Keeping Schools Open in a Pandemic, School Year 2020-2021

Located on Long Island, Nassau County is home to some 1,339,532 residents. It is bordered by New York City to the west and Suffolk County to the east. Nassau County's demographic profile is 72.98% white, 11.13% black, 7.63% Asian/Pacific Islanders and 14.58% Hispanic. Children in Nassau County attend both public and private schools.  New York is home to 56 independent public-school districts with over 300 schools among them, educating approximately 200,000 students (https://data.nysed.gov/profile.php?county=28).  Each school district acts and operates independently with various administrative structures, led by a School Superintendent. School District boundaries are not aligned necessarily with geographic zip codes or towns; children from portions of zip codes may attend different school districts depending on where the lines are drawn.  School Districts are funded by residential taxes that are separate and apart from the county.  School Boards are derived and elected by the community which attends their respective School District.  While each School District wields its own powers and policy determinations, they must adhere to New York State regulations and conform to the guidelines adopted by New York State.

The COVID-19 Pandemic hit Nassau County hard in March of 2020. Nassau County Department of Health (NCDOH) responded to this unprecedented time. According to New York State Department of Health (NYS DOH), two peaks with rates over 100/100,000 people during the 2020/2021 school year including April 8, 2020 with 1592 cases and January 14, 2021 with 1858 cases (https://coronavirus.health.ny.gov/positive-tests-over-time-region-and-county).  The emergence of COVID-19 in early 2020 presented many challenges to keeping schools open, and as per an executive order by the New York Governor on March 13^th, they were ordered to close in-person teaching to stem the overflowing tide of new cases of morbidity and mortality from which the state was suffering.  To prepare for fall instruction, New York State provided guidance to schools and required a COVID-19 plan in an effort to thwart transmission for following months.  The overreaching public health challenge emerged:  How to best keep schools open during a pandemic. The model public health practice to address this challenge was coined (and still is) Real-time Epi Assessment and Decision Making with Schools (READS).

Multiple challenges existed as September instruction began. First, each School District had different policies and community interests.  Second, the science around COVID-19 evolved overtime. Third, cross-jurisdictional issues complicated school communities which relied on different transportation companies and staff from other jurisdictions.  Fourth, the county had limited resources which were stretched as a whole during the Pandemic.  Nassau County Health Department had to address these issues in a comprehensive and standardized way, as much as possible, while simultaneously being attuned to different needs of the schools over the course of the ever-changing epidemiology and policies during the year. 

The overall goal was to keep children in school during a Pandemic, limiting school closures due to high case counts. Additional objectives were 1) maintain standard messaging across all school districts; 2) provide on-going communication with school administrators and the community; 3) assess and tailor the guidance to fit the circumstances.

Objective 1 was met by creating a school liaison who was available to school district leadership, communicable disease staff who spoke often with school nurses, a health department call center who addressed hundreds of calls from the community during the day.  Communication within the health department, between the local health department and state health department, and the local health department and the school community were key components.  Collaboration was the hallmark of this effort.

Objective 2 was met by constant evaluation and interpretation of NYSDOH and CDC guidance.  This effort was conducted in consultation with NCDOH legal offices, medical personnel and epidemiologists. Direct lines of communication with stakeholders and decision makers in the schools were established to implement ever-changing policies in real-time, without bureaucratic obstacles.

Objective 3 was met by understanding the dynamic of particular school interactions, and community priorities.  Different options were provided for schools that fit both the specifics of the case and close contact relationship as well as the community's acceptance. Schools presented nearly each case/situation to the health department for consultation.

The public health impact of this practice was that schools could remain open, because case counts were not high as a percentage of the population (see data in results section).  In addition, school administrators felt that the health department was providing assistance, verification and guidance necessary as they implemented their respective plans.  Finally, no schools or school districts were closed by Nassau County Department of Health (NCDOH) during this year.

In order to address the needs of the school districts and their communities including administrators, teachers and staff, unions, transportation/food services, boards of education, students and parents, a wide community engagement effort was underway.  This was a multi-pronged approach that was only possible because of the historical relationship that the health department had in the community.  This community engagement was a collaborative effort based on regular, communication with leaders in all these sectors. For example, Nassau County leaned on its partner, BOCES, a collaborative and collective resourced body, as a vehicle to distribute information and respond to feedback. 

