Abstract
In this case study, we describe a well-resourced private school in New York City that implemented COVID-19 mitigation measures based on public health expert guidance and the lessons learned from this process. Avenues opened in New York City in 2012 and has since expanded, becoming Avenues: The World School, with campuses in São Paulo, Brazil; Shenzhen, China; the Silicon Valley, California; and online. It offers education at 16 grade levels: 2 early learning years, followed by a prekindergarten through grade 12. We describe the mitigation measures that Avenues implemented on its New York campus. We compare COVID-19 case prevalence at the school with COVID-19 case positivity in New York City, as reported by the New York State Department of Health. We also compare the school's indoor air quality to ambient indoor air quality measures reported in the literature. The school's mitigation measures successfully reduced the prevalence of COVID-19 among its students, staff, and faculty. The school also established a consistently high level of indoor air quality safety through various ventilation mechanisms, designed to reduce common indoor air pollutants. The school received positive parent and community feedback on the policies and procedures it established, with many parents commenting on the high level of trust and quality of communication established by the school. The successful reopening provides useful data for school closure and reopening standards to prepare for future pandemic and epidemic events.
Introduction
This case study describes the COVID-19 mitigation measures undertaken by the New York City campus of a private school, Avenues: The World School, and discusses how the school population's experience with COVID-19 differed from other schools in the New York City metropolitan area. Given the scarcity of data about COVID-19 mitigation measures undertaken by other schools, it is impossible to determine with certainty that Avenues New York's package of measures alone led to a lower, more favorable case rate. However, this case study is useful for comparing different schools and providing insights for future pandemic planning initiatives related to schools and educational systems.
Avenues opened in New York City in 2012 and has since expanded, becoming Avenues: The World School, with campuses in São Paulo, Brazil; Shenzhen, China; the Silicon Valley, California; and online. This case study focuses specifically on the mitigation measures undertaken by the Avenues New York campus from March 2020 to January 2023. Avenues New York is a private school that opened in 2012, with 16 grade levels encompassing students ages 2 to 18 years, with a total of about 1,700 students for each of the 2019-2020 and 2020-2021 school years. The school kept records of all mitigation measures implemented throughout the 2020-2021, 2021-2022, and 2022-2023 academic years, with multiple forms of measurement taken to gain real-time information on how the mitigation measures were working; as such, the school's experience offers multiple examples of how to respond to infectious disease threats. We examine indoor air quality (IAQ) measures, testing and tracing mechanisms, masking policies, ventilation procedures, and other interventions. Our findings can help develop IAQ guidelines for public spaces, as well as long-term strategies for reopening access to education during future epidemics and pandemics.
This case study adds to the emerging picture of how COVID-19 affected the health and education of children. The COVID-19 pandemic led to disruptions in access to education and public school-based services in the United States and around the world.1-4 Many areas of the United States instituted lockdowns and school closures as cases began to rise, but school closures, virtual learning, reopenings, and COVID-19 mitigation measures differed from one district to another for both public and private schools, even within the same state. New York's state government announced the closure of its public schools in mid-March 2020 following the rapid rise in COVID-19 cases during the initial stages of the pandemic, and by May 1, 2020, it moved to full closure for the remainder of the academic year.5,6 New York City Mayor Bill de Blasio also ordered the city's schools to close in mid-March 2020 and decided to keep them closed through the academic year in mid-April 2020, prior to state closure orders. 7 While technically operating under the New York state government, the city controlled much of its own pandemic policy for education.5,6
Schools in the United States, and by extension in New York State, used highly variable mitigation measures. They were also subject to national and state guidance and restrictions on reopening, including measures required for schools to successfully reopen. Universal masking was frequently implemented, often with specific mask grade requirements (eg, N95, KN95, surgical grade) as guidance was updated, to improve mask efficacy.8,9 COVID-19 testing at schools varied widely, from requiring a negative antigen test to return to school, to school-mandated polymerase chain reaction (PCR) and antigen testing multiple days a week for the entire school population. Indoor air measures often included deploying indoor air purifiers, upgrading heating, ventilation, and air conditioning (HVAC) filters to higher minimum efficiency reporting values (MERVs), installing ultraviolet germicidal irradiation, improving window and door ventilation, and implementing social distancing measures. Since the onset of COVID-19, we have learned that high efficiency particulate air (HEPA) filters, natural ventilation, and more sophisticated indoor ventilation systems are effective mechanisms for decreasing airborne transmission of SARS-CoV-2.9,10 While these mitigation measures are most effective when combined with mask-wearing, proper IAQ maintenance alone, when accurately measured and consistently implemented, can act as a sufficient intervention to decrease SARS-CoV-2 transmission.8,9,11-13 Vaccination became required after a certain period for many schools, first for teachers and adult staff, 14 and then for children15,16 as COVID-19 vaccines were approved for these populations by the US Food and Drug Administration and recommendations were provided by the US Centers for Disease Control and Prevention (CDC). A meta-analysis of the safety and efficacy of COVID-19 vaccines in children clearly indicates that the vaccine is both safe and effective. 17
Multiple papers have suggested that without robust mitigation measures, COVID-19 prevalence in local communities could accelerate through the reopening of schools.18-20 Because COVID-19 was perceived to pose relatively fewer risks to the health of children compared with adults, it was initially believed that schools would not significantly contribute to community transmission. However, research has since indicated that school closures are associated with a reduction in R0 values for COVID-19 transmission and that the prevalence of infection among different age groups increased after school reopening, particularly after short-term school holidays.18,21 A 2022 systematic review found that measures fell into 4 major categories: (1) measures reducing the opportunity for contacts, (2) measures making contacts safer, (3) surveillance and response measures, and (4) multicomponent measures. 21 The combination of broad measures implemented in school settings, when evaluated together, were found to be effective; however, specific studies disentangling various combinations of measures and quantifying the efficacy of individual interventions were not found.
An agent-based modeling study conducted in Indiana found that schools with multiple mitigation measures often maintained lower levels of transmission, similar to a scenario with fully remote learning. 22 The model accurately represented the effect that school reopening had on SARS-CoV-2 transmission in that state, with the worst impacts on local communities and adult staff. A case study of community-based school reopening in Seoul, Korea, described the implementation of multiple layered safety measures, including masking, frequent disinfection, desk spacing, thermal imaging, improved ventilation measures, and active case monitoring. 23 A similar case study conducted in Rio de Janeiro, Brazil, examined a PCR-based pool testing strategy, finding that pool testing, in combination with measures such as masking, increased hygiene, and contact mitigation, could be an effective reopening strategy due to the very low prevalence rate found in widespread testing of 1,500 individuals. 24 Additionally, a study examining the association between ventilation and SARS-CoV-2 transmission in Marche, Italy, found that with mechanical ventilation, the relative risk of infection decreased by at least 74%, which validated the need for high IAQ to reduce the risk of airborne disease transmission. 25
Avenues Reopening Strategies for Student, Faculty, and Staff Safety
2020-2021 School Year
Prior to reopening, Avenues: The World School established a global pandemic team and actively sought input from leading researchers and operators at the Harvard Medical School, Johns Hopkins Center for Health Security, Indoor Science, and Corsi Indoor Air Quality. The school also followed the protocols for IAQ set by the Healthy Buildings program at the Harvard TH Chan School of Public Health and worked closely across departments to set testing requirements, vaccination guidelines, and operational protocols across its New York, São Paulo, and Shenzhen campuses, with an additional satellite campus opened in East Hampton, New York, for approximately 100 students during the 2020-2021 school year. The reopening strategy was summarized as a multilayered strategy to reduce the transmission of COVID-19, as depicted in Figure 1.
A visual overview of the multilayered strategy to address system vulnerabilities to SARS-CoV-2 infection and transmission, used by Avenues New York.
The school reopened in September 2020, offering in-person instruction to all grades. Upper-division students were offered a flexible education wherein they could attend classes remotely or in person for some days as part of the standard Avenues Campus Flex program. This program allows students to engage in project-based learning, such as external research or fieldwork outside of the classroom. Students were placed into self-contained classrooms with a nonmixing, pod-based strategy of roughly 18 students per pod; students were not to mix with students or teachers outside their designated pod to minimize intermingling, limit onward transmission, and enable better contact tracing. Universal masking requirements, arrival checks to prevent symptomatic individuals from entering the building, and COVID-19 testing measures were implemented for all students, faculty, and staff. Point-of-care testing on campus was administered by the health office or operations team members trained in administering rapid tests. Weekly PCR tests were swabbed at home and brought to school for testing in pools.
