lot of controversy at the time around masking. CDC said, "If you're vaccinated, you don't have to mask, and if you aren't vaccinated, then you do have to mask.", and California Department of Public Health said, We're just going to have everybody masked in schools because we don't want there to be this weird, like who's vaccinated? Who's not vaccinated? There's going to be have to be a masking police and there's also going to be kids who then no, you got vaccinated, you didn't get vaccinated. Why are you wearing mask while you're not wearing mask? We know is already contentious at that time, it was just going to lead to a lot of stress in the schools. That was the decision behind masking, and the balance was if this masking stayed, it meant that according to the CDC guidance, so if we were following the precepts of the CDC guidance, that actually meant that we could get rid of the physical distancing requirement because it was still in the CDC guidance in the summer of 2021, and so we said stick with the masks, don't do any physical distancing full in-person and structure, every kid can be in a seat. Then we also said if you have a mask on and there's an exposure, you can actually stay in school. That was another piece that the CDC had very tiny print and we picked up on it and said, Okay, keep the kids in school. If they have masks on and they can do a little bit of testing and they can stay in school, they do not have to leave school for 10 days at a stretch just because they got exposed. That was a big part of what happened in the summer to really try and help support schools to stay open, and then the one other piece that was helpful for us to know about, which I'll tell you a little bit more in a minute or two is about there was a study that came out of Marine that nobody else knew about yet because it hadn't been published, but we had heard about from the Marine Department of Public Health where there was a big outbreak in a school from a teacher who is not masked, and you could see it was like across the entire classroom that basically she had been reading out loud and it just infected a ton of kids. So we said we got to keep the mass on. That was Delta, and Delta was all of a sudden so much more infectious than anything we had seen before, and so the goal was to keep kids in school and not have them go out when they're infected. This is the conceptual model just to help people think through what the spread from schools that helped us to think about how should schools be safe? If you think about it, Step 1, in order for there to be spread in schools or anywhere else, there has to be virus in the community, then the virus has to get onto the school campus, then there has to be in-school transmission. It goes from one person to another, and then it has to go back out of the school and infect some body else who wasn't on the school campus. In the first phase of the pandemic, we focused a lot on Step 3, we shut down the schools that we focused on physical distancing, small cohorts, handwashing, walking in one direction in the hallways. We had some ventilation, but as we moved into the next year in 2021-2022, we knew that we could do a lot with vaccines to get rid of virus in the community, that we can really decrease that burden, which would decrease the likelihood of a virus in school. We also knew we had school based testing that was much stronger than it had been before, so we could do less of the focus on physical distancing and stable cohorts on that Step 3, and that's what really allowed us to have full school again. These are the key safety layers, this is the famous Swiss cheese model where the virus is going through the Swiss cheese, but if it goes through this hole, it doesn't get through it because there's a solid wall there, etc, so that's a way of decreasing your risk of getting any transmission by putting together a couple of different layers. Layer Number 1 everyone is vaccinated layer Number 2 is testing, and if you're sick, you should stay home. Layer Number 3, just use the masking indoors, some hand hygiene, and then use your ventilation either by improving your indoor air quality or using the outdoors when possible. This is the reason we went with that model, like I said, we were debating, should we do the CDC mask optional thing, and this is really what drove the point home for us that we should just like, Delta's coming, it's ugly, this was from May 2. Here's the teacher in the front of the classroom, and all the light gray boxes or light blue boxes are symptomatic patients, and then anything that's outlined in blue, so that's positive, positive, positive, positive, symptomatic, positive, positive, even at the back of the class positive and symptomatic. There is a lot of infection that came through that classroom just from that one teacher being unmasked and reading in the front of the classroom. Then this is just another picture from that study that shows that how this is the original teacher and that there is infection that spread to many other students. Then there's another small cluster that they discovered through using fancy genetic biological testing, looking at genomic sequencing, that there's actually another class at the same school that spread actually at a sleepover party, so there are a couple of key points. We knew that from this study, spread was going to potentially happen outside of school as well which is important for the people who are worried about going back to school. We knew that we could do save layers in school and we knew things happen outside of school, so it wasn't that school is the only place that was going to happen, and school could be a relatively stable and structured environment where there will be less chance of an infection getting passed compared to your sleepover parties, which is what this was. Then a couple of other important take-home points based on what was happening in that teacher's classroom was measured, you're vaccinated. I'm sorry, I forgot to say she wasn't vaccinated. Make sure people are getting vaccinated, putting on their mask stay home when they're sick because she was symptomatic at school. As I mentioned, it informed our mask policy and why we decided to