Nassau County, while a wealthy community includes nine underserved geographic zip codes.  These selected communities as they are collectively identified (see CHA) historically have a higher burden of disease and barriers to health care.  These issues were exacerbated during the Pandemic.  Furthermore, Nassau County Department of Health was particularly cognizant of how NYS DOH and CDC policies and guidance might affect these communities and the schools that served them.  In many situations, specific case-by-case scrutiny was necessary to deal with school issues as they intersected with mitigation of disease efforts.  For example, issues of students who resided in homeless shelters but required isolation or quarantine were addressed during the year; or difficulty with access to Wi-Fi for remote learning during periods of isolation or quarantine were tackled. 

This public health practice was new to the field of public health ironically because of its simplicity. The Pandemic required a novel mechanism to deal with immediate cases in schools.  Certainly, as the Pandemic evolved, schools were forced to be partners in controlling disease. Often school stakeholders found themselves implementing and enforcing public health, as if they were part of the health-care system rather than the traditional educational system. Real-time Epi Assessment and Decision Making with Schools (READS) allowed for direct access and evaluation of particular case/contact situations within the school environment between leadership at the health department and schools.  The evaluation was conducted within the framework of the most current guidance and an understanding of the unique school dynamic or scenario.  The assessment and recommendations could be tailored because they were not automated responses.  The schools could immediately implement the guidance knowing that their local health department supported the decision making. With each encounter, the model practice was indeed improved and standardized across the county.

School administrators, boards of education, staff, children and their parents were (and continue to be) all affected by the Pandemic. In Nassau County, there are 56 school district who serve approximately 200,000 children and 33,000 staff.  In addition, there are private schools who also serve a large swath of the population.  For this analysis, the public-school data is presented as it is more reliable and verifiable.  READS reached all (100%) public-school district administrators, their respective school administrators and bus service directors.

How to best keep schools open during a pandemic was debated throughout the county over the course of the following school year.  The scope of the problem was vast, and causes were many. As the Pandemic was rolling in at an alarming pace in NY in the Spring of 2020 with ensuing fear and panic, the stage was set for uncertainty the following school year. First, each School District had different policies and community interests. School Districts worked within the framework of the New York State guidance to improve social distancing by designing different classroom experiences and dynamics. The systems that were put into place needed to be acceptable to the community in which they resided as well as approved by their respective boards of education. Furthermore, these plans needed to address the issues of isolation and quarantine as actions necessary for exposures. While Nassau County Health Department did provide some general guidelines and FAQs, the county was well-aware that each case and school community was different and would impose varied methods to improve social distancing. To reduce exposure. Therefore, Nassau County Department of Health was poised to tailor recommendations to both ensure each school communities' health and simultaneously be as acceptable to the community as possible. Actions attempted be tolerable to the community, or enforcement efforts would have their own challenges. One size did not fit all.

Second, the science around the COVID-19 evolved overtime. What we knew and learned about infectious periods and incubation timing changed. Laboratory testing also changed in availability and speed with PCR remaining the gold-standard, but rapid testing provided important information which could mitigate transmission through immediate quarantine. Limitations regarding the sensitivity and specificity of rapid antigen testing and the time to perform molecular test complicated the problem. Early-on, variants emerged which required quicker action on the part of schools and health departments to identify, contact trace and quarantine. Now, variants are more commonplace and expected. Due to the increasing scientific evidence and technology, CDC and New York State guidance continuously changed, but not always at the same time. New timelines, restrictions, special classifications such as essential workers and healthcare providers, and travel orders contributed to confusion on the part of the schools and the public. Therefore, Nassau County Department of Health recognized that it needed to be a singular resource to interpret the guidance and standardize process for the school community as best as possible.

Third, school communities are a function of cross-jurisdictional components.  While children often are from a common geographic area, staff are not and hail from neighboring areas.  Different areas across the county had different rates of infection at different times and so, understanding geographic boundaries was necessary, but recognizing that these boundaries had many access points was more important.  Further, different transportation companies fed into different schools, crossing not only school districts, zip code boundaries but also different counties. The cross-jurisdictional nature of the schools and their constituents posed challenges when notification and policies were concerned. Nassau County Department of Health sought to provide classroom and bus guidance to schools located within the borders of the county regardless of where the students may live.    

