Sick Kids Hospital and Medical Officers of Health recommend schools open – with caveats

At the end of January, two different groups of medical experts made recommendations for re-opening schools: