Implementing Mitigation Strategies in Early Care and Education Settings for Prevention of SARS-CoV-2 Transmission

Eight States, September-October 2020

Fátima Coronado, MD; Sara Blough, MPH; Deborah Bergeron, PhD; Krista Proia, MPH; Erin Sauber-Schatz, PhD; Marco Beltran, DrPH; Katherine Troy Rau, MSW, MPP; Andria McMichael, EdD; Tracye Fortin, MA; Mark Lackey; Jovanna Rohs, PhD; Tracey Sparrow, EdD; Grant Baldwin, PhD


Morbidity and Mortality Weekly Report. 2020;69(41):1868-1872. 

In This Article

Abstract and Introduction


The Head Start program, including Head Start for children aged 3–5 years and Early Head Start for infants, toddlers, and pregnant women, promotes early learning and healthy development among children aged 0–5 years whose families meet the annually adjusted Federal Poverty Guidelines* throughout the United States. These programs are funded by grants administered by the U.S. Department of Health and Human Services' Administration for Children and Families (ACF). In March 2020, Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act,§ which appropriated $750 million for Head Start, equating to approximately $875 in CARES Act funds per enrolled child. In response to the coronavirus disease 2019 (COVID-19) pandemic, most states required all schools (K-12) to close or transition to virtual learning. The Office of Head Start gave its local programs that remained open the flexibility to use CARES Act funds to implement CDC-recommended guidance[1] and other ancillary measures to provide in-person services in the early phases of community transmission of SARS-CoV-2, the virus that causes COVID-19, in April and May 2020, when many similar programs remained closed. Guidance included information on masks, other personal protective equipment, physical setup, supplies necessary for maintaining healthy environments and operations, and the need for additional staff members to ensure small class sizes. Head Start programs successfully implemented CDC-recommended mitigation strategies and supported other practices that helped to prevent SARS-CoV-2 transmission among children and staff members. CDC conducted a mixed-methods analysis to document these approaches and inform implementation of mitigation strategies in other child care settings. Implementing and monitoring adherence to recommended mitigation strategies reduces risk for COVID-19 transmission in child care settings. These approaches could be applied to other early care and education settings that remain open for in-person learning and potentially reduce SARS-CoV-2 transmission.

In collaboration with ACF, CDC conducted a mixed-methods study during September–October 2020 in Head Start programs in eight states (Alaska, Georgia, Idaho, Maine, Missouri, Texas, Washington, and Wisconsin). Head Start programs, each with five to 17 centers and 500–2,500 children, were selected by the Office of Head Start. The four-phase study design included reviews of standard operating procedures (SOPs) for COVID-19 mitigation, deployment of an online survey for program directors to document mitigation strategies implemented and COVID-19 cases reported, in-depth interviews with staff members from five programs overall, and observation of mitigation strategy implementation during a virtual visit to one Head Start site. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.

All program sites closed for periods ranging from 2 weeks to 2 months after state-initiated mandates in April and May and upon reopening offered a hybrid** learning model (i.e., in-person and virtual). The Office of Head Start allowed administrative flexibility in how programs could use funding, encouraged innovation in implementing CDC guidance,[1] and provided resources for implementing multiple concurrent preventive strategies (e.g., delivery of webinars to >240,000 staff members, parents, community members, and partners). All programs developed SOPs during March–April 2020 and began implementing these procedures in April. All SOPs covered multicomponent mitigation practices and promoted behaviors designed to reduce infection spread, create healthy environments, facilitate healthy operations, and explain procedures to follow in the event of identification of a COVID-19 case.