Overall, this situation, was unprecedented and so little can be said about what historically had been implemented.  The health department would speak and consult with school districts as it related to various reportable communicable disease if it affected their community.  Notifications to schools with collaboration from the local health department is not a new concept.  But, in the case of the Pandemic, the school administrators were burdened with making the decisions, doing preliminary case-investigations and contact tracing in real time on behalf of the health department and as required by various executive orders from NYS.  They required consultation to understand the distribution of disease within their school, classroom and the questions necessary to determine others as risk.  Especially, as the school year began in Fall 2020, educators needed to be educated in epidemiology, on-the-job training.  And, this had never been done.

This program particularly addressed health inequities.  The virus had the potential to infect all.  But the virus was more dangerous to those who had underlying comorbidities.  And those with underlying health issues and who had less access to health care were even more at risk for poor results. This was true in terms of treatment for COVID-19 but also for vaccination rates due to hesitancy among different populations for different reasons.  Therefore, the collaboration between the schools that served vulnerable populations and the health department providing guidance required additional efforts.  Examples of actions taken on behalf of the health department and schools included finding temporary housing and food for families with children during periods of isolation or quarantine, coordinating social services from the schools to identify needs, providing testing services to families at risk or who were suspected to have COVID-19, providing vaccination PODS in underserved communities and disseminating information to schools and finally assisting the schools in these communities to implement the latest school guidance.

Principles of health equity were sewn into this practice:  Case investigation data included demographic questions, including race and ethnicity, and increased needs for community support.  Schools were uniquely aware of household circumstances that required additional efforts on behalf of the schools and relayed to the health departments.  Schools utilized their community in much of the decision process as possible.  Different guidance precluded some choices in this regard, but as much as possible their communities provided feedback to the schools and the schools provided it to the health department. The health department utilized information to address existing policy gaps.  Information became clear that some communities did not have access to care or were not given the appropriate education regarding vaccinations and treatment and so additional outreach was extended. 

As described above, this practice was novel in that never before had school districts operated in the domain of public health to the degree that they were required. In order to do this, they needed not just the support of the local health departments, but comfort and confidence to make these decisions with the continuity of direct guidance that was practical and specific to their scenarios. The easy access that the schools could simply pick up the phone and describe case/close contact scenario was credited with being novel.

The current practice is evidence-based as per these current results.  Additional analyses will be submitted for publications, but the NACCHO Model Practice Award allows for the first discussion of this project and results from the 2020-2021 school year.

The overarching goal was to keep children in school during a Pandemic, limiting school closures. Additional objectives were 1) provide on-going communication with school administrators and the community; 2) maintain standard messaging across all school districts; 3) assess and tailor the guidance to fit the circumstances.

Objective 1 was met by creating a school liaison who was available to school district leadership, communicable disease staff who spoke often with school nurses, a health department call center who addressed hundreds of calls from the community/day.  Communication within the health department, between the local health department and state health department, and the local health department and the school community were key components.  Collaboration was the hallmark of this effort. Specific steps included identifying a small group of individuals who would provide guidance to the schools in different capacities.  School liaison spoke with administrators; clinical team spoke with school nurses; and a call center staffed with customer service-oriented health department representatives spoke to much of the public. Because the group was small; the messages could be clear. Phone numbers and contact information were made available and were the main conduit of communication.

Objective 2 was met by constant evaluation and interpretation of NYSDOH and CDC guidance.  This effort was conducted in consultation with NCDOH legal offices, medical personnel and epidemiologists. Direct lines of communication with stakeholders and decision makers in the schools were established to implement ever-changing policies in real-time, without bureaucratic obstacles. Specific steps included taking the time to perform detailed reading of the guidance documents. Discussion with NYS representatives and diagramming policies assisted in this effort. Health department staff collaboration and meetings when available assisted with final interpretation of the information.

Objective 3 was met by understanding the dynamic of particular school interactions, and community priorities and was the key to this practice.  Different options were provided for schools that fit both the specifics of the case and close contact relationship as well as the community's acceptance as much as possible. School Districts employed different plans and designed systems dependent on staff, space and community engagement. As a result, Nassau County offered different recommendations for isolation and contact tracing to adjust to different scenarios. The following models were utilized by different school districts' plans in operation.