All students, faculty, and staff also needed to clear a daily COVID-19 screening through the QT app developed by the school, which would permit them to enter the building. This app was originally designed as a geofence feature that would notify the school when a parent was within a certain radius of the school for student pickup, reducing unnecessary congestion and student density at previously high-traffic times; however, it was eventually modified to allow entrance based on COVID-19 symptom screening. Answers that indicated a possibility of COVID-19 infection generated a red square, while cleared students received a green square with a QR code; without the green QR code, entry to the school was not possible. Along with the daily COVID-19 screening, temperature checks with thermal scanners were conducted, and movement routes within the building were monitored to moderate student traffic. Table 1 shows a summary and timeline of all mitigation strategies taken by Avenues New York starting in the fall of 2020.
Summary and Timeline of Concurrent Strategies Taken by Avenues New York to Mitigate the Spread of COVID-19
Abbreviations: HEPA, high efficiency particulate air; IAQ, indoor air quality; NAAT, nucleic acid amplification test; PCR, polymerase chain reaction.
Social Distancing
Social distancing measures were followed as appropriate, such as during student pickup and dropoff and at large gatherings. Classes were held outdoors whenever possible, but due to the necessary closeness of students within an enclosed classroom, all students in a self-contained classroom were defined as close contacts. The People and Culture Department, which is responsible for staff hiring and management, changed faculty and staff job responsibilities to avoid mixing students across pods. This meant that faculty who taught classes that catered to multiple levels (eg, math, science) taught online instead, with students from multiple sections attending the same class online without mixing physically. Meals were provided in classrooms, with box lunches provided, and a preorder system implemented with several choices—meals were then delivered to each classroom.
Masking
Masking was made mandatory, with the school providing 3-layer cotton facemasks with a fine particulate matter (PM2.5) charcoal filter insert to all students and staff at the start of the school year. Students were given 2 to 3 masks with the expectation of washing and reusing them, while teachers were given 5 masks for a daily rotation. Administrators noticed that although PM2.5 filters were provided, faculty and students never fully adopted the measure. Throughout the fall, administrators also noted that students began wearing their own surgical facemasks. A well-fitting full-face covering mask was the established rule, with neck gaiters being impermissible.
Testing and the Test-to-Stay Policy
Avenues New York administrators attempted to secure point-of-care testing in the early phase of the pandemic; however, many companies and testing kits had not yet reached the market or successfully received emergency use authorization from the US Food and Drug Administration. To quickly secure reliable and high-quality testing, Avenues New York applied for a limited-service laboratory license with the New York State Department of Health (NYSDOH) to administer tests on school grounds. The school implemented a hybrid approach to testing, with weekly pooled PCR test screening for each member of the on-campus population beginning in October 2020. Over 45,000 COVID-19 tests were administered throughout the 2020-2021 school year at Avenues New York, using both rapid and PCR testing. The rapid tests included the Abbott ID NOW (molecular; Chicago, Illinois), Cue Health (molecular nucleic acid amplification; San Diego, California), Abbott BinaxNOW (antigen; Chicago, Illinois), and BD Veritor (antigen; Franklin Lakes, New Jersey). The pooled PCR tests used anterior nasal swabs collected at home and brought to campus and collected in pools. Pools were sent to JCM Analytics' Clinical Laboratory Improvement Amendments-certified laboratory partners for analysis.
Using the testing infrastructure described here, Avenues New York implemented a test-to-stay system, wherein students who were exposed to COVID-19 would take a rapid antigen test daily, and if tests remained negative, they could continue attending school. Inconclusive or positive tests would result in the student staying at home, with their return to school conditional on symptom resolution and negative test results. Families could choose to keep students home, but the school did not offer remote education unless an entire class was in quarantine.
Additionally, Avenues New York calculated that due to their test-to-stay policy, 3,800 instructional days were saved. This was calculated by multiplying the number of classrooms with a positive COVID-19 case by the number of standard quarantine days, and then multiplying by the number of students in those classrooms. If the test-to-stay policy had not been executed consistently, each student in each pod would have been quarantined for the full period in every classroom with a single positive case.