Seven of eight Head Start programs, representing 55 centers, responded to the survey. All reported implementing SOPs and adjusting them depending on guidance from the local public health authorities or education department, local level of transmission and related factors described below. Multiple strategies were implemented simultaneously, including training teachers and encouraging caretakers to adhere to SOPs and mitigation strategies; instituting flexible medical leave policies for staff members; providing and requiring use of masks for all staff members and children; and supervising handwashing and hand-sanitizing for children (Box). Variations regarding methods for screening the health of staff members and children were noted; among these methods, self-administered temperature checks upon arrival were most frequently reported for staff members. Screening for signs and symptoms†† of illness upon arrival was most frequently reported for children. Mask policies for children varied, and exemptions for children aged <2 years and those with special health care and education needs were allowed. All programs reported increased cleaning and disinfecting or sanitizing of high-traffic areas, high-touch surfaces, and toys. Five programs reported increasing cleaning and disinfecting of bedding and improving ventilation. Guidance from public health or education agencies and state or local mandates were the factors most commonly reported to influence decisions about SOP adjustments. Other, less frequently reported, factors included concerns about transmission of SARS-CoV-2 within facilities and perceived pressure from the community.

All programs reported having plans in place for managing children and staff members experiencing COVID-19 symptoms. Three programs identified nine cases among children in three centers (range = one to four cases per center) during May and June. Administrators followed SOPs for notification, isolation, facility closure, and cleaning and disinfection. All three centers were closed for in-person operation for 14 days after identification of a case but offered virtual options to continue providing services. Respondents from all seven programs reported that centers had a designated isolation area. One program did not report whether a designated isolation area existed; however, this program reported ability to isolate a suspected case. All but one program had a protocol for working with the local health department if a positive case was identified; all indicated that the local health department would be contacted if a case was identified. All programs had established procedures for notifying parents or caregivers of close contacts.

Interviews were conducted in September and October with program directors identified by the Office of Head Start in five states (Alaska, Georgia, Maine, Missouri, and Wisconsin). A common theme identified was the flexibility offered for staffing and operations, including flexible medical leave, enhanced benefits during the pandemic (e.g., additional financial benefits to cover health care–associated costs), and remote working options. Staff members who were at increased risk for severe illness§§ because of underlying medical conditions or age and those with caregiving responsibilities were offered virtual and hybrid teaching opportunities, flexible hours, and staggered shifts. Policies were put into place for staff members to stay at home without fear of job loss or other consequences. In addition to providing personal protective equipment (e.g., gloves and masks), staff members were furnished with cleaning and other supplies and were offered training, ongoing reinforcement of SOPs, and incentives to abide by mitigation strategies (e.g., a program provided a financial incentive for staff members to purchase additional supplies).

A second theme identified was ongoing communications among program administrators, parents and caregivers, and teachers and other staff members to ensure understanding of SOPs. Communications included updates on program websites, development of instructional videos, written information, virtual meetings, media coverage, social media postings, and posted signage at facilities.

Factors facilitating successful implementation of mitigation strategies included extensive communication with consistent messaging to staff members and parents; ongoing training and support to staff members; continuous engagement of community partners and parents; and collaboration with program nurses, local health departments, hospital systems, and community organizations (e.g., United Way and Boys & Girls Club). Challenges included maintaining recommended social distancing, ventilation, weather concerns during the fall and heading into winter, parental mental health concerns (e.g., chronic stress, depression, anxiety, and trauma related to losing a loved one to COVID-19), questions concerning effects of staff members wearing masks on infant and toddler psychosocial development, maintaining guidance vigilance, and concern that programs were being overly cautious.

A virtual visit to a Head Start site in Texas found that staff members and children observed social distancing. In rooms with children aged <2 years, mask use was only observed among staff members, per CDC guidelines. Physical dividers were observed, including an innovative playground divider purchased with CARES Act funding that allowed for more outdoor play time for children. Cleaning and disinfecting protocols were described, along with guidance for stocking and monitoring the supply room to ensure adequate supplies. Plans for responding to positive SARS-CoV-2 tests were reviewed, and all included a rapid notification system for all enrolled families. To continue enrollment for the fall, a contactless application system using quick-response codes on community flyers had been implemented.