keep masks on at the beginning of school year. Then a couple of things to just highlight about the public health leadership jobs, so there's very specific decisions like that. Then there's how do we help support schools and the huge diversity of California's 58 counties? I just showed these pictures of these are the case rates in December 2021. Then these are the some recall results, so many of you guys have probably heard that there's the political divide reflects also the divide of how people felt about and acted on their COVID mitigation strategies. But the thing that for me was extraordinarily meaningful is that we had a partnership at every week, I would go in and present to 58 counties, all the Department of Public Health Leadership to talk to them about schools that we have is a big meeting about everything. But I always had a section on schools and working with the diversity of public health officers, everybody was extraordinarily dedicated to keeping their communities as safe as possible and to getting them through the pandemic and whatever way it was going to work for their community. I really appreciate it actually how much people care about doing it together, and despite whatever political differences there were, there was a very common shared goal of we need to work on this together. There was a lot of Teflon, I joke. You know I'm a pediatrician, I'm very nice, I'm not used to getting attacked, I got attacked a lot, so I had to build up a little bit of Teflon, it was also a good learning experience. I got really attacked on Twitter for a period of time, and I have to say the best lesson for me, which I did because I was working too hard to do anything else, but I just stayed off Twitter. I heard from somebody that it was ugly on Twitter against me and I said, okay, then I will not be looking at Twitter because I got to get this job done, and it does allow for some more symmetric bravery when your courage is really needed, and actually when we rolled out that mask guidance in the summer of 2021, we needed some courage to just say like we think of this the right thing to do, I know it's hard, but it's probably the right thing to do, so that was helpful. This is the slide I use quite often, which is about the unprecedented levels of collaboration. We really had to call on people to pull together, if you want to go quickly, go alone. If you want to go far, you've got to go together. This was particularly important when we were dealing with the controversy of the CDC putting out their mask guidance and then we put out mask guidance that was fairly different. This is another idea, which is that if we don't enforce, COVID enforces because a lot of the schools and some of the public health leadership were saying, Well, California's guidance says we have to wear masks, the masks are mandatory in schools, but what if we don't enforce what's going to happen? What are you going to do? Basically, somewhat contentiously, they would say, What's going to happen, and we said, you should do it, this is our recommendation, and if we're not enforcing it, it's not that nothing is going to happen. It's like COVID is going to enforce it and it's going to result in infections in your schools. We did call on people to come together and say this is a really important thing. We were thinking at the time that we just had to, like COVID was pulling out the big guns, was pulling out Delta and if you're in the alien invader movie, this is the last end of the Alien invader movie. Everybody needs to come together, get vaccinated, keep your mask on, get Delta out of the way, and it was an important thing for people to be able to try and come together, and most people actually really did go along with that, there were a couple of counties who didn't. It was contentious, but I think a helpful moment where we can all try and come together. Then I just pull out this last piece which is the role of the judicial branch. We've talked about legislative- executive branch. The reason I pull it out is because I got sued twice personally sued along with Governor Gavin Newsom. The dubious distinction of being named on two lawsuits with the Governor Newsom. One was about distancing in March of 2021 and high schools not being able to open as early as other schools. Then the second one was the masking lawsuit. The people use the judicial branch when they felt like the legislative body and the executive branch, were not doing what they wanted them to do so that people went to suing the government. It wasn't just about schools there multiple suits that came out against the government for multiple different reasons around COVID. The first time I was upset about it and felt terrible and my husband said, it's schools, Naomi, it schools and COVID, of course, you're going to get sued. I just was wondering why it's taking so long, and so I think that was the truth. It's very contentious. It's still contentious. The masking lawsuit we knew was going to come because people had said, if you do this, we're going to sue you. We actually thought that it was the right thing to do and to say, okay, you're going to sue us that is what it is. In part because it meant that at the state level, we could take the heat of dealing with the masking issue and take that off the backs of the public health officials in those counties and take it off the backs of the school administrators. Because the school administrators were getting a ton of heat from both sides. People who wanted to keep the mask on, people who didn't want to keep the mask on. That level of conflict and contention in the face of what we knew is going to be very infectious Delta variant, we just thought we would take the heat and accept the risks that was going to happen. The last theme is related to that theme of how do you make these decisions about how to help out communities? When do you step in and actually have state-level control as opposed to local control? One really important piece was that I discovered or that I thought about on reflection was how important it was to listen and lift up all voices. We got a lot of incoming furious email from people who are very activated and empowered and tended to be higher socioeconomic status. We didn't hear from a lot of people who are disenfranchised. I actively reached out to a bunch of people around the state with help from people in the department of public health and other state partnerships to basically find out, what does everybody else feeling who's not sending us a lot of angry emails. Part of the reason why we also weren't hearing from those people is because we had safety level layers in place and they felt comfortable with what was happening. People don't tend to say I'm comfortable. If they're comfortable, they just feel comfortable so they don't send me emails. I would say, this is a lesson I learned from being in leadership and I pass on to other people. You should send the appreciative emails, or if you feel like something is going wrong, you should also send the emails because they do make a difference. People listen to them. But we, as public leadership, we also need to remember to listen to the often silent voices to reach out to them. Otherwise, it's just the loud voices dominate and you miss the fact that there's a bunch of disenfranchise people who you are also trying to help in state leadership to make sure that they have a high quality of life and public health is supporting them as well. Just to summarize, a couple of stories and lessons learned, there's an interplay between the legislative branch, the executive branch, and the judicial branch, and how they work together, and how they provide a way for people to have voice or not to have voice. I think were really interesting pieces looking back at what happened during COVID. The other piece is always thinking about compared to what. People were saying, it has to be a safe. We looked at all of these metrics. Get every day, all the time public health, all of our communities were focusing on COVID rates. We didn't have great data on how many kids were missing school and how much mental health stuff was going on. Which to me is the successful piece. You can't just look at the public health numbers of COVID cases. You also have to think about what are the other elements that are really important to mental health of the kids, the long-term economic productivity for the kids. Being able to be successful adults is partly about being in school as well as your mental health. That to me is a really important piece that I don't think we ever really got great data on the compared to what piece. We had the COVID data, but we didn't have to compare to what part. You've already heard me talk a fair amount about the only way we're going to get through this is through unprecedented levels of collaboration. The great diversity of California and how important it was to partner with local public health officers and partner with schools. We did a ton of work with the County superintendents and many of the principles throughout the state helping to remind everybody that COVID is the enemy rather than each other. There's a lot of contention, as you all know. The more we can remember that COVID is the problem rather than other people who are in leadership, we're trying to prevent it from being a problem, I think is very helpful where of course in a different phase now I think than we were then because of vaccines and because we have better therapeutics. But certainly people forgot sometimes the COVID was the enemy. Then fighting an equity. Whose voices get heard? Thinking about that, listen to the silence. What are we not hearing in making sure we're lifting up all the voices. Then to finish off with setting the stage for some of the key lessons learned and therefore where we're going to look for it and think about what we learned and how to continue to get through this pandemic slash. Hopefully we're moving into endemic. This is a map of school closures from what's called the Burbio school tracker. This is from December. I just use the snapshot because it shows that California is actually relatively sparse. In terms of school closures, most of these were actually closures in rural counties that actually didn't go along with the mask guidance. That likely we kept schools open, I think A, because of the masking B, we had a decent number of vaccinations in that age group. At that point I was actually just 12 and up. But even so we had some decent vaccination levels and many of those in many communities. Then also that modified quarantine, meaning you could stay in school if you've got exposed, were all things that I think really helped us to keep the schools open. Much of what we did actually during the school opening phase is when there were schools where there are huge outbreaks. We'd send testing teams and vaccination teams out there to try and help address whatever was going on in those communities that tended to be the under vaccinated communities. I think those are important lessons learned. There are a couple of things that we did right before the school opened in the summertime, which was actually doing communications campaign for the other half. Some people were, don't make me mask. I'm done with the pandemic. Then there's a large group of other people who are quite worried about sending their kids back to school. We did a lot of work on a communications campaign to actually help instill confidence. As explained, we did the mask mandate, but no minimum physical distancing that test to stay tool was very helpful, the high vaccination rates. Then theme I didn't talk about is that there's a huge testing capacity with $887 million for school-based testing for the State of California minus LA, which had its own $300 million pot. We oversaw that whole testing program actually of over a billion dollars for just school-based testing alone, which also really helped provide a safety layer as well as a way of preventing confidence for people. Just to finish up, where are we now and what should we consider on the pathway forward? Our current situation is that there's still some ongoing searches, unfortunately, master off but sometimes coming back on there, so like Alameda is now doing some required indoor masking. There's still long isolation and quarantine practices. We are luckily coming into vaccines for the youngest kids. We can still leverage some tools which is