Supplemental Information: COVID-19 and Safe Transportation in Motor Vehicles

During the COVID-19 pandemic, as always, all children should ride properly restrained in the appropriate car safety seat (CSS), belt-positioning booster seat, travel vest, or seat belt on every trip in every vehicle. Appropriate restraint use saves lives, and caregivers have a responsibility to transport children safely. (On public transit buses, or for older children on school buses, a separate restraint device may not be required.) Guidance is offered for families, schools, child care programs, social service agencies, and all who transport children in motor vehicles.

SARS-CoV-2, the virus that causes COVID-19, spreads during close contact from person to person, mainly through respiratory droplets produced by coughing, sneezing, or talking. Droplets can transmit infection when they land on mucous membranes, when inhaled, or less commonly through fomites or contaminated surfaces. Droplets can land and persist on surfaces, with potential secondary spread when touched. SARS-CoV-2 spreads easily and can be transmitted by those who may not have symptoms to others in the home or community.

The general and setting-specific guidance is offered in addition to established precautions to reduce the spread of SARS-CoV-2, including immunizations, use of face masks, physical distancing, and hand hygiene. The guidance should also be applied in the framework of the extent of SARS-CoV-2 transmission in the community. This guidance is intended to support mitigation of risk for a child or caregiver during transportation but cannot eliminate risk entirely. Current guidance from the American Academy of Pediatrics (AAP) includes wearing masks in school and child care for all children 2 years and older and staff, regardless of vaccination status; this includes during transportation on a school bus. This guidance is extremely important, because people who are asymptomatic may transmit SARS-CoV-2 even if vaccinated. In accordance with Centers for Disease Control and Prevention (CDC) recommendations, all bus drivers and support personnel should be vaccinated and wear masks properly on the bus. It is acknowledged that implementing this guidance may increase expense to schools, early childhood programs, child care providers, child welfare and foster care systems, and others. Because all programs must operate with the resources available to them, difficult choices may be necessary. The AAP strongly advocates for financial support from federal, state, and local governments to ensure that programs can operate as safely as possible.

General Guidance for the Management of Seating Systems

The proposed guidance is suggested during the COVID-19 pandemic to balance the needs of all individuals to access care, services, or other necessities while decreasing the risk of contracting SARS-CoV-2 infection during transport. This guidance provides information that providers may share with caregivers who request information on reducing the risk of contracting SARS-CoV-2 while traveling in motor vehicles.

If there has been a sick person or someone who tested positive for COVID-19 in your facility or vehicle within the last 24 hours, you should clean AND disinfect the space. Disinfection should be conducted using an Environmental Protection Agency (EPA)–registered disinfectant. 

Cleaning with products containing soap or detergent reduces germs on surfaces by removing contaminants and may also weaken or damage some of the virus particles, which decreases risk of infection from surfaces. 

Car safety seats and seat belts, as specified by the manufacturer, may be cleaned but must not be disinfected, because chemicals can degrade the necessary strength, possibly affecting crashworthiness. In most cases, all parts of car safety seats and vehicle seat belts can only be cleaned with mild detergent and water; this helps ensure the restraint system will perform as intended in the event of a crash. 

Vehicle passengers touch or engage seat belts or car safety seats (including conventional car safety seats, safety vests and harnesses, and attachable seating devices for school buses) when they secure themselves or a child for transportation in a motor vehicle. If SARS-CoV-2 has landed on the seat belt, harness, or car seat, a person is at risk for possibly being infected by this virus. Children frequently cough, sneeze, drool, and chew on harnesses and seat belts. If an occupant restraint system is used multiple times daily, it may serve as a fomite or vector to transmit the virus. 

Management of Seating Systems 

If no one with confirmed or suspected COVID-19 is known to have been in a space, cleaning once a day is usually sufficient to remove virus that may be on surfaces. 

• If an adult or child, is identified as being SARS-CoV-2 positive, any seat system that individual had contact with or was in proximity to (less than 6 ft/2 m) needs to be removed from service for at least 24 hours and then be cleaned according to the manufacturer’s specifications. If needed, a person who is positive for SARS-CoV-2 could continue to use his or her own seat for travel. However, other individuals should exercise due caution to prevent becoming infected. 
• Alternatively, because the manufacturers of seat belts, car safety seats, travel vests, and attachable seating devices for school buses do not allow disinfecting of components of the car safety seat and harness systems, that occupant restraint system should be removed from the vehicle using proper personal protective equipment (PPE) techniques as outlined by the CDC, labeled with a date, and stored either out of reach or in a securely tied plastic bag where no person will handle it and potentially be exposed to the virus. If possible, the car safety seat should ideally not be used for 72 hours to ensure all viral particles are inactivated. During this time, a substitute car safety seat or harness device must be used. 
  
  After that period, the car safety seat, seat belt, harness, and anchor systems can be returned to service. 
• Seat belts cannot be removed from vehicles for thorough cleaning, so the seating position used by the individual should be taken out of service ideally for 72 hours, after which the seat and seat belt can be returned to service.