Contact Tracing
The school developed and piloted a process to identify every individual's location, as well as their proximity to others, through the usage of Bluetooth cards issued to each student, faculty, and staff member. Bluetooth signals from each card pinged Wi-Fi access points throughout the facility, which allowed for the determination of who was in a classroom and for how long. The accuracy of this method did not suffice for contact tracing using the 6-foot rule established by the CDC as the minimum distance considered to be not in “close contact,” 26 but it was helpful to manage population density in classrooms and common spaces.
Indoor Air Quality
Avenues New York considered IAQ a high-priority improvement and modification strategy to prevent transmission of cases, and the school continually updated its air quality improvement measures throughout the 2020-2021 school year to lower the potential for airborne transmission.
Prior to the school's reopening in September 2020, several upgrades and modifications were made to the indoor air ventilation system at Avenues New York. In May 2020, the school measured the air changes per hour to meet the standard of 5 to 6 air changes per hour, as recommended by the Healthy Buildings program for excellent air. Much of the building already met this standard, using Airthings View Plus sensors (Oslo, Norway) installed in multiple locations; 100 sensors were installed. FEND nasal misters (Sensory Cloud, Boston, Massachusetts) were piloted and eventually incorporated as an additional layer of protection in the upper age divisions.
Avenues New York hired the UL Healthy Building program in July 2020 to conduct an indoor environmental quality assessment and audit to test air, water, and surface quality and evaluate cleaning procedures throughout the building. The school made all recommended changes and received a certificate establishing that its facilities met the safety requirements for reopening. The main outside air handlers had 2 levels of filtration for outside air: an initial MERV 7 or MERV 8 prefilter followed by a MERV 14 or MERV 15 filter. Indoor return air filters were all upgraded to MERV 8 or higher. These were the maximum levels of filters that the internal systems could handle without undue pressure drops or harm to the system. They also installed bipolar ionization, which was later demonstrated in a large-scale test to not be beneficial. 27 At the end of the school year in June, indoor air-quality sensors were purchased and piloted.
Co curricular Education: Music, Physical Education, Athletics
No extracurricular athletic activities occurred in 2020-2021, and physical fitness activities were limited to low respiratory activities and conducted outdoors when possible. Students and faculty wore masks during indoor physical activities. Music classes and activities were also not conducted in 2020-2021, due to their high-risk status.
Vaccination
COVID-19 vaccines became widely available to individuals over the age of 16 years in the United States in spring 2021. After vaccines became available to educational workers through the state of New York in January 2021, Avenues implemented a vaccine mandate for all adults and students ages 12 to 18 years to be fully vaccinated by the start of the 2021-2022 academic year.
2021-2022 and 2022-2023 School Years
Many of the same protocols implemented in the 2020-2021 school year were continued into the next 2 academic years, with some modifications added due to changing SARS-CoV-2 variants of concern and knowledge about vaccination and transmission mitigation methods. For example, modifications included eliminating temperature measurements at the door, remixing vaccinated students in grades 7 to 12 with specialty classes, resuming in-person education, stopping weekly testing for faculty, and resuming athletics programs for upper division students. In grades 7 to 12, data were not collected by pods but rather by grade, since vaccination had become widely available for students over the age of 12 years. Additionally, masks were still required for all faculty and staff at the beginning of the year, but as student, staff, and faculty populations became fully vaccinated, masking was relaxed during lower-risk activities but maintained for higher-risk activities, such as large group gatherings. Students who were too young to be vaccinated maintained mask requirements until they were eligible for vaccination. Music and athletics activities were reinstituted, with a ramp-up back to normal activity, involving specific mitigation measures such as limitations on activities, outdoor activities, and smaller groups. Ramp-down processes for mitigation measures were developed for masking and other restrictions based on assessments of the percentage of students vaccinated, new variants, and the level of community transmission.
