A former school nurse explains why the recommended single nurse per 750 students isn’t nearly enough to provide safe care

Temperature check on playground during COVID-19
School nurses are leaders who “address the physical, mental, and emotional health needs of students.”

  • Professor Beth Jameson believes COVID-19 has exposed the flaw in havingone school nurse for every 750 kids.
  • School nurses have a lot of responsibilities and the pandemic has raised them exponentially.
  • More manageable workloads for nurses will mean better student health and academic outcomes.
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When many people think of a school nurse, they imagine a person who hands out Band-Aids for boo-boos.

But school nurses do so much more. They are school leaders who address the physical, mental, and emotional health needs of students.

As the COVID-19 pandemic played out, many school nurses took on even greater responsibilities. These include monitoring and evaluating staff and students for COVID-19 exposure and symptoms, contact tracing, and educating students, staff and community partners on vaccine and prevention measures. School nurses are also developing initiatives to deal with the anticipated increase in mental health services that students, families and staff will need in the post-pandemic world.

And yet, the US Department of Health and Human Services and the Centers for Disease Control and Prevention recommend that public elementary, middle, and high schools aim to have one school nurse for every 750 students.

As a former school nurse and current nurse scientist and professor of nursing, I know that this one-size-fits-all model does not consider the full role and responsibilities of the school nurse.

What’s more, as far as I can tell, no published research or evidence supports this ratio. It’s been traced at least as far back as the early 1970s and the Education for All Handicapped Children Act of 1975, now known as the Individuals with Disabilities Education Act.

Safety net for vulnerable kids

School nursing is a specialized practice that operates in environments very different from an acute care hospital setting. School nurses work alone, practice independently and are typically the sole health care provider in the building.

As part of our public health system, they play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening and asthma education.

And they are a safety net for society’s most vulnerable children. For example, if a student is experiencing food insecurity, the school nurse might coordinate with a community partner or school social worker to help the student and their family not go hungry.

Most school nurses will tell you they are unable to carry out many of these functions, often due to huge workloads or poor staffing.

I know from personal experience. From 2009 to 2014, I was the sole school nurse responsible for the health and safety of over 900 public elementary school children. This included special education classrooms for preschoolers and students with nonverbal autism. I now research how school health policies and practices effect the work environment of school nurses, and the challenges and barriers they face.

Research shows how a positive work environment for school nurses increases job satisfaction, reduces turnover and improves academic outcomes for students. A study of school nurses in Massachusetts schools demonstrated that for every dollar invested in school nursing, society would gain US$2.20 as a result of kids’ better health and disease prevention.

No one-size-fits-all ratio

A school nurse’s workload depends on a number of significant variables. For example, how many students in the school have chronic illnesses and need medication administered? How many students attend the school? What ages are they? What is the average number of student visits to the health office each school day? Are students spread across multiple buildings? What level of experience and specialized skills does the school nurse have?

The number of students in a school who are dealing with poverty or other health equity issues – including access to quality education, safe housing and health care – also impacts and increases the workload for school nurses.

These evidence-based variables can be used to guide school administrators and school nurses on what constitutes safe staffing. Making sure school nurses have a safe, appropriate workload is critical to ensuring that students have their health needs met at school.

Parents who are concerned about their child’s health at school may want to find out how many students their child’s school nurse cares for. How many students does the school nurse see on a typical day? Is a school nurse in the building every day? Does the school nurse cover more than one building? What happens when there is an emergency, such as a child with a life-threatening allergic reaction? Where are the emergency care plans kept? Is there stock medication available such as epinephrine and albuterol for students with severe allergies or asthma?

I believe school nurses need more manageable workloads in order to provide the safe care needed for better student health and academic outcomes. This leads to better health not just in individuals but in communities that need it most.

Beth Jameson, assistant professor of Nursing, Seton Hall University

The Conversation
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COVID-19 lockdowns may be preventing kids’ immune systems from maturing, according to an immunologist

Children playing outside
Outdoor activities are crucial to help reduce the risks of allergic diseases in young children.

