The National Association of Pediatric Nurse Practitioners (NAPNAP) strongly urges multi-modal COVID-19 mitigation strategies to support return to in-person education for all students pre-K to grade 12.

These strategies are essential as pediatric cases continue to rise, with a 1,000% increase since spring 2021. The COVID-19 public health crisis has been associated with asymptomatic and acute, sometimes severe life-threatening, COVID-19 illness in children and adolescents, disproportionally impacting underrepresented populations. Post-infectious multi-system inflammatory syndrome (MIS-C), often associated with critical illness, typically impacts children who reported asymptomatic or mild COVID-19 infection or those that were completely unaware of their COVID-19 infection. More recently, pediatric post-COVID syndrome, or COVID long haul syndrome has increasingly been identified in children.

The hypertransmissable Delta variant is more contagious and spreads faster than prior forms of SARS-CoV-2 calling for comprehensive, sustained methods to combat this illness and protect children from harm. Key priorities in returning kids to in-person education include child safety, equitable access to education, mental health services and social health safety nets.

The proportion of children ineligible for vaccination due to age, combined with children that are at high risk for disease complications (e.g. immunosuppressed, chronic health conditions, obesity, etc.) accentuates the need for preventative efforts. Prioritizing a safe return on in-person education fosters much needed interpersonal communication, educational resources and identification, and application of additional services and support that are needed by students. Stringent strategies are essential to reduce risk for transmission and illness among students, staff and school visitors to maximize safety among in-person learning.

Vaccines are proven to be safe and effective and are a critical mitigation strategy for vaccine-eligible individuals. Individuals that are not yet eligible for vaccines can be afforded some protection when surrounded by fully vaccinated individuals in their homes and schools; known as herd immunity. Vaccination optimization must be used in conjunction with other strategies, including universal masking, physical distancing and hand hygiene to reduce transmission risk.

Not only has COVID-19 impacted the physical health of children, the toll on children’s mental health is extraordinary.  A recent study suggests that, globally, 1 in 4 youth experienced elevated depressive symptoms and 1 in 5 youth experienced elevated anxiety symptoms in the first year of the pandemic (Racine et al., 2021). These numbers are a call to action for addressing mental health in children. The combined burden on physical and mental wellbeing associated with COVID-19 requires comprehensive, sustained efforts to prevent disease in children and to identify children suffering from associated impacts on mental health and well-being.

NAPNAP seeks to partner with families and schools to educate and support best practices for optimal child physical and mental health in conjunction with return to in-person learning. We recommend the following strategies:

• Prompt and complete vaccination of:
  • All eligible children ≥ 12 years of age
  • All eligible family and household members
  • All eligible school faculty and staff members
• Availability of on-site school vaccination programs to promote student and family vaccination
• Universal masking for vaccinated and unvaccinated students, teachers, staff and visitors on school campuses
  • Appropriately sized and applied masks covering both nose and mouth
  • Accessibility to masks for all students, including pediatric sized masks for younger groups
• Widely accessible hand washing/sanitizing stations with required hand washing/sanitization after meals, cough, sneezing
• Physical distancing of at least 3 feet as allowable by school footprint, in addition to mask wearing
• Optimized ventilation systems
• Routine symptom surveillance coupled with strict policies to keep children and school staff home when ill with referral to health care provider for evaluation and testing
• In-school mental health/depression screening for all children and tools to engage in appropriate resources
• COVID-19 testing for all symptomatic students/school staff and testing of fully vaccinated individuals with known exposure to someone with documented or suspected COVID-19 3-5 days post-exposure regardless of symptoms
• Schools need to have policies and procedures for regular cleaning and disinfecting of all areas of the building
• Schools should not encourage families to seek a health care provider’s letter to exempt a child from wearing a mask unless the child meets the very limited criteria set forth by the CDC

Pediatric nursing professionals are essential resources in addressing parental and educational leader concerns about disease transmission, vaccine safety and pediatric mental health. Dispelling misinformation with reliable information sources using clear and understandable language to families and educational leaders is critical. Because of varying state, local and school district policies, we encourage health care providers and families to directly advocate on behalf of their children’s health and well-being by sharing evidence-based information with local officials and school leaders.

• Vaccines are safe and effective in reducing transmission and severity of COVID disease
• Vaccines are free to all eligible individuals, regardless of insurance coverage, at all points of vaccine distribution
• Vaccination should be made widely available and administered to stop the spread of the virus for eligible students ages 12 and older
• COVID-19 vaccines may be safely co-administered with other vaccines (e.g. flu, other)
• Without current vaccine eligibility for all school-aged children, it is imperative that we maintain the best defense against the spread of COVID-19 by wearing appropriately sized masks, keeping a social distance of at least 3 feet when in an enclosed space and continuing to promote proper hand hygiene for everyone in the school environment.

As experts in pediatrics and advocates for children, NAPNAP supports comprehensive multi-modal strategies to promote safe return to in-person education. Continuous evaluation and evolution of the COVID-19 virus and its mitigation strategies will continue to inform best practices and recommendations.  NAPNAP’s commitment accessible, equitable care for all children can be accessed through the NAPNAP’s COVID resource page. We further call for inclusion of pediatric-focused advanced practice registered nurses (APRNs) as crucial contributors to these multi-modal life-saving efforts.

Download our templated letter for HCPs to send to local officials advocating for evidence-based mitigation strategies.

Download our templated letter for parents/caregivers to send to local officials advocating for evidence-based mitigation strategies.

References:

• American Academy of Pediatrics and Children’s Hospital Association. Children and COVID-19: State-level data report. https//services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
• Bloomberg, B., Mohn, K.GI., Brokstad, K.A., .. & Langeland, N. (2021). Long COVID in a prospective cohort of home-isolates patients. Nat Med. https://doi.org/10.1038/s41591-021-01433-3.
• Centers for Disease Control and Prevention [CDC] (2021). Delta variant. https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-variant.html
• Centers for Disease Control and Prevention [CDC] (2021). Guidance for COVID-19 prevention in K-12 schools.  Guidance for COVID-19 Prevention in K-12 Schools | CDC https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html
• Racine, N., Arthur B.A., Cooke, J.E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19 A Meta-analysis. JAMA Pediatr. doi:10.1001/jamapediatrics.2021.2482, E1 – E9.
• Saatci, D., Tanger, T.A., Garringa, C. et al. Association between race and COVID-10 outcomes among 2.6 million children in England. JAMA Pediatr. Published online June 21, 2021. Doi:10.1001/jamapediatrcs.2021.1685

Aug. 16, 2021