Some new protocols shifted focus toward improving indoor environmental quality by installing portable HEPA filters and upper room germicidal irradiation in crucial spaces, such as the gymnasium, cafeteria, health and physical movement areas, theaters, music rooms, and the health office. A far-ultraviolet system was rolled out for all classrooms and finished by December 2022. Additionally, Avenues New York joined the International WELL Building Institute and plans to pursue WELL building certification and has received a RESET indoor air quality certification at the high-performance level in its New York office.
Outcomes
We observed a difference between COVID-19 prevalence at Avenues New York and COVID-19 prevalence in children ages 5 to 19 years living in New York City boroughs during the 2020-2021 and 2021-2022 school years, based on data from the NYSDOH, 28 as depicted in Figure 2. When reporting began, the Avenues New York school population and the children of New York City had comparable rates of prevalence during the spring of 2021. No cases were reported at Avenues New York from mid-June to early September due to summer vacation closure, so comparable data for that time period was omitted from the data sourced from NYSDOH. However, when the 2021-2022 school year began, similar patterns repeated from the end of the previous academic year. One significant caveat with these data is that New York State sourced its data from the Electronic Clinical Laboratory Reporting System, a NYSDOH database that contains reported results from all laboratories testing samples from New York State residents. This would, therefore, result in the surveillance system collecting data potentially missing asymptomatic COVID-19 cases in that age group, especially if the desire to test was driven by symptomatic presentation of COVID-19.
Avenues 14-day trailing test positivity percentage compared with the percentage of positive cases (per 100,000) among New York City's population of children ages 5 to 19 through the school years 2020-2021 and 2021-2022. 29 Dates reflect the date/week that the tests were administered. Reflects Avenues New York's trailing 2-week adjusted prevalence based on the total onsite tested population. Data provided by Avenues: The World School global operations.
Comparisons between Avenues New York and other schools and school systems are difficult to make, based on the available literature. Few other schools or school systems tracked their COVID-19 cases among staff, students, and faculty with the same level of stringency as Avenues New York, with elements of a test-to-stay policy, surveillance screening, diagnostic testing, and other measures. Additionally, public schools cannot provide a direct comparison group due to the differences in available resources, testing protocols, student socioeconomic backgrounds and demographics of students, and variability of student addresses because students from all over New York City's boroughs attend the school.
Testing and screening measures differed significantly across schools, which affected test positivity and prevalence rates and hindered the ability to make comparisons. This article addresses this knowledge gap, and we hope that case studies from other schools will help to draw comparisons in the future.
Indoor Air Quality Readings
Table 2 and Figure 3 represent more than a year of ambient IAQ data, with measurements aggregated during the times of day when students and staff were present at Avenues New York, thereby showing information during peak usage times. PM10 and PM2.5 levels are often present at less than or equal to 20% of the safe upper limit, indicating very consistently safe levels of PM10 and PM2.5 over the year. 29 Low PM10 and PM2.5 levels are a good indicator of filter efficacy since the air filtration systems are responsible for reducing the presence of these particles in the air. CO2 levels are also present at roughly 80% of the safe lower limit, indicating that ventilation measures may be working well over a prolonged period. Volatile organic compound (VOC) levels often straddle the safe lower limit, with instructions provided by the consulting industrial hygiene firm to investigate VOC levels above the lower safe limit. Avenues New York is actively engaged in tracking and identifying which VOCs are present in these rooms to determine how to best reduce those VOC levels. 29 Current results indicate that the most common classroom VOCs were ethanol, isopropanol, and acetone, which were primarily associated with personal care products, such as perfume or cologne, hand sanitizer, and nail care products.
Measures of ambient indoor air quality at Avenues New York from September 2021 to November 2022, as collected by Airthings ViewPlus sensors. Measurements are aggregated from multiple locations, with measurements collected during school operational hours. Measurements are calculated as percentages of acceptable upper limits, 32 with the upper limit represented as 100%. Measures include carbon dioxide, PM10, PM2.5, and volatile organic chemical measurements. Prior to April 2022, 20 sensors were used for data collection. After April 2022, 80 sensors were used for data collection.
Measures of Ambient Indoor Air Quality From Avenues Sensors, September 2021 to November 2022
Note: Data were collected by Airthings View Plus sensors. Measurements were aggregated from multiple locations, with measurements collected during school operational hours. Measurements were calculated as parts per million (ppm), μg/m3, and parts per billion (ppb), based on the scale at which the data were collected. Measures included carbon dioxide, PM10, PM2.5, and volatile organic compound levels.
