Summary
What is already known about this topic?
In-person child care offers significant developmental benefits for children; however, child care facilities have been identified as settings where SARS-CoV-2 transmission can occur.
What is added by this report?
This report highlights the successful implementation of CDC-recommended guidelines and supplementary measures within Head Start and Early Head Start programs that remained operational. These programs effectively delivered in-person learning by adopting these strategies, providing a model for mitigating virus transmission in similar child care environments.
What are the implications for public health practice?
The consistent application and monitoring of recommended mitigation strategies are crucial for minimizing SARS-CoV-2 transmission risks in child care settings. These proven methods are adaptable to other early care and education facilities offering in-person programs, potentially playing a significant role in controlling the spread of coronavirus disease 2019.
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Head Start programs, encompassing Head Start for preschool-aged children (3–5 years) and Early Head Start for infants, toddlers, and expectant mothers, are vital in fostering early learning and healthy development for children from birth to 5 years from families meeting federal poverty guidelines across the U.S. These initiatives are federally funded through grants managed by the Administration for Children and Families (ACF), a division of the U.S. Department of Health and Human Services. In response to the COVID-19 pandemic, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was enacted in March 2020, allocating $750 million to Head Start, which translated to roughly $875 per enrolled child in CARES Act funding. As the pandemic unfolded, most states mandated K-12 school closures or shifts to virtual learning. The Office of Head Start granted flexibility to local programs that chose to remain open, allowing them to utilize CARES Act funds to implement CDC-recommended guidance and additional supportive measures. This was crucial for maintaining in-person services during the early stages of SARS-CoV-2 community transmission in April and May 2020, a period when many comparable programs were suspended. The CDC guidelines included recommendations on mask usage, personal protective equipment, facility layout, necessary supplies for hygienic environments and operations, and the importance of increased staffing to maintain smaller class sizes. Head Start programs demonstrated success in applying these CDC mitigation strategies and other supportive practices, effectively minimizing SARS-CoV-2 transmission among both children and staff. To document these effective approaches and inform mitigation strategy implementation in other child care contexts, the CDC undertook a mixed-methods analysis. The findings emphasize that consistent implementation and monitoring of recommended mitigation strategies are key to reducing COVID-19 transmission within child care settings. These strategies are applicable to a broader range of early care and education settings that continue to offer in-person learning, potentially contributing to a significant reduction in SARS-CoV-2 spread.
In collaboration with the ACF, the CDC conducted a comprehensive mixed-methods study between September and October 2020, focusing on Head Start programs across eight states: Alaska, Georgia, Idaho, Maine, Missouri, Texas, Washington, and Wisconsin. The Office of Head Start selected these programs, each comprising between five and 17 centers and serving 500–2,500 children. The study was structured in four phases: reviews of Standard Operating Procedures (SOPs) for COVID-19 mitigation, an online survey for program directors to record implemented mitigation strategies and reported COVID-19 cases, in-depth interviews with staff from five programs, and observational virtual visits to a Head Start site to assess mitigation strategy implementation. This project underwent CDC review and was conducted in accordance with federal law and CDC policy.
Following state-mandated closures in April and May, which ranged from two weeks to two months, all program sites reopened with a hybrid learning model, combining in-person and virtual instruction. The Office of Head Start provided administrative flexibility regarding funding use, promoted innovative approaches to CDC guidance implementation, and offered resources for deploying multiple concurrent prevention strategies. This included webinars for over 240,000 staff members, parents, community members, and partners. All programs developed SOPs between March and April 2020, initiating implementation in April. These SOPs addressed comprehensive mitigation practices and promoted behaviors aimed at reducing infection spread, fostering healthy environments, ensuring healthy operations, and outlining procedures for managing identified COVID-19 cases.
Seven out of the eight Head Start programs, representing 55 centers, participated in the survey. All respondents confirmed the implementation of SOPs and their adaptation based on guidance from local public health authorities or education departments, as well as local transmission levels and other relevant factors. Multiple strategies were implemented simultaneously, including comprehensive training for teachers, encouraging caregiver adherence to SOPs and mitigation strategies, instituting flexible medical leave policies for staff, providing and mandating mask use for all staff and children, and closely supervising handwashing and sanitizing among children (see Box). Variations were observed in health screening methods for staff and children, with self-administered temperature checks upon arrival being the most common for staff. For children, symptom screening upon arrival was most frequently reported. Mask policies for children varied, with exemptions noted for children aged.