MAXIMUM SOCIAL DISTANCING (MSD): With space permitting, all students were in class at the same time where desks are six feet apart; students and staff maintained excellent mask compliance with controlled mask breaks; teachers remained at the front of the class; limited movement occurred within the class; desk barriers provide protection during lunch; regular sanitization and cleaning of the rooms were scheduled. In the event of an exposure, only the case would be isolated; individuals who had close contact with the case would be quarantined but not the class. Examples of individuals with close contact could include friend that traveled to school with the case, or friend that worked closely with the case on a project. Essentially, these are name individuals who spent 10 to 15 minutes with the positive case.

HYBRID CLASSROOM (HC): When space was an issue, some classrooms in order to achieve MSD, would only instruct half the class in-person at a time, and the balance of the class would be do remote learning. With the same safeguards in place as described above, limited class quarantining would be necessary. In the event of an exposure, only the case would be isolated; individuals who had close contact with the case would be quarantined but not the class. Examples of individuals with close contact could include friend that traveled to school with the case, or friend that worked closely with the case on a project. Essentially, these are named individuals who spent 10 to 15 minutes with the positive case

COHORTED CLASSROOM (CHC): Very often, especially in elementary schools, the same children and teachers remained in the same classroom for the entire day. When social distancing did not meet the six feet distance and/or mask compliance was not well controlled, then the cohort option could preserve other classes in the school from being included. In the event of an exposure, the case would be isolated, and two quarantine methods could be used for the remaining close contacts. One method recommended was that the entire class could be quarantined, in addition to any individual close contacts identified, as these individuals spend much time in one space together. The second method was that a radius could be drawn around the positive case and those who sat 6 feet or closer would be quarantined, in addition to any individual close contact identified. The caveat in the latter method, was that the positive case might be identifiable. In many situations, the positive case had self-disclosed on social media and so the school administrators felt as if they were not breeching any personal information; and they were simultaneously able to preserve the rest of the class for in-class instruction. If the teacher was the positive case, and did remain in the front of the class, then the class could remain in-person, or the first row of children could be quarantined. This method required a seating chart. Some communities preferred this method, so fewer students are quarantined. Other communities preferred anonymity is maintained.

Special circumstances encountered that exemplified specificity of recommendations by Nassau County Health Department were the following. Last year, we learned of special scenarios where despite social distancing and masking, additional steps were necessary to mitigate transmission of COVID-19. Classes that work with children with special needs provided an example. In this classroom, sometimes mask compliance and social distancing was difficult to achieve and therefore in addition to the positive case isolated, the whole class would be quarantined as well. Often, multiple staff also are present in these classes, and so such quarantining would expand to other colleagues that work in the classroom. Indoor music classes with wind or brass instruments or chorus groups also required quarantining either of the whole class or utilizing the radius method. Individual one-on-one circumstances often result in identified close contacts. For example, guidance counseling sessions, reading support sessions, occupational therapy sessions or other opportunities for extended and engaged conversation and time would constitute close contact, even with times of shorter duration. In the situation of kitchen or cafeteria staff who test positive, Nassau County Department of Health recommended quarantine of colleagues, not students. Staff to staff transmission was more likely than any transmission from staff to students. While COVID-19 is not considered a food borne disease and generally transmitted from person to person not via food as a vector, these cases were routinely transferred to food protection as well. Similarly, custodial staff who test positive, often require additional quarantining of other selected custodial staff. This contact tracing required an understanding of where and when these interactions may have taken place. Often the custodial staff shared a similar lunchroom or maintenance area where transmission was identified. Administrative staff who share a suite or similar space needed to quarantine. Often this scenario was similar to a cohorted class and was compounded by frequent communication and engagement among adults who shared information regularly. This was particularly problematic when they were responsible for school operations.

Bus safety and protocols were considered good when the buses were at least 50% capacity, and the children were compliant with masking. Some districts could use video to determine close contacts and confirm behavior. Transmission was evident between bus drivers and bus attendants and therefore almost always warranted quarantine. Communication to bus companies notifying of a case was important so that the companies were made aware in real-time, for the safety of their employees.

