School Reopening Recommendations from SickKids
COVID-19: Guidance for School Re-Opening argues that the primary impetus for school re-opening should be “to optimize the overall health and welfare of children and youth, rather than solely to facilitate parent/caregiver return to work or reopening of the economy”.
The authors state, “it is critical to balance the risk of direct infection and transmission of SARS-CoV-2 in children and youth, school staff and the community with the harms of school closure, which is impacting children and youth’s physical health, developmental health, mental health and learning. Based on the evidence available at the present time and the current epidemiology, it is our view that the adverse impacts of school closure on children and youth significantly outweigh the current benefit of keeping schools closed in order to reduce the risk of COVID-19 in children, youth, school staff and the community at large.”
The paper cites data from multiple countries suggesting that children under the age of 10 are probably less likely to transmit the virus than are older children or adults, however it stresses that ongoing surveillance and research will be necessary once schools reopen, particularly on the role of children and youth who are asymptomatic in propagating transmission. The recommendation of the document is “that children and youth return to a daily school model with risk mitigation strategies in place,” and that backup plans be in place for temporary transition to hybrid or full-time distance learning should a large-scale school-based outbreak occur.
The document expresses concern based on emerging evidence indicating that the social and economic burden of COVID-19 disproportionately impacts racialized communities and those with less wealth. As well as housing and health-care access issues and other risk factors, “distance learning further disadvantages children and youth living in higher-burden COVID-19 areas where socioeconomic and language barriers limit access to quality online learning. The effect on these children’s and youth’s education has already been substantial and further delays of return-to-school will almost certainly compound educational disparities.”
The discussion paper reviews a variety of risk mitigation issues, giving detailed recommendations in each area. We have extracted some comments of particular relevance for families with younger children:
1. Screening to prevent symptomatic individuals from entering the school: “It is essential that strict screening and exclusion policies are in place for students and employees who are symptomatic or have been exposed to SARSCoV-2 and directed to self-isolate by public health.”
2. Hand hygiene: “SARS-CoV-2 and other respiratory viruses are primarily spread by respiratory droplet transmission and should be the focus of preventative measures. As a result, and because virus shedding may occur prior to symptom onset or in the absence of symptoms, routine, frequent and proper hand hygiene (soap and water or hand sanitizer) is critical to limit transmission. Proper hand hygiene is one of the most effective strategies to prevent the spread of most respiratory viruses, including SARS-CoV-2, alongside respiratory etiquette, particularly during the pre-symptomatic phase of illness.”
3. Physical distancing: “Physical distancing will likely be difficult to strictly enforce in elementary school children, but developmentally and age-appropriate education can emphasize the importance of hand hygiene, avoiding body fluid exposure, avoiding putting toys in their mouth good respiratory etiquette and avoiding close contact especially for long periods of time (e.g. touching, hugging, hand holding).”
“During outdoor activities, such as recess, physical distancing should not be strictly enforced especially in elementary school children. A cohorting strategy is preferred. All students should perform hand hygiene before and after sports activities/outdoor play/playground use. “
4. Non-medical and medical face masks for students: “The use of non-medical cloth masks/face coverings (NMMs) in the school setting is a complex and nuanced issue. Unfortunately, current evidence does not provide clarity on the optimal approach and needs to consider the broad range of student ages and developmental levels, the varying ability to practice physical distancing indoors, as well as the dynamic level of risk associated with community spread at any particular time and within specific communities.”
“In children and youth, there are limited data on the effectiveness of NMM use for source control, but there remains a theoretical benefit especially for older children and youth. However, in order to be effective, NMMs would need to be worn correctly, which for many otherwise healthy children and youth will be difficult to do for a full school day; even more significant barriers exist for children and youth with underlying medical, developmental and mental health conditions.”
5. Cohorting: “The purpose of cohorting is to limit the mixing of students and staff so that if a child/youth or employee develops infection, the number of exposures would be reduced. It also allows for more timely case and contact follow-up…. Cohorting is likely most beneficial in elementary school children where physical distancing is less practical.”
“The benefits of cohorting will be attenuated in many, such as those who require bus transport to school and those who require after-school care; such children could potentially be present in several cohorts (e.g. class cohort, bus cohort, after-school cohort).”
“To the extent possible, cohorting classes could be considered for the younger age groups and for children and youth with medical and/or behaviour complexities (see Section 9), so that students stay mostly with the same class group and there is less mixing between classes and years. This applies to both indoor as well as selected prolonged outdoor activities with close physical interactions.”
6. Environmental cleaning: “A regular cleaning schedule, using Health Canada approved disinfectants, should be used with emphasis on high-touch surfaces and washrooms. Efforts should be made to reduce the need to touch objects/doors (no-touch waste containers, prop doors open). Policies to ensure there is “no sharing” of food, water bottles or cutlery should be enforced as a priority. The importance of hand hygiene to children after contact with any high-touch surface (such as door handles) should be reinforced. When possible, toys and class equipment that can be cleaned and disinfected by staff and/or students (as appropriate) should be used.”
7. Ventilation: “Adequately ventilated classroom environments (e.g. open windows with air flow, improved airflow through ventilation systems and reduction in recirculated air) are expected to be associated with less likelihood of transmission compared with poorly ventilated settings… Attention should be paid to improving classroom ventilation (e.g. optimizing ventilation system maintenance and increasing the proportion of outside air brought in through these systems) in consultation with experts in physical plant design and modification.“
“The use of outdoors or environments with improved ventilation should be encouraged (e.g. keeping windows open, weather permitting).”