vaccines, masks, testing, ventilation, as we might need them for the next phases of this. We know we're probably going to continue to have ongoing searches. It does not look like COVID has decided to stop making variants. I didn't talk about the Omicron surge and how that affected things, but it's an ongoing evolution. But I think that's safe and successful are still the twin goals. The theme now, I think, is much more about not on our watch, schools should be safe places for kids to be able to go to school, which is why it's still okay to put the mask on sometimes, even if in the warrior stadium no one is required to wear masks. Kids are required to go to school and we want to keep them there. Using masks judiciously, take them off, putting back on as we go through waves is totally not an unreasonable way of doing it because we're stuck in this situation where it's going to continue to go on for a while. Then schools continue to be a structured environment. Those masking policies are generally more effective in schools and they will be outside of school because outside of school, kids might still pass around to each other. But when you're on school campus, kid should know like okay, they're not going to have a huge risk of getting COVID. Families should know their kid is not going to have huge risk of bringing COVID back from the school. I know San Diego Unified is now doing a mask policy linking to case rates and the community and outbreaks on campus. That is where they're thinking about an an off ramp for masking. There is a big push last year in the summertime when we were talking about our guidance, people said, what is our offering up look like? I think we're really out of place now where we can talk about doing off ramps. Where we say, okay, if we're not surging, fine, let's just go back to normal. Vaccine as much you can, but masks are recommended maybe in some situations, but really they're optional. That's what it is in SFSD right now. I think we can move in that direction. I would definitely say that as we think about how to use masks, it's probably really helpful to think about if we can use masks to help minimize those isolation and quarantine practices if you're in the setting of good masking. Kids have to stay out for a long time if they're are positive, if they have been exposed, sometimes, if they're not vaccinated and so the younger kids. Right now for the kids, the fear about getting COVID is about missing on and events and schools. It's not about putting a mask back on. They're like, Okay, whatever effect about the mask back on, not a big deal. If we're searching, it makes sense. Let's use those mass to make it so the kids don't have to miss out on things anymore. Those are the comments, I'm no longer in California leaderships. Don't take what I say is like an indicator of what California is going to do. But I certainly feel like these common sense approaches are still where we are going to need to go as we continue to manage these searches going up and down a bit. I often end with this quote, which is a James Baldwin quote, which is ignorance allied with power, is the most ferocious enemy justice can have. It's part of the reason why I do all the research trying to figure out what is the right information. I don't have a political perspective on this. I just want to get kids back to school and do it in a safe way possible. That's the right approach, is that we should support everybody to get the education in the way they need to, and it should be informed by evidence. I think that's it. I'm happy to take any questions. Thanks, Naomi. Q&A The first one that came in was when you were describing developing plans for the school reopening, the question is, how were or are immunocompromised or chronically ill or disabled students and teachers and staff, the whole group's there, accounted for in the research and in the planning? It's a really important question. That was a complicated piece of it. We had in the guidance, a discussion and CDC has a nice section in their guidance also about disabled students, and there's a tension there. There's two different pieces there. One of which is, how do we keep the school environment safe for kids who are immunocompromised or who have a chronic condition that might make them at higher risk? That's part of the reason why it tended to be a little bit more on the, let's keep the masks on because we need everybody to have access to a safe and free education. That's a California specific piece of it. Then the other part of it is also is there are some kids who because of their disability or learning difference, particularly kids on the autism spectrum who have sensory integration disorder, they had a lot of trouble with masks. Trying to figure out how could you support everybody to feel like you were in a safe environment. For that second situation, sometimes we recommend doing more testing for those kids or getting better testing resources, so they could do more frequent testing so they could be in the class and not necessarily wear a mask, but also not have to be totally ostracized to the other side of the room. They can still actually be in school. As another question that just came in that I think has some relation to what you were talking about. The question is, do you foresee the potential of the dual world where unvaccinated individuals are really collectively approached differently and continue to use health care services or need health care services differently because of the differential risks. Do you see that schools may need to have permanent things in place that separate vaccinated and unvaccinated? Going a little broader, would providers, insurers, do you foresee a world in which providers and insurers are going to get pushed to seek different payments based on vaccination status or antibody status or whatever the status may be. In some ways, I think the school question is probably a little bit more straightforward. Generally speaking, at the federal level, at the state level, there's a move to not differentiate between the vaccinated and the unvaccinated in the school setting. I think that everybody has felt like nobody wants to try and differentiate and if somebody's vaccine