  • Current isolation policies will negatively impact young children’s immune systems’ ability to self-regulate.
  • When people are less exposed to the natural environment, there’s potential for an increase in allergic diseases.
  • Children in lockdown for over a year now are at risk for developing allergies, asthma, and autoimmune issues.
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“Eat dirt!” is a phrase I remember well. It was in the title of an article published by Harvard University environmental health professor, Dr. Scott T. Weiss, and it captured my attention while I was learning about an immunological concept known as the “hygiene hypothesis.”

The core of the idea is that we live in a microbial world: an environment full of bacteria, parasites, viruses, and fungi. And that our interactions with these microbes after birth are extremely important to educate our immune systems to function properly. When we are born, our immune systems are still maturing.

I like the way researchers led by microbiologist Sally F. Bloomfield expressed it in their study:

“The immune system is a learning device, and at birth it resembles a computer with hardware and software but few data. Additional data must be supplied during the first years of life, through contact with microorganisms from other humans and the natural environment.”

The immune system has many potent mechanisms for killing pathogens. It needs to be carefully regulated to ensure it can eliminate dangerous microbes from the body without causing excessive harm to our own tissues. The interactions we have with our environment early in life are essential for our immune systems to learn to differentiate between safe and dangerous disease-causing microbes.

Our bodies are covered inside and out with microorganisms that, under normal circumstances, happily cohabitate with us and promote a healthy immune system. If infants, toddlers, and young children are not sufficiently exposed to the microbial world around them, their ability to properly regulate their own immune systems can be compromised.

To return to the computer analogy, the data that gets uploaded into the software is incomplete. This lack of data can cause the immune system to struggle to differentiate between what is truly dangerous and should be eliminated, and what is not dangerous and should not be responded to. In plain terms, this scenario can promote allergies, asthma, and autoimmune diseases.

Concrete jungles

Scientists are moving away from using the term “hygiene hypothesis” because it could be misinterpreted as meaning that hygiene is not good for a developing immune system. This is not true, nor should anybody advocate for actually eating dirt to gain exposure to microbes. Moderation and targeted hygiene would be best.

Specifically, we need to practice proper hygiene in the context of trying to prevent infectious diseases, but still allow our immune systems to interact with safe and essential microbes. Many middle-income countries have seen an epidemic of allergic diseases over the past several decades. This is, in part, due to increased urbanization which is akin to living in “concrete jungles” with reduced exposure to the natural environment.

Societies have also adopted behaviors that limit exposure to microbes. The overuse of antibiotics exacerbates the problem by non-discriminately eliminating good microbes along with bad ones.

Bloomfield and her team of microbiology researchers came to some important conclusions in their study:

“Evidence suggests a combination of strategies, including … increased social exposure through sport, other outdoor activities, less time spent indoors … may help … reduce risks of allergic disease. Preventive efforts must focus on early life.”

Now think about government-led responses to COVID-19, which was declared a pandemic by the World Health Organization on March 11, 2020. The lockdown and restriction policies that have been enacted to help prevent the spread of COVID-19 contradict the recommendations to ensure proper immunological development in children.

Data suggest that SARS-CoV-2 does not represent a greater danger to children than the annual flu. Yet social interactions of children have been severely limited, including removing them from schools. Most of their extracurricular activities have been canceled and they have been discouraged from leaving their homes. Even the air they breathe is often filtered by masks and there is prevalent use of hand sanitizer.

Compromised immunological development

In short, most COVID-19 policies have maximized the potential for children to develop dysregulated immune systems. As a viral immunologist, I was not overly concerned about this in the early stages of the pandemic when “temporary” measures were put in place to “flatten the curve.”

However, there is cause for concern one year later, after many places in Canada and other countries have spent months in lockdowns or with very limited social contact and activities to prevent the spread of COVID-19.

The youngest among us have had their immunological development compromised for one year and growing. The more immature the immune system is, the more prone it will be to becoming dysregulated during the pandemic.