8. Mitigation of risk for students at higher risk for severe disease: “The majority of children and youth with underlying medical conditions should be able to safely attend school provided that the appropriate enhanced safety measures are in place. However, it is recommended that parents/caregivers discuss this with the child’s health-care providers so that they can make an informed decision based on individual circumstances. This is particularly relevant for children with newly diagnosed illnesses requiring the first-time use of new or augmented immunosuppression.”
9. Special considerations for children and youth with medical, physical, developmental and/or behavioural complexities: “Return to school will present unique challenges to children and youth with medical, developmental and/or behavioural complexities and their families. This includes children requiring intensive supports for activities of daily living and/ or medical conditions, such as feeding, toileting or breathing supports. Many of these families have had a prolonged period of time in home isolation compounded by a lack of respite and/or homecare supports. In particular, the challenges for families and children/youth with neurodevelopmental disorders, such as autism spectrum disorder, caused by cessation of school during the pandemic have been identified. Transitioning medically and behaviourally complex children and youth back to school requires specific focus and should be prioritized as many of these children/youth and families have been disproportionately impacted by the pandemic response and are already in crisis mode. Consultation with their parents and families to better understand their individual circumstances and needs is recommended.”
10. Mental health awareness and support for all children: “Flexibility in program and/or school enrolment should be provided for children and youth who have transitioned to a new program or school for the 2020-2021 school year. Students who are particularly anxious about attending a new school should be offered the opportunity to visit the school in the week prior to the first day of school. “
“Increased and timely in-school educational support should be provided to students and classroom teachers to enable early identification and remediation of learning gaps that some students will have incurred during the school closures.”
“Teachers should be vigilant to potential child maltreatment situations given current concerns regarding possible elevated risk of child maltreatment that may have been undetected during the period of school closures.“
“Children and youth with mental health concerns may or may not require graduated transition back to school; where required, active communication between the school, parent, youth and therapist should be undertaken on a regular basis to ensure continued progress toward full-time return to school.“
“Accessible mental health support services adapted for diverse groups and at-risk populations should be provided, ideally in collaboration with educators, mental health professionals, and paediatricians.”
11. Protection of teachers and school staff: “Although this document is focused on school-aged children and youth, we believe the safety of school staff is paramount, with the goal of having teachers and school staff, at a minimum, as safe in the classroom as they would be in other community or work environments. We recognize the tremendous challenge that teachers face from a personal, health perspective, as well as from an operational lens.“
12. Protection of at-risk persons or families: “With regards to children and youth’s home environment, it would be appropriate to consider the risk posed by potentially infected children/youth and school staff to household members (e.g. children, siblings, parents, grandparents, roommates). The risk posed by SARS-CoV-2 likely varies in relation to socioeconomic status, household overcrowding and the presence of other children/youth and adults at increased risk of severe COVID-19 at home.”
13. Management of suspected and confirmed SARS-CoV-2/COVID-19 cases and their contacts: “It is anticipated that there will be cases of symptomatic and asymptomatic SARS-CoV-2 infection identified at schools and it is important that public health authorities and schools be prepared to respond to cases involving both students and staff. This includes the need for readily available testing and contact tracing, which is critical for the timely detection and avoidance of outbreaks. Parents and caregivers need to be empowered by their employers to be able to take paid sick days and/or work remotely if their children/youth are not able to attend school.”
14. Communicating about COVID-19 to children, youth and parents/caregivers: “Parents/caregivers should be made aware that SARSCoV-2 causes mild disease in the majority of children, youth and young adults. The best overall strategy for these cohorts and the population at large, taking into account the massive secondary adverse health and well-being implication of the lockdown, is to return to school with enhanced safety measures in place.”
“Ensuring up-to-date childhood immunizations, as well as annual influenza vaccination, should be promoted as a strategy to reduce the circulation of a common infectious agent circulating in fall/winter and thus limit, where possible, other preventable infections.”
15. Opportunities to improve evidence-based decision making: “Decisions about reopening schools in the safest way possible for students, families, teachers and other school staff are of unprecedented complexity especially given the existing gaps of evidence-based data relating to SARS-CoV-2 transmission and effectiveness of mitigation strategies in children. As schools begin to reopen over the coming months, this represents an opportunity to conduct rigorous research that will help close the knowledge gap and will therefore continue to improve and inform decision-making during the school year.”
16. Additional considerations: “Guidance for their safe return to work should be developed in collaboration with occupational health and safety and public health groups. In particular, bus drivers and transportation to school is an important consideration that will need detailed recommendations, including bus scheduling options, addressing bus capacity, and other safe operational considerations.”
“Guidance for parents/caregivers and children/youth on alternative travel options should be developed. One potential concern is that more parents/caregivers will drive their children/youth to school, either because of reduced school bus capacity (related to public health measures for buses) or because they feel it is safer, which could increase traffic congestion and risk of pedestrian injury. Strategies to accommodate such a scenario could include enhanced safety supervision and education, and expanding drop-off and pickup locations near the school. For children and youth who do not live far from school, walking or cycling/scootering should be encouraged, weather permitting. Expanded facilities for storage of bicycles and scooters may be needed.”