Guidance for Carriers Who Transport Multiple Children 

• Because individuals can be contagious and spread the virus without having symptoms, people riding a bus with seat belts, harness systems, travel vests, or car safety seats should use the same device every trip, and the device should not be used by any other person. To facilitate accurate record of which child is using a specific child occupant restraint device, the child and car safety seat must be paired for each trip. As an additional measure, loading the bus from back to front and unloading from front to back may help reduce the risk of encountering viral particles exhaled by another passenger. It is recognized that organizations should have an organized seating plan and may need to expand their car safety seat and occupant restraint inventory to meet the need of their transportation requirements. 
• If the seating position or car safety seat is being used by the same individual on a daily basis and no one else uses the seating position, car safety seat, or harness and the individual is not showing symptoms of SARS-CoV-2 infection, then routine cleaning is appropriate. 
• If the person using a specific seat is suspected or identified to be SARS-CoV-2 positive, then the car safety seat, harness, or seat belt position should be removed from service for at least 72 hours. After that period, or if the person is determined not to have COVID-19, the device can be returned to service. Out of an abundance of caution, if vehicle stock permits, programs may choose to take the vehicle out of service during this period. 
• The seating area where the car safety seat used by a child infected with SARS-CoV-2 was anchored should be cleaned and disinfected if less than 24 hours has passed or cleaned if 24 to 72 hours has passed, according to manufacturer and CDC guidelines. 
• If the vehicle (car, bus, or van) is being used to transport multiple groups of children during a 24-hour period, then it is possible that an asymptomatic carrier may have occupied this seating position. Because of the risk of respiratory droplets being deposited on the seat, seat belt, and other harness devices, these areas should be cleaned between each group of children. Most vehicle seat manufacturers allow for disinfectant to the seat cushion material and surrounding area. However, seat belt manufacturers do not allow for disinfectant use on seat belts. A thorough airing of the vehicle, if practical based on location and weather, may facilitate dispersal of any viral particles present in the vehicle. 
• The safest approach is for organizations to use multiple vehicles or have multiple car safety seats or harness systems available to safely transport passengers while COVID-19 exists in the community. This increased expense may not be feasible for all programs. Policy makers should consider devoting appropriate resources for schools and child care, social services, and other programs that transport children so that these programs can operate safely. 
• Caregivers and organizations need to be informed and recognize that infection can be transmitted by asymptomatic individuals to unaffected contacts, including family members who may be at high risk if infected. 
• Passengers are generally at increased risk of crash injury when riding in a passenger car versus a school bus. Caregivers and organizations should thoughtfully weigh the risk of crash injury against the risk of SARS-CoV-2 transmission when selecting the form of transportation a student will use to access education. 

Guidance for Children and the Use of Public Transit Systems 

• Public transit systems present situations in which the risk of contracting an infectious disease may be increased. Risk is particularly increased in municipalities that do not require masks and PPE while in public or when using public transportation. The frequent on-boarding and de-boarding of riders limits the ability of bus personnel to adequately disinfect surfaces. Also, it is difficult to enforce physical distancing on busy bus routes. Given these limitations, public transportation should be used sparingly and only if necessary, to reduce the risk of transmitting SARS-CoV-2 to an individual at higher risk. 
• When using public transportation, all riders, especially those in higher risk groups, should practice physical distancing, wear face masks, and practice frequent hand sanitizing. For added safety, passengers may consider wearing eye protection.

Guidance for Transportation of Children With Special Health Care Needs 

• Children with special health care needs should have the same access to proper resources for safe transportation as other children. However, they may present challenges because of physical limitations, airway issues, or behavioral problems. Each child’s specific needs must be taken into consideration while developing a plan for transportation. 
• Patients and caregivers who have an increased risk of infection should discuss with their medical provider ways to minimize risk of contracting COVID-19. Infants, children, and adolescents with compromised immune systems need to discuss with their medical team the risks and benefits of participating in public events, school, or school activities and decide on use of PPE, social distancing, and appropriate hygiene versus nonparticipation. 
• Infants, children, and adolescents with tracheostomy tubes for airway management present specific challenges. These individuals may need suctioning, airway clearance, or administration of medications while being transported. Care should be taken to reduce aerosolization of respiratory secretions and droplet deposition of SARS-CoV-2 or other infectious agents. Caregivers should wear PPE and practice standard precautions while caring for these children. Disinfecting surfaces and equipment in the vicinity (within 6 ft/2 m) of the child with a tracheostomy tube is recommended. Closed systems for either ventilation or humidity should be used to help limit spread of infectious agents to a person with a tracheostomy tube. 
• Infants, children, and adolescents who need to be transferred from one mobility platform to another while being transported on a school bus, multipassenger vehicle, or public transportation (eg, wheelchair to bus seat) need special consideration. Infants, toddlers, and young children should be transported in an appropriate car safety seat for age, size, and developmental status that is appropriately anchored to the vehicle seat. Guidance for the management of these seats during the COVID-19 pandemic is outlined above. Larger children who may transfer with assistance to a bus seat, although less safe, may need to remain in their wheelchairs to limit exposure. 

Additional Information

• COVID-19 Guidance for Safe Schools
• Guidance Related to Childcare During COVID-19
• COVID-19: How to Protect Yourself & Others (CDC)
• COVID-19: Cleaning and Disinfecting Your Home (CDC)