For example, the problem would likely be more prevalent in infants than toddlers. Although the human immune system is largely mature by approximately age six, some important components are still developing into adolescence. As such, the only people who can be certain that current isolation policies will have no negative impact on their immune system’s ability to self-regulate are adults.

An unfortunate and underappreciated long-term legacy of this pandemic will likely be a cluster of “pandemic youth” that grow up to suffer higher than average rates of allergies, asthma, and autoimmune diseases. This will hold true for children in all countries that enacted isolation policies.

Interestingly, it has been noted that the new messenger RNA-based COVID-19 vaccines that are packaged inside liposome nanoparticles might be contraindicated for some individuals with a propensity towards severe allergic responses. Ironically, we may be setting up many of our youth to develop hypersensitivities to this vaccine technology when they are older.

Raising children during the pandemic has largely occurred in isolated/sanitized environments that are unprecedented in extent and duration. These kids are at greater risk of developing hypersensitivities and autoimmune diseases than anyone before them. The immune systems of children are not designed to develop in isolation from the microbial world, so let’s consider letting children be children again.

Byram W. Bridle, associate professor of viral immunology, department of pathobiology, University of Guelph

The Conversation
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Black Americans have legitimate reasons to be skeptical of getting the COVID-19 vaccine – a bioethicist explains why

covid vaccine
It’s important to learn the painful medical histories of Black people to help combat their trust in the medical system.

  • Black Americans are being hospitalized and dying from COVID-19 at higher rates than white Americans, says bioethicist Esther Jones.
  • Still, many Black people are skeptical about receiving the vaccine due to distrust of the American medical system. 
  • Jones says healthcare workers and policymakers can help close racial health gap by understanding the source of this skepticism. 
  • Visit the Business section of Insider for more stories.

Black Americans have been the least inclined of any racial or ethnic group to say they’d get vaccinated against the coronavirus. The proportion of Black people who said they’ll probably or definitely take the shot has risen over time – but even by mid-January, with two COVID-19 vaccines authorized for emergency use in the US, only 35% of Black survey respondents said they’d get it as soon as they could, or already had gotten the shot.

At the same time, the COVID-19 pandemic has disproportionately harmed Black, Indigenous and other people of color in comparison to white members of American society. With Black Americans being hospitalized at rates 2.9 times higher than white Americans and dying from COVID-19 at rates 1.9 times higher, you might assume that Black people would be lining up at breakneck speed to receive the vaccine as soon as it’s available to them.

But the Black community has reasons for distrust – even beyond what might be attributed to the mixed messaging of the nation’s COVID-19 response. And it’s not a simple or sole matter of miseducation. I’m a medical humanist and bioethicist who studies history, ethics, and literature to understand racial and gender health disparities. My research explores the history of unethical and abusive treatment Black Americans have experienced at the hands of the medical establishment. Based on past experience, Black people have many legitimate reasons to be in no hurry to get the vaccination.

A troubling track record

The American medical establishment has a long history of unethical treatment of Black research subjects. Medical ethicist Harriet A. Washington details some of the most egregious examples in her book “Medical Apartheid.” There’s the now notorious Tuskegee syphilis experiment, in which the government misled Black male patients to believe they were receiving treatment for syphilis when, in fact, they were not. That study went on for a total of 40 years, continuing even after a cure for syphilis was developed in the 1940s.

Perhaps less widely known are the unethical and unjustified experiments J. Marion Sims performed on enslaved women in 1800s US that helped earn him the nickname the “father of modern gynecology.” Sims performed experimental vesicovaginal fistula surgery on enslaved women without anesthesia or even the basic standard of care typical for the time.

Sims experimented on Anarcha, a 17-year-old slave, over 30 times. His decision not to give anesthesia was based on the racist assumption that Black people experience less pain than their white peers – a belief that persists among medical professionals today. Historian Deirdre Cooper Owens elaborates on this case and many other ways Black women’s bodies have been used as guinea pigs in her book “Medical Bondage.”