Extracurricular activities often presented opportunities for transmission of disease. This was evident in certain sports where mask-wearing was not enforced and/or the sport occurred indoors, and quarantining was more likely. Careful scrutiny of sport rosters often identified additional positive cases in these circumstances. Outdoor soccer and lacrosse where social distancing was maintained on the sidelines did not warrant additional quarantine, in general, whereas, ice-hockey, and indoor lacrosse did see transmission, for example. Once NYS issued guidance for high-risk sports and allowed it to occur, Nassau County supported School Districts self-determination. That led to a variety of safeguards to be set in place including increased remote learning, routine surveillance testing, and smaller within-team squad formations. In addition, often individuals who played sports together often socialized together as well, and it was the social experience—the parties and get-togethers, where transmission is occurring. Repeatedly, Nassau County counseled the public to refrain from reckless get-togethers. Socializing was not unique to children; many staff socialize out-of-school and therefore these gatherings were sources of transmission. In some situations, the schools facilitated this close contact identification off-campus.

While this practice is ongoing, this analysis covers the time frame from September 1, 2020, to June 28, 2021. 

Nassau County involved the schools and their respective school communities as stakeholders.  The practice was predicated on the mutual respect and exchange of information and could not have achieved success without.  In order to address the needs of the school districts and their communities including administrators, teachers and staff, unions, transportation/food services, boards of education, students and parents, a wide community engagement effort was underway.  This was a multi-pronged approach that was only possible because of the historic relationship that the health department had in the community.  This community engagement was a collaborative effort based on regular, communication with leaders in all these sectors. For example, Nassau County leaned on its partner, BOCES, a collaborative and collective resourced body, as a vehicle to distribute information and respond to feedback. School superintendents regularly called to understand the latest policy and how to implement it for their community—when to make larger notifications or pivot a classroom to remote learning.  Nurses and Principals called to discuss specific contact tracing issues.  Bus company coordinators called to often describe issues of travel across multiple jurisdictions and how to properly identify cases and quarantine.  Nassau County Department of Health coordinated with NYS DOH and neighboring counties including NYC who often followed different protocols from the rest of the state.

Collaboration was fostered first by necessity.  NCDOH needed the partnership with the schools to carry out the executive orders and the schools needed the health department to assist in their decision making.  Quickly, the relationship between the schools and the health department was mutually beneficial. NCDOH assisted with the schools' communications to their community of parents and staff.  District administrators were forthcoming with details because they were aware and fearful of bad outcomes, as this was unchartered territory; they knew that NCDOH would help to support their decisions. They received timely responses from Nassau County so that quick but thoughtful decisions were possible.  The relationships were easy and therefore self-perpetuating. 

All schools had the opportunity to participate in this effort.  The public schools were organized with strong leadership and therefore were prepared—and the health department continues to have strong relationships with all of them (100%). 

In-kind costs covered this effort, as all other health department work was suspended during this year.   

During the 2020-2021 school year, Nassau County Department of Health learned that schools could remain open with proper protocols in place and with directed real-time guidance from the local health department.  School Districts felt supported in carrying out the executive orders from the state in a way that best fit each and every scenario. 

The overarching goal was to keep children in school during a Pandemic, limiting school closures. Additional objectives were 1) provide on-going communication with school administrators and the community; 2) maintain standard messaging across all school districts; 3) assess and tailor the guidance to fit the circumstances.

Objective 1 was met by creating a school liaison who was available to school district leadership, communicable disease staff who spoke often with school nurses, a health department call center who addressed hundreds of calls from the community/day.  Communication within the health department, between the local health department and state health department, and the local health department and the school community were key components.  Collaboration was the hallmark of this effort. Specific steps included identifying a small group of individuals who would provide guidance to the schools in different capacities.  School liaison spoke with administrators; clinical team spoke with school nurses; and a call center staffed with customer service-oriented health department representatives spoke to much of the public. Because the group was small; the messages could be clear. Phone numbers and contact information were made available and were the main conduit of communication.

Objective 2 was met by constant evaluation and interpretation of NYSDOH and CDC guidance.  This effort was conducted in consultation with NCDOH legal offices, medical personnel and epidemiologists. Direct lines of communication with stakeholders and decision makers in the schools were established to implement ever-changing policies in real-time, without bureaucratic obstacles. Specific steps included taking the time to perform detailed reading of the guidance documents. Discussion with NYS representatives and diagramming policies assisted in this effort. Health department staff collaboration and meetings when available assisted with final interpretation of the information.