status to serve say you have to do this versus that. Now that being said, there's probably at a community level, there are communities who tend to be under vaccinated that will probably have different school policies than the more highly vaccinated communities. But those, as you might imagine, the unvaccinated community probably going to be less restricted because of their tendency already to be less paying attention to the COVID mitigation strategies. Probably be at a community level that there will be differences. The differences will probably actually not play out the way you might think they would play out in terms of being more restrictive for the vaccinated, they will be more restrictive for the unvaccinated. They'll probably be less restrictive for the unvaccinated. So that's the school piece. Then it'll be interesting to hear you weigh in on this piece, but I think that the whole issue of an insurer who pays for people who have made a decision potentially or not had an opportunity to get vaccinated. For the unvaccinated people, are people going to have to deal with paying for those very high health care costs that might happen with those unvaccinated folks? I know I've heard people talk about it. I do not know where that's going to go. I think that it won't really be tolerated here in the United States. I know other countries, and I'm forgetting if it was Canada or the UK where they talked about doing that, or maybe it's France actually decided to do that. But I don't know. Do you have thoughts, Joan? I think it's going to depend on how the data shakeout. When the data is showing that, at this point, I think it's probably 95 percent of Americans are estimated to have antibodies and those data are even a little bit old. We know that your overall immune response and protection might vary based on vaccine versus naturally acquired antibodies like you got sick. I've run into people who got vaccinated and also got sick twice. We'll have to see what the data do. If the risks really start narrowing up as more and more people are exposed, then it'll become a moot question. But if we see really persistent on-going differences in risks of severe illness between vaccinated and unvaccinated, then maybe insurance companies at some point will start to do that. But I think it's really important to note that as far as I know, there's no insurance company in the US that differentiates based on whether you got your flu shot or whether really you got your tetanus or any of your other routine vaccinations. Why COVID vaccination would be treated differently than flu or tetanus or measles for that matter, is not clear. That would really set a very different trajectory for how we approach vaccination and insurance premiums in general. For the COVID piece, love to see what the data show. For the rest of it, it's like if we decide to go there, that's a slippery slope. You see how broad they go. Another question that came in pretty early is, did you feel supported by the state political leadership during your work with the state? The questioner adds with all the fractures in our culture. Here she's curious whether pre-COVID relationships between departments and organizations within the government remained professional and united given that there was some acrimony occurring over that time. That is such an interesting question. I was so appreciative and really amazed at how well the state leadership actually functioned. It was interesting because as a newbie, I walked into the organization having really no idea about how any of the agency, what, who, what? What agency? Who does what around here? But they were saying that the State Board of Education, I worked pretty closely with the State Board of Education and they were reflecting at some point, they really didn't ever talk to the Department of Public Health because they didn't really need to, and it was really great. Everybody really appreciated how much people were talking to each other. Certainly within the executive branch piece, I actually felt like there was a lot of great communication and a lot of people were really happy to collaborate and work together. Mostly because we felt like, oh my God, everybody needs us to actually work really well together. We can not do it. The level of professionalism I thought was actually quite high. Then there's how does the governor work? Legislature and that piece is a little bit more complicated. I felt like I didn't get too much heat from the legislature. I could've gotten heat from people, but I didn't particularly. There are a couple of people who asks for a lot of help for us to go talk to their communities. But I've had experience that there was a lot of contention coming from that direction. That's great. Yeah, which is nice. [inaudible] positive message. [LAUGHTER] I can only imagine how much stress and how much work the job was. Having good collegial and supportive relationships across the agency must have at least helped to make it all bearable. Let's see, to mitigate future outbreaks, if you could wave a magic wand and universally change one behavior in the population, only one, what would we all do differently? I think everybody should get vaccinated, I would probably say. If I only have one, I'm just going to say vaccinated. We are in such a different space than we used to be because of vaccines. Now, sorry, I guess actually the question was infections. Mitigate all infections, was that the question? Let's see. What was the exact wording? To mitigate future outbreaks. Outbreaks, yeah. I don't know. I still think it's vaccination. They decrease your risk of being infectious. There's all these really interesting stories now of people who are all vaccinated and boosted in the same household. One person gets it. Then everybody else doesn't test positive, but they have some symptoms that look exactly like COVID symptoms. They're not testing positive prior because they're not shedding a whole lot because their prior immunity from a vaccine is doing such a great job killing off the virus that it's giving them some symptoms. Because their immune system's actually fighting it off, but they're actually not shedding out virus to be infectious. I think the vaccine