Cases of medical malfeasance and malevolence have persisted, even after the establishment of the Nuremburg code, a set of medical ethical principles developed after World War II and subsequent trials for crimes against humanity.

In 1951, doctors harvested cervical cancer cells from a Black woman named Henrietta Lacks without her permission. Researchers went on to use them to create the first immortal cell culture and subjected her descendants to ongoing study for years without informed consent. Investigative journalist Rebecca Skloot details the cascade of ethical violations in her book “The Immortal Life of Henrietta Lacks.” Despite heightened awareness after the book’s publication, the ethical violations continued when a group of scientists mapped the HeLa genome without her family’s knowledge or consent.

Advances in genomics are still being used to resuscitate theories of racial “science.” For example, a now-debunked 2007 study purported to isolate a so-called “warrior gene” in Maori Indigenous men and argued they are genetically “hard-wired” for violence. Scientists and news outlets in the US jumped on board, suggesting there’s a genetic predisposition for Black and Latino males to engage in gang activity.

Legal scholar Dorothy E. Roberts explains in her book “Fatal Invention” how incidents like this one perpetuate the harm of race-based science. Using biological data and flawed reasoning tainted by racial stereotyping reinforces racist beliefs about Black people. Such logic focuses on purely biological factors and ignores the social and systemic factors that produce negative and inequitable health outcomes.

While there is now an ample body of scholarly research that reveals these truths about racism in the medical establishment, Black Americans need only to gather around the kitchen table with a few friends and family to share and hear personally experienced stories of medical malfeasance.

Present day persistence of racism in healthcare

Even though their experiences at the hands of researchers like J. Marion Sims were central to advances in modern gynecology, today Black women have not benefited from these advances to the same degree as white women. Black women still suffer worse outcomes and more deaths from gynecologic cancers and have worse health and more deaths affiliated with childbearing, just to name two.

When tennis star Serena Williams gave birth, she saw firsthand how Black women are disbelieved by the medical establishment. She might have died from postpartum blood clots if she hadn’t advocated for herself in the face of dismissive medical professionals.

Black people are acutely aware of this history of racism in the medical establishment, and the ways it persists today on both an individual and a collective level. Stereotypes about Black patients, whether the result of explicit or implicit bias, continue to affect the care they receive and their medical outcomes. Again and again, when surveyed, Black Americans report that medical providers don’t believe them, won’t prescribe necessary treatments, including pain medication, and blame them for their health problems.

And the association between racism and increased disease cases and deaths has held true during the COVID-19 pandemic.

Overcoming these challenges

Ongoing trust issues around the COVID-19 vaccines are just the latest indication of racial health disparities in the US.

Still, there are ways to begin to close the COVID-19 racial health and mortality gap. Vaccinations for Black people may otherwise continue to lag in proportion to population size.

Esther Jones, associate professor of English, affiliate with Africana studies and women’s & gender studies, Clark University

 

The Conversation
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Despite trillions in coronavirus aid, many US families are still struggling to pay for basic necessities like food and rent

Supermarket queue
Research show that the first round of pandemic aid barely helped many families in need.

  • Americans are still financially struggling during the pandemic despite aid from the government.
  • A new study suggests further government aid is needed on a larger scale to help tens of millions of families.
  • Low-income Black and Latino households may need more than others.
  • Visit the Business section of Insider for more stories.

As Congress prepares another injection of COVID-19 aid for businesses and individuals, there’s been debate about whether it’s necessary on top of the US$3.5 trillion spent so far.

President Joe Biden had initially hoped to get bipartisan support for his $1.9 trillion proposal, but the only counteroffer from Republicans was a $600 billion bill, with many in the GOP suggesting more money wasn’t needed. And some economists have expressed concern that giving Americans too much right now could overheat the economy.