Objective 3 was met by understanding the dynamic of particular school interactions, and community priorities and was the key to this practice.  Different options were provided for schools that fit both the specifics of the case and close contact relationship as well as the community's acceptance as much as possible. School Districts employed different plans and designed systems dependent on staff, space and community engagement. As a result, Nassau County offered different recommendations for isolation and contact tracing to adjust to different scenarios. The following models were utilized by different school districts' plans in operation.

Percent of public-school cases due to COVID-19 remained relatively low throughout the year.  This data used was publicly reported to NYS DOH directly from the 56 school districts (webpage) between September 1, 2020 to June 28, 2021. This data was supplemented by Nassau County DOH case investigation reports which also indicated school name.  When discrepancies between the two existed, the total count that was higher was used in an effort to decrease bias for underreporting. 

Results were the following:  56 school districts with 307 schools reported. The percent positive was calculated by number of school students testing positive/total school student population per building, as a percent.  These percents were averaged across all schools. Differences in means were calculated using the student's t-test.  The average percent of students positive was similar between school district report and case investigation report (6.09% vs 6.14%, p=0.15); therefore, the dataset with the larger values was included.  The average percent of students of the student population was 6.14% (std 3.19%) and was significantly different from the average percent of staff of the total staff population of 10.14% (std 4.68%), p<0.05. When separated by type of school, whether elementary, middle, or high school, elementary schools had the lowest average percent positive, followed by middle and then high school. All average percentages were significantly different, p<0.05, from each other:  elementary schools (5.36%, std 2.56%), middle schools (6.24%, std 2.91%), high school (8.45%, 5.17%).  When evaluated by school district including staff, the average percent positive was 7.43%, std 2.26%. 

By these calculations, the average percent of students testing positive during the whole year was small.  Throughout the country, many cities and communities chose solely remote learning.  Nassau County did not.  Schools remained open throughout. Furthermore, Nassau County Department of Health did not officially close any school or school district during the 2020-2021 year.

This READS program is sustainable because it already has been sustained.  It is also sustainable because it continues to be necessary.  The cost is the staff time dedicated to the efforts; and certainly, organizational structure could be modified in order to continue the work in this arena.  Other circumstances, as we move out of COVID-19 emergency mode, would also benefit from the relationship that Nassau County Department of Health has built.

Lessons learned from the practice included the following:  There were a wide range of methods by which schools planned within COVID-19 guidance and that the health department needed adapt recommendations to suit their needs. NYS DOH and CDC guidance was not a one size fits all framework.  In addition, much of the guidance contradicted each other and therefore, flexibility and interpretation were necessary during this aspect of the response. Cell phone communication was key during this response because administrators could make inquiries 24/7 and receive responses.   Understanding the current regional epidemiology as well as knowledge regarding the school disease distribution was central to recommendations. Complete case investigations and contact tracing reports were important for decision making; in some cases, school reports were more complete and had to supplement case information as the volume of cases increased from time-to-time during the Pandemic. Communication among Nassau County Health Department staff was necessary in order to message the latest information from state guidance to schools. 