All programs reported having established protocols for managing children and staff exhibiting COVID-19 symptoms. Three programs reported a total of nine cases among children across three centers (ranging from one to four cases per center) during May and June. In each instance, administrators adhered to SOPs for notification, isolation, facility closure, and thorough cleaning and disinfection. Each of the three centers was temporarily closed for in-person services for 14 days following case identification, but continued to offer virtual learning options. All respondents from the seven programs indicated the presence of designated isolation areas within their centers. One program did not specify whether a designated isolation area existed but confirmed the capacity to isolate suspected cases. All but one program had protocols in place for collaborating with local health departments upon identifying a positive case, and all confirmed that local health departments would be contacted if cases arose. Additionally, all programs had established procedures for informing parents or caregivers of close contacts.
Interviews were conducted during September and October with program directors from five states (Alaska, Georgia, Maine, Missouri, and Wisconsin), as identified by the Office of Head Start. A recurring theme was the operational and staffing flexibility afforded to programs. This included flexible medical leave, enhanced pandemic benefits such as financial support for healthcare-related expenses, and remote work opportunities. Staff members at higher risk of severe illness due to underlying conditions or age, and those with caregiving responsibilities, were offered virtual or hybrid teaching roles, flexible hours, and staggered shifts. Policies were enacted to ensure staff could stay home when necessary without fear of job insecurity or negative repercussions. Beyond providing PPE like gloves and masks, staff received cleaning and other essential supplies. They also benefited from training, continuous SOP reinforcement, and incentives for adhering to mitigation strategies, such as financial incentives for purchasing additional supplies in one program.
Another key theme was the importance of ongoing, clear communication among program administrators, parents/caregivers, teachers, and staff to ensure comprehensive understanding of SOPs. Communication methods included updates on program websites, instructional videos, written materials, virtual meetings, media engagement, social media updates, and informational signage at facilities.
Factors that facilitated successful mitigation strategy implementation included extensive and consistent communication to staff and parents, continuous staff training and support, ongoing engagement with community partners and parents, and strong collaborations with program nurses, local health departments, hospital systems, and community organizations like United Way and Boys & Girls Clubs. Challenges encountered included maintaining recommended social distancing, ensuring adequate ventilation, addressing weather-related concerns moving into fall and winter, managing parental mental health issues (such as stress, depression, anxiety, and trauma related to bereavement from COVID-19), addressing concerns about the impact of mask-wearing on infant and toddler psychosocial development, sustaining vigilance in adherence to guidelines, and addressing perceptions of over-caution.
A virtual visit to a Head Start site in Texas confirmed that staff and children were consistently practicing social distancing. In classrooms with children aged.
Discussion
It is well-documented that children can contract and transmit SARS-CoV-2 within school and child care environments. Since the onset of the COVID-19 pandemic, Head Start and Early Head Start programs have effectively applied CDC-recommended mitigation strategies and developed innovative approaches to minimize SARS-CoV-2 transmission among children, educators, and staff. This was achieved through maximizing program flexibility and strategically allocating financial and human resources. As the CDC’s understanding of COVID-19 evolved, the agency provided updated guidance for various settings, including child care programs, refining recommendations for screening children upon arrival. This guidance is designed to prevent the admission of children with fever or other illness symptoms and suggests additional measures for situations where PPE supplies may be limited.
Investigations into SARS-CoV-2 transmission in Rhode Island and Utah have indicated that the implementation of CDC-recommended mitigation strategies played a crucial role in limiting virus transmission within child care facilities in these states. This report further illustrates how a comprehensive, multi-faceted approach to SARS-CoV-2 mitigation, particularly within early care and education settings like Head Start programs, can effectively slow transmission, evidenced by the low incidence of reported cases. The allocation of financial and staffing resources to prioritize mitigation strategies, coupled with robust support systems for staff and parents, were critical components. These measures helped to minimize the potential adverse impacts associated with child care center closures, such as job and wage losses for providers, challenges for parents returning to work, and reduced educational, social, and nutritional opportunities for children.
The consistent implementation and monitoring of CDC-recommended mitigation strategies are vital in diminishing SARS-CoV-2 transmission risks in child care settings. The CDC has developed various tools and resources for child care programs, including evaluation questions, relevant qualitative and quantitative indicators, and suggested data sources to assess the effectiveness of COVID-19 mitigation strategies in these environments. For instance, child care facilities can identify facilitators, obstacles, and other factors influencing the successful implementation of mitigation strategies. Baseline data, including program characteristics like enrollment numbers, child-to-staff ratios, parental and community attitudes and involvement, and staff/volunteer retention and attrition rates, can be invaluable. This data can help pinpoint gaps and areas where mitigation strategies can be enhanced or newly implemented.