Abbreviations: CO2, carbon dioxide; PM, particulate matter; ppb, parts per billion; VOC, volatile organic compound.
Costs and Benefits of Mitigation Measures
The average cost for mitigation measures per student was about $1,345 the first year and $415 the second year, for a 2-year average cost of about $880 per student (Table 3). Many of these were capital costs that will provide more benefits in the future.
Summary of All Costs Incurred by Avenues New York
Note: Full summary of all costs incurred by Avenues New York as it pertains to safety and mitigation measures, building upgrades and renovation, and transmission mitigation.
Abbreviations: HEPA, high efficiency particulate air; HVAC, heating, ventilation, air conditioning; IAQ, indoor air quality; UV, ultraviolet; UVGI, ultraviolet germicidal irradiation.
The benefit of implementing mitigation measures was that Avenues New York was able to operate in-person schooling and avoid the educational disruptions associated with remote instruction.
The educational cost of school closures has been estimated as 1% to 2% of the net present value of lifetime earnings, which is roughly equal to $10,000 to $20,000 per student per year.29,30 In addition, school closures were found to reduce parental work hours by 10% to 15%. If we assume that the mean personal income of a parent is $57,000, the reduced work hours could have contributed to an additional $5,000 to $9,000 of income that could benefit a child raised in that household. The annual per-child cost of school closures is therefore $15,000 to $30,000, before adding in the costs of mental health effects. This means that the benefits of these mitigation measures are about 15 to 30 times the costs, under a very conservative estimate that ignores both the future benefits of the IAQ investments and noneconomic harms of school closures.
Parent/Guardian Response
The educational and government responses to COVID-19, particularly concerning closures, reopening, and safety measures, have become a source of political contention, with many school boards under fire for both adhering to and disregarding COVID-19 mitigation measures. 30 Between 2021 and 2022, Avenues New York sent 3 individual surveys to parents and guardians asking for their feedback on school standard operating procedures, with responses showing that most families supported school safety protocols.
Parents praised the pragmatism and sensibility of COVID-19 policies and the school's frequent communication with parents, mainly when policies or implementation methods changed. Most responses from parents related to COVID-19 policies were positive, with scores of 4 or 5 (out of 5). Positive parent comments included praise for flexible schooling options, protocols to keep the campus open, and the school “proactively finding ways to make school more ‘normal.’” One parent noted that “Avenues [New York] is always the first school to adopt pragmatic and sensible COVID[-19] policies. […] I always cite this to friends as som[e]thing we are so happy about.” Many parents noted the positive impact these measures had on their children, including a lack of excessive worry among their children about the pandemic. Transparent communication and the fluidity of protocol adaptations were noted many times as program strengths, especially as the COVID-19 pandemic evolved.
While many parents provided positive feedback, some parents had more neutral or negative feedback, designated by scores of 1 to 3 on the surveys. Negative comments from parents included their wish for Avenues New York to remove masking mandates for young children, due to lower rates of severe COVID-19 among young children and the belief that, as 1 parent stated, “mandates may be harming our children by impeding language and emotional development.” Additionally, some parents felt that communications about COVID-19 testing policies were unclear, with limited follow-up communication addressing questions. Some neutral comments specifically included the desire to end mask mandates, which is representative of parents who did not fully trust the existing COVID-19 mitigation measures. Interestingly, some parents believed that Avenues did not go far enough, with 1 parent stating they were “really disappointed that Avenues [New York] is not running a vaccine drive for the 5 to 11-year-old age group.” Other parents specified their comfort with fully approved vaccines, followed by a request that students not be required to get vaccines that have only emergency use authorization. Parents across the United States received COVID-19 policies in similarly variable ways, with such policies being a polarizing topic addressed in many school districts.30,31
Lessons Learned
During the ongoing COVID-19 pandemic, as well as during future epidemics and pandemics, schools need support to engage in and use policies that will allow them to remain open as much as possible. 32 The learning loss endured by students during COVID-19-related school closures and virtual, asynchronous education has caused significant backsliding among children in the United States,1,4 and the positive impact of in-person education has become clear.33,34 In-depth guidelines developed now, based on case studies documenting COVID-19 mitigation measures, can provide valuable evidence to inform the design of policies that enable schools to prepare for and remain open during future crises, including future disease outbreaks.