is still going to win for actually trying to decrease outbreaks. I guess, if you have number too, you'd say wear your masks. Yeah, totally. [LAUGHTER] Wear your mask in public situations. Not that I loved masks, but they're definitely better than physical distancing, shutting things down. It's certainly true. Another question just came in. Has long COVID been a consideration in all of this around school openings in the policy realm? It's a great question. The data on whether or not kids get long COVID, we don't have great data. The data we have, the best day we have, doesn't really look like kids get long COVID. Certainly not at the rate that the adults seem to get it, so I'm relatively reassured. It's certainly a discussion, but it's not something that seems to be really prevalent for the younger kids. That's just schools and that's the students' side. Then there's the teacher side, but the teacher side, I've always had a perspective like it's really important. We've got to make sure that teachers feel protected and have the tools they need to feel they're protected. Vaccines, allowing them to mask, and giving them the ability to have some control over their own classroom, which I think many places do, although there's definitely some communities that are anti-mask. In general, a teacher in that community would have a harder time. That was definitely an issue that came up sometimes, but making sure that people have their tools in order to prevent long COVID. The adults in the school setting is important too. Yeah. It's been interesting hearing about different states, what the norms are and what the policies are. We have a very good family friend who teaches in North Carolina. They were in school for the whole year that we were closed, but they had mask mandates. At least, in his district, they had mask mandates. I think they were doing half of the kids in the classroom at a time for the elementary school, so they were swapping days. Then the second year, mask became optional for the teachers. Some teachers chose to mask, some teachers chose not. Our family friend is quite young and had had COVID before he was vaccinated. Then he was vaccinated and boosted, so he opted not to wear a mask. He also is a music teacher, which is not exactly the easiest thing to be teaching masked, but no singing, no wind instruments. But there were other teachers in the school who did choose to wear a mask because of their personal decisions on their own risks. Some of the kids did, some of the kids didn't. It was really interesting hearing about just what was happening there while different things were happening here. I wish we had more data to really tease it out even further, now that we are in a largely vaccinated world. North Carolina had some great schools that actually that they came out with, which we use to help encourage people to do less physical distancing and all that. Yeah. Let's see another question. Does the prevalence of online medical records offer public health departments better access to real-time data? The questioner says, "I've heard that the CDC checks in with Kaiser Permanente on Monday to look for infection trends that they can tap into their system to look at overall trending symptoms." That is super interesting. I don't know about that Kaiser, that they're able to look into that Kaiser data systems. That's interesting, if they can. They certainly have a pretty robust reporting system for COVID in particular. They developed all these reporting systems, so there's a lot of visibility for the CDC into the state-level data. They stood up a crazy data system to try and better understand what's going on in the ground, which now of course is a little bit limited because so many people have home antigen tests, and there's no way to actually report those into the state. You have to go get a PCR test somewhere in some medical systems. I think that that level of visibility is mostly through the state ongoing access to all of the testing that happens in a medical setting or outside of a medical setting. But absolutely, I think the large access to online medical data's definitely is going to be a game changer. It's already a game changer for our ability in general to do better health care delivery and public health management. I have not heard that what the question or asked about with Kaiser potentially sharing. I'm sure, it's abrogated. Nobody's patient records are being revealed, but I had COVID not that long ago. I didn't go into their website, where they have COVID tools. You can report that you had a positive antigen test. They basically give you a page of advice. I think at my age, they basically said, call us, if you feel sicker. They didn't even want me to go in for a PCR test. They may have some information about antigen test results. Who knows how many people actually go into their medical records, and tell Kaiser that they have it. But anyway, it's just intriguing of how that shakes out. I think that maybe there is some surveillance happening there, but who knows? Yeah. Part of the discussions at some point in late 2021 I think was whether or not the State Department of Health would even accept non-PCR tests. Even it's just an antigen test done in a clinical setting, whether or not they would accept that as counting as an infection or not. They eventually were like, of course, we're going to do that, but it took a while actually for those numbers to start showing up on the state dashboards. This question of how do we know, yes or no, and where is it in our community? How do we document that is actually a really important one. Thank you so much for spending your evening with us. Thank your kids and your family for letting us get your wisdom this evening, really appreciate it. I personally really appreciate this work. I've got a bunch of friends who are teachers here in California. They are so glad to have the students back in the classroom, and in a way, that they feel confident about being able to return to teaching. On the behalf of a few friends of mine, thank you for your hard work on this, and for taking the heat, the lawsuits, and everything else. My pleasure. Thank you. Very meaningful work. Hard, but very meaningful. [MUSIC]