Lessons learned from practice in relationship to the school partners were the following:  The health department provided the opportunity for the school to talk through a case.  A description of the story surrounding the case and the case's interactions often revealed who the close contacts appeared to be.  Using the health department as a sounding board with the proper questions from both the department and school demonstrated what protocols worked, what protocols may have been breached and next steps.  Each individual story also provided evidence and information for the next example and best practice.  Both the schools and the health department learned together the best approaches. Schools and their communities were individual.  While a standardized approach to case investigation and contact tracing is necessary across the region; there is space for adaption and modification.  The schools felt that they had some flexibility and ultimately were responsible for their decisions, but they made them in collaboration with the health department. Busing was key factor to consider in the discussion; and while the details of the transportation was important the bus company emerged as a partner. The bus coordinators, dispatchers, drivers and aides, required notifications and often were sources of information which improved contact tracing. As the year progressed and the community rates increased, the school's numbers of cases reflected the uptick.  Therefore, the number of cases within a classroom required comparison to community spread in order to determine if transmission was due to the school setting.  Under most situations, social connections were the major source of case-to-case transmissions.  Quarantine and isolation time required some explanation. Simply how to count days from last day of exposure for quarantine was an important concept that some schools struggled to understand. While this concept is obvious to those in public health; it was not so easy to understand for many.  Exposure to the positive case might be last day of school for some, or last time children were socializing together.  That last day of exposure was considered day 0,” and then the first day of quarantine the following day, day 1,” and then quarantine was in place through (not to) day 10.”  Looking back at infectious window of 48 hours prior to symptom onset or the collection date of the specimen, the day of the doctor's visit, also required an understanding length of potential exposure.  Furthermore, extension of quarantine for household members who could not properly separate from the case, became necessary in some circumstances.  School nurses and administrators often knew of these situations and required the support of the health department to lengthen quarantine time an additional 10 days post end of the positive case's isolation.  Finally, additional school exposures were mitigated by sending the message home to not attend school awaiting a test result.  While it seems like an obvious direction, many health care providers used both antigen and PCR tests at the office visit, and when the antigen test was negative student came back to class that same day.  PCR tests which are more valid and sensitive, would indicate a positive result but that finding was often reported days later, after an unintentional exposure occurred.  For the most part, internal school-related labor disputes remained within the school.  However, two specific issues arose that required the health department to adjust its methods.  One challenge surrounded teacher unions which promulgated misinformation that any contact was a close contact.  To address this, additional education was necessary to differentiate that not all contacts in school required quarantining.  The health department did its best to quiet fears among teaching staff while also and simultaneously addressing complaints lobbed at schools.  Administrators were called to ensure that contact tracing was occurring with a deft approach and staff and students were appropriately quarantined if truly deemed as close contacts.  For proper use of sick time, NYS made provisions and executive orders to allow staff 10 days of quarantine time.  In order for schools to have proper verification they required confirmation from the health department of such orders of quarantine or isolation. However, due to a multitude of reasons, staff may not have had contact with Nassau County Department of Health, reasons ranging from laboratory posting issues and timing of notification to the failure to reaching individuals due to phone number errors.  The health department knew that a lack of communication with each and every case should not negate the importance and necessity of quarantine and isolations, whether confirmed or not by the health department.  Therefore, the health department established a link on its website which would ask the case or contact to attest to the quarantine or isolation and provided the proof needed for demonstrated and approved leave.

Lessons learned from the practice in relationship to community engagement were the following:  The schools provided the best proxy for understanding the community's response and acceptance to the collaborative decision making that was underway.  Compassion for children and staff who had to isolate, or quarantine was required.  This program was trying to improve public health, and there is often a disconnect between public health and personal health.  As guidance was ever-changing from NYS DOH and CDC, it was natural for the public and community to be confused.  Frankly, at times we as the local health department were confused.  Nevertheless, we had to do our best to interpret and make reasonable decisions that provided the clarity and consistency. Had time been available for longer and engaged communication with parents at board of education meeting, perhaps some of the confusion in the public could have been mitigated.  Unfortunately, due to the volume and priorities of the health department as leading the effort in the Pandemic, that type of engagement was not possible on a large-scale basis.  National politics became an obstacle in the community over the course of the year.  The schools and the health department had to navigate resistance to the guidance.  As result the health department learned that education, patience and supporting the school administration were necessary to execute the guidance and mitigate risk.

There is definite stakeholder commitment to sustain this practice and NCDOH has learned that this now very strong connection with the schools as partners can be adapted to other situations.  Because of COVID-19 response and the schools' regular implementation of these policies, they are better poised to deal with other public health issues.  One recent example was a notification that was made to a school regarding another reportable disease (tuberculosis). While this notification and communication was always necessary, this time, since the Pandemic, there was a stream-lined flow of information.  It was quick; the community's understanding was measured; and a statement that would be best accepted and least alarming in terms of messaging was developed in collaboration with the school district.

Sustainability plans include the continuation of Nassau County Department of Health's commitment to the schools individually, as an entity and to the community.  From an organizational perspective, the liaison position to the schools has been maintained. Furthermore, sustainability plans include maintaining relationships and updating contact information as personnel changes.  And finally, the school organizations have continued to invite and appreciate the health department's participation in their meeting and advisory structure.