The findings of this report are subject to certain limitations. Firstly, this qualitative descriptive analysis may not be fully generalizable beyond the Head Start programs studied. However, the programs were selected to represent geographical diversity across all four U.S. Census regions. Secondly, while the study documents mitigation strategies and outcomes, it cannot definitively attribute outcomes solely to these strategies. Nonetheless, the efficacy of multicomponent mitigation approaches in reducing SARS-CoV-2 transmission is supported by existing research. Further evaluation is necessary to fully understand the dynamics of multicomponent mitigation strategies in child care settings that remain open for in-person learning, especially in areas with high community transmission rates.
The advantages of child care programs, such as supporting developmental milestones, providing nutritional support, fostering socialization, and enhancing mental health, are well-recognized. Understanding the capabilities of child care programs in implementing COVID-19 mitigation strategies offers practical insights for public health officials, child care administrators, and evaluators. This knowledge is crucial for effectively implementing and adapting strategies to reduce SARS-CoV-2 transmission. Child care settings should adopt concurrent preventive measures and dynamically adjust these strategies based on current community transmission data.
Acknowledgment
Jason M. Clemmons, Office of Head Start.
Corresponding author: Fátima Coronado, FCoronado@CDC.gov.
1CDC COVID-19 Response Team; 2Office of Head Start, Washington, DC; 3Educare Learning Network, Chicago, Illinois.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* https://aspe.hhs.gov/poverty-guidelines.
† https://www.acf.hhs.gov/ohs/about/head-start.
§ https://home.treasury.gov/policy-issues/cares.
¶ 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 501 et seq.
** https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html.
†† https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
§§ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.
References
BOX. COVID-19 mitigation strategies implemented by Head Start and Early Head Start child care programs — eight states,* September–October 2020
Everyday prevention actions
- Reinforcement of hand hygiene behavior and respiratory etiquette
- Supervised handwashing and hand-sanitizing for children
- Intensified cleaning and disinfection efforts (e.g., with toys, frequently touched surfaces, and bedding)
- Required use of masks for staff members, visitors, and children aged >2 years
- Social distancing to the extent possible
- Daily health screening procedures on arrival for children and staff members
- Drop-off and pick-up procedures
- Monitoring for absenteeism
- Ability to monitor and restock supplies
- Steps to increase ventilation including installation of ion air purifiers
- Steps to decrease occupancy in areas without increased ventilation
- Use of outdoor space as much as possible
- Cohorting by classroom to minimize exposure between groups
Actions when someone is ill
- COVID-19 point of contact identified
- Staff members trained in COVID-19 safety protocols
- Requiring ill children and staff members to stay at home
- Vigilance for symptoms
- Daily screening of staff members and children for signs and symptoms before facility entry
- Standard operating procedures for when a child or staff member experiences symptoms
- Identification of isolation room
- Plan to notify local health official of COVID-19 cases
- Plan to distribute instructions for primary care referral, testing, or both
- Plan to distribute instructions or guidance for home isolation
- Plan to require close contacts to wait 14 days before returning
- Flexible COVID-19 medical leave policies for staff members
Communications and support
- Training and ongoing reinforcing of standard operating procedures and mitigation measures with caregivers, teachers, and other staff members
- Vigilance and training for the identification of COVID-19 related symptoms
- Masks and other personal protective equipment (e.g., face shields and gowns) provided to teachers and other staff members
- Incentives to adhere to mitigation strategies
- Flexible medical leave policies for staff members with emphasis on persons at higher risk for severe illness and those with caregiving responsibilities
- Flexible work hours and staggered shifts
- Telework options for staff members at higher risk for severe illness
Abbreviation: COVID-19 = coronavirus disease 2019. * Alaska, Georgia, Idaho, Maine, Missouri, Texas, Washington, and Wisconsin.
Suggested citation for this article: Coronado F, Blough S, Bergeron D, et al. Implementing Mitigation Strategies in Early Care and Education Settings for Prevention of SARS-CoV-2 Transmission — Eight States, September–October 2020. MMWR Morb Mortal Wkly Rep 2020;69:1868-1872. DOI: http://dx.doi.org/10.15585/mmwr.mm6949e3.
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