In this case study, we discussed several COVID-19 mitigation measures that were accessible and usable by a single private school, Avenues New York, and whether implementation of these measures were associated with decreased COVID-19 prevalence, compared with COVID-19 test positivity in New York City as a whole. While individual measures cannot be disaggregated and examined for efficacy, the combination of measures implemented at Avenues New York during the pandemic can be associated with reduced case COVID-19 prevalence at this school but cannot be causally linked. Additionally, ongoing research indicates that improvement of IAQ could benefit students not only during an active pandemic but also reduce illness incidences year-round 12 due to the association of indoor air pollutants with poorer respiratory health outcomes in children.35-38 Moreover, the school demonstrated success in the essential step of ensuring that open lines of communication were maintained with the school community, particularly parents, to ensure long-term support for and compliance with the school's policies.
The school's administration indicated that lessons learned from the experience included improved communication with parents and guardians, such as partnerships the school engaged in for COVID-19 mitigation, which reinforced the school's commitment to research and investment in pursuing innovative solutions. Additionally, providing customized masks was noted as an unnecessary investment because students quickly purchased and brought their own masks to express personal identity and fashion preferences, and because of the quick evolution of the industry to provide more-than-sufficient masks for students and faculty to purchase on their own. The school administration would also like to pursue options in the future to improve the quality of classroom-provided meals for students. The Bluetooth contact tracing measure required improvement in execution, as the location of access points caused “bleeding” in signal reading between rooms, rendering it difficult to determine the number of students in a classroom. The administration continues to work with the company and may provide data to support future studies on the feasibility of this mitigation measure.
Recommendations that might reduce future respiratory disease case rates in schools include implementing more robust case surveillance systems and deploying technological innovations around contact tracing within buildings to limit case spread during an active outbreak. Case surveillance systems can include routine testing for students, either through antigen or PCR tests— particularly after holiday breaks—to track potential surges of cases, and through novel Bluetooth systems that measure exposure to other individuals while maintaining necessary levels of privacy. Additionally, long-term investment in improving IAQ may help prevent outbreaks of COVID-19 and other highly transmissible seasonal illnesses among students, faculty, and staff. This includes modifying local ventilation systems using windows and doors and installing high-quality HVAC systems and MERV 13 or higher filters.
Insufficient funding could pose challenges to implementing public health recommendations to mitigate disease transmission in schools. Public schools rely on property and general taxes collected by the government and distributed to fund their activities, which, in addition to education, often include social safety net responsibilities such as feeding students, particularly those from lower-income backgrounds, and providing after-school safe childcare. Public schools often receive limited funds to implement such programs.39,40 As a private school, Avenues New York is not bound to additional obligations beyond education in a way that public schools often are. Avenues New York collects tuition from most of its students, with a minority of students attending on scholarship disbursements. As such, the school uses the tuition it collects to fund the entirety of its activities and does not have to stretch its funding in the same way that many public schools do, as tuition rates take these additional costs into account when setting the price. Governments, as well as private school administrations, should consider disease transmission mitigation costs when creating future budgets.
This case study reflects the state of knowledge and the state of the pandemic in January 2023. Future developments, such as newer or more transmissible variants of SARS-CoV-2 and reevaluations of IAQ improvement, may necessitate further research into mitigation measures to reduce transmission of disease.
The measures within this case study can be examined only in the context of Avenues New York, in the form of correlations or associations, because causality between the school's measures and a decreased prevalence of COVID-19 cannot be established. As such, the aims of this study are not to prove definitively that the presented mitigation methods are intrinsically causative of a decreased disease prevalence, but rather to document an experience of a school during the COVID-19 pandemic and the need for similar high-quality data collection and proactive multilayered mitigation efforts in future pandemic and outbreak scenarios.
Footnotes
Acknowledgments
The authors would like to thank Avenues: The World School for providing information about its mitigation protocols that can be used to help others. The authors would also like to thank Alyson Browett for editing this document.