In school nurses' offices around Vermont, runny noses, strep throat and stomach ailments are resurging. After two years of keeping a laser-like focus on COVID-19, school nurses report a return of perennial childhood health ailments that were likely kept at bay by masks and other measures intended to prevent COVID-19 transmission.

Those face coverings have largely come off since the state lifted its masking guidance on March 14 — and, with them, some of the benefits that health experts say kept cases of the common cold and stomach flu to lower-than-normal levels. Because low-grade illnesses such as colds are not tracked systematically, the evidence of a comeback is mostly anecdotal. But school nurses say the run-of-the-mill ailments that used to occupy most of their time have returned to pre-COVID-19 levels.

Pediatrician Tracy Tyson of Monarch Maples Pediatrics in St. Albans and Enosburg Falls backs up their ground-level observations.

"We're definitely seeing more illness now than we have the last two years," Tyson said.

Research published last year in the journal Academic Pediatrics found that pediatric sick visits declined during the first seven months of the pandemic.

Few people sought emergency care for influenza-like illnesses during the past two flu seasons, according to the Vermont Department of Health. During the 2020-21 flu season, University of Vermont Medical Center, Southwestern Vermont Medical Center and Central Vermont Medical Center reported a total of just 13 positive flu tests, compared to 2,013 a year earlier — before the pandemic. Many people avoided doctors' offices and hospitals during the pandemic to limit their risk.

COVID-19 has by no means left the building. Districts are no longer required by the state to track positive COVID-19 tests unless they are administered in schools, so it's hard to gauge how prevalent the virus is right now. In some schools, though, cases are climbing back up.

At Essex High School, there's been a "higher than usual number" of COVID-19 cases in the last few weeks, according to Essex Westford School District's COVID-19 coordinator, Diana Smith. Vergennes Union Elementary School, which has 285 students, reported 30 COVID-19 cases among students and staff during the first week of April, Addison Northwest superintendent Sheila Soule said last Friday.

Addison Central School District's COVID-19 coordinator, Kelly Landwehr, a nurse at Middlebury Union High School, has been dealing with a COVID-19 outbreak at Cornwall Elementary School, as well as rising cases in other schools over the last few days. But she's also spending her time on more typical nursing duties.

In an email to Seven Days, Landwehr wrote that on a recent day she met with the state epidemiology team to discuss COVID-19 cases but also cared for students with headaches, sore throats, splinters, anxiety and fatigue.

In the Champlain Valley School District, COVID-19 coordinator Jocelyn Bouyea, a nurse at Shelburne Community School, said that at the request of parents, she continues to update a weekly COVID-19 dashboard for the district's six schools, which saw 38 cases last week. When it comes to non-COVID-19 illnesses, Bouyea said that what has stood out most is the change in mindsets of both adults and children about spreading illness.

"You used to be rewarded or praised for dragging your sick butt to work," Bouyea said. "I think people are just much more aware of sickness than they were before. If you had a runny nose, pre-COVID, you wouldn't have called your doctor for a test."

A heightened awareness of disease transmission has made people more cautious about how their germs might affect others, Bouyea said. Some students are anxious and preoccupied with spreading germs.

On the flip side, a number of school nurses noted that since the official masking guidance was lifted a few weeks ago, students have relaxed precautions that were emphasized for the past two years.

"There are other things that happen when masks come off: We forget to wash our hands; we forget that we're close to someone who has germs," said Vermont State School Nurses Association president Becca McCray, who works as a nurse at Edmunds Middle School in Burlington. She likened the situation to someone getting a cast taken off and "all of a sudden, they're more apt to have an injury because that cast was a visual sign that they were someone that needed to be more protective of their body."

Middlebury nurse Landwehr said she's noticed students reverting to pre-COVID-19 practices, such as sharing drinks and snacks.

"Masks coming off definitely did bring about a certain amount of complacency," she said.

Landwehr said adults in the school community should continue to remind kids how to prevent infections with nudges such as, "Let's remember why we had our own water bottle and why we were washing our hands before we had lunch."

During the pandemic shutdowns, keeping sick kids out of school helped prevent the spread of illness. Some parents now find it more difficult to keep children home if their employer doesn't approve of them staying home with sick kids.

It has also become trickier to judge when students should be kept out of school. Families became accustomed to using diagnostic COVID-19 tests to determine whether their kids should attend school. Now, parents must decide based on less clear-cut information when it comes to garden-variety illnesses.

"What is healthy?" Bouyea said. "That's all very subjective, and it's very hard for parents. They want something measurable ... Those algorithms we've had for the last two years have been so black-and-white."

Some nurses say they have observed kids showing up to school sick but asserting that it was acceptable because they had tested negative for COVID-19 at home.

Soph Hall, a Kingdom East School District nurse, tells families that kids should stay home if they are unwell — COVID-19 or not.

Bouyea offers similar advice: "If your student has symptoms that are going to make it hard for them to be a student today, then they should stay home."

Contact tracing during COVID-19 illustrated for people how the tendrils of contagious illness spread, Hall said. "Two years of not having sick kids in school and not having sick adults in school should have set a precedent," she said.

But in order for that precedent to have a lasting impact, some say, a larger societal shift is necessary.

McCray said that when she has asked high school students why they came to school sick, they have told her they worry about missing work and falling behind, and in some cases feel pressure from their teachers not to miss school.

She said the Agency of Education should rethink its truancy policy, which calls for schools to send formal letters to families starting when children miss five days of school, even if those absences are excused due to sickness.

"Parents should be rewarded and not punished for keeping kids home," McCray said.

Tyson, the Franklin County pediatrician, said that while she used to write doctor's notes mainly giving kids permission to go back to school after being sick, she now often finds herself writing to employers, asking them to excuse parents because their child is ill.

Parents "are getting a lot more pushback. They had to take so many days off this past year whenever their kid was exposed," Tyson said.

Kingdom East school nurse Hall said visibly ill students have told her that their parents directed them not to go the nurse's office during school hours because they can't miss more days of work. Hall said she tries to reassure them that calling home when they feel sick at school is the right thing to do.

"We need to do something more for our working families, because not showing up to work and not having money coming in sucks, and a lot of [parents] just don't have paid sick time," Hall said. "And that's an incredible burden for a family or child to live with."