We are public opinion scholars at the Harvard T.H. Chan School of Public Health. In cooperation with our partners at the Robert Wood Johnson Foundation and National Public Radio, we conducted a survey in July and August of last year to try to understand how the first round of aid had affected American families in need. What we found shocked us then and feels relevant now as the government negotiates its next steps.

Despite trillions of dollars in government assistance, about two-thirds of families that suffered job losses or reduced wages during the pandemic still reported facing serious financial hardship.

Many people were struggling – and still are – just to pay for basic necessities, like food and rent.

The first round of pandemic aid

Congress passed most of the initial relief in March, including direct payments to qualifying families, expanded unemployment benefits and loans to small businesses that turned into grants if they kept workers on their payroll.

By July 1, when we began our survey, most Americans entitled to a direct check should have received it, and unemployed adults were still receiving supplemental aid of $600 a week on top of state benefits.

We wanted to understand the financial burdens experienced by American families that were economically harmed by the coronavirus pandemic. And we wanted to see whether the government aid was helping the people who needed it most.

Using a nationally representative, randomized survey design, we contacted 3,454 adults and asked them about the financial problems facing their households. We focused on the 46% who said they or other adults in their household either lost a job, had to close a business, were furloughed, or had their wages or hours reduced since the start of the coronavirus pandemic. We published our findings in the economic affairs journal Challenge in January.

Serious financial problems

While it seems like a no-brainer that Americans weren’t ready for the unexpected employment disruptions caused by the COVID-19 pandemic, it was surprising to us that federal aid and charitable assistance seemed to be doing so little to support the people it was intended to help.

We found that the aid didn’t put much of a dent in the financial problems faced by families earning less than $100,000, whether because relief was delayed or wasn’t spent, the amount wasn’t adequate or the funds never made it to the intended recipients.

Among households with employment or wage losses during the pandemic, 87% of those earning less than $30,000 a year and 68% of those earning $30,000 to $99,999 told us they were still facing serious financial problems. And more than half of households in these income brackets reported they had already used up all or most of their savings – or they didn’t have savings to begin with. That share jumped to over three-quarters for people with incomes under $30,000.

Savings take years or decades to accumulate, so it’s likely these households are in even worse trouble now. What’s more, significantly less aid has been provided from the federal government since we conducted our survey.

The Conversation

Many Americans still need a lifeboat

Our findings suggest there is a definite need for further government aid on a large scale for tens of millions of families.

A useful way to think about this is how the government provides relief after a natural disaster. In disasters, cash payments are often sent directly to those in need, like lifeboats launched to rescue people at risk of drowning.

And in fact, the pandemic has been an economic disaster for some – particularly low-income and Black and Latino households – more than others. They still need a lifeboat to get them through the storm.

Mary G. Findling, research associate at the Harvard T.H. Chan School of Public Health, Harvard University; John M. Benson, senior research scientist at the Harvard T.H. Chan School of Public Health, Harvard University, and Robert J. Blendon, Richard L. Menschel Professor of Public Health and professor of health policy and political analysis, emeritus, Harvard University

The Conversation
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One in 3 COVID survivors may suffer from symptoms even after recovery. Researchers don’t yet know how long it could last.

fatigue tired
People with lingering symptoms may experience brain fog, pain, or debilitating fatigue.

  • About one in three people retain symptoms after recovering from COVID-19, says scientist Stephanie LaVergne.
  • Patients with both severe and mild cases are susceptible to lingering symptoms.
  • Researchers are still trying to determine why some symptoms remain and how long they will persist.
  • Visit the Business section of Insider for more stories.

A few months ago, a young athletic guy came into my clinic where I’m an infectious disease physician and COVID-19 immunology researcher. He felt tired all the time, and, importantly to him, was having difficulty mountain biking. Three months earlier, he had tested positive for COVID-19. He is the kind of person you might expect to have a few days of mild symptoms before recovering fully. But when he walked into my clinic, he was still experiencing symptoms of COVID-19 and he could not mountain bike at the level he was able to before.

Tens of millions of Americans have been infected with and survived COVID-19. Thankfully, many survivors get back to normal health within two weeks of getting sick, but for some COVID-19 survivors – including my patient – symptoms can persist for months. These survivors are sometimes dubbed long-haulers, and the disease process is termed “long COVID” or post-acute COVID-19 syndrome. A long-hauler is anyone who has continued symptoms after an initial bout of COVID-19.

Numerous studies over the past few months have shown that about one in three people with COVID-19 will have symptoms that last longer than the typical two weeks. These symptoms affect not only people who were very sick and hospitalized with COVID-19, but also those with milder cases.

Long COVID is similar to COVID-19

Many long-haulers experience the same symptoms they had during their initial fight with COVID-19, such as fatigue, cognitive impairment (or brain fog), difficulty breathing, headaches, difficulty exercising, depression, sleep difficulty and loss of the sense of taste or smell. In my experience, patients’ symptoms seem to be less severe than when they were initially sick.

Some long-haulers develop new symptoms as well. These can vary widely person to person, and there are reports of everything from hair loss to rapid heart rates to anxiety.

Despite persistent symptoms, SARS-CoV-2 – the virus itself – is not detectable in most long-haulers. And without an active infection, they can’t spread the virus to others.

Who are the long-haulers?

Patients who were hospitalized for COVID-19 are the most likely to have persistent long-term symptoms.

In a study published in July 2020, Italian researchers followed 147 patients who had been hospitalized for COVID-19 and found that 87% still had symptoms 60 days after they were discharged from the hospital. A more recent study, published in January, found that 76% of hospitalized COVID-19 patients in Wuhan, China, were still experiencing symptoms six months after first getting sick.

This Wuhan study was particularly interesting because the researchers used objective measures to evaluate the people reporting lingering symptoms. People in the study were still reporting persistent breathing problems six months after getting sick. When researchers performed CT scans to look at the patients’ lungs, many of the scans showed splotches called ground-glass opacities. These likely represent inflammation where SARS-CoV-2 had caused viral pneumonia. Additionally, the people in this study who had severe COVID-19 could not walk as fast as those whose illnesses were less severe – these lung problems reduced how much oxygen was moving from their lungs into their bloodstream. And remember, this was all measured six months after infection.

Other researchers have found similar objective health effects. One study found evidence of ongoing viral pneumonia three months after patients left the hospital. Another study of 100 German COVID-19 patients found that 60% had heart inflammation two to three months after initial infection. These German patients were relatively young and healthy – the average age was 49, and many had not needed hospitalization when they had COVID-19.

The sickest COVID-19 patients are not the only ones to suffer from long COVID. Patients who had a milder initial case that didn’t result in hospitalization can also have persistent symptoms.

According to a recent survey done by the Centers for Disease Control and Prevention, 35% of nonhospitalized patients who had mild COVID-19 cases did not return to baseline health 14 to 21 days after their symptoms started. And this wasn’t just in older people or people with underlying health conditions. Twenty percent of previously healthy 18-to-34-year-olds had ongoing symptoms. Overall, research shows as many as one-third of individuals who had COVID-19 and weren’t hospitalized will still be experiencing symptoms up to three months later.

To put these numbers in context, only 10% of people who get the flu are still sick after 14 days.

Long-term symptoms, long-term effects

The medical community still does not know just how long these symptoms will persist or why they occur.

According to recent research that has yet to be peer-reviewed, many long-haulers cannot return to work or do normal activities because of brain fog, pain, or debilitating fatigue. Before my patient got sick, he would bike up a mountain in our Colorado town almost every day. It took him four months to recover to the point where he could climb it again.

SARS-CoV-2 hurts people in more ways than the medical community originally recognized. At Colorado State University, my colleagues and I are studying long-haulers and exploring whether immune system imbalances play a part in their disease process. Our team and many others are diligently working to identify long-haulers, to better understand why symptoms persist and, importantly, to figure out how the medical community can help.

Stephanie LaVergne, research scientist, Colorado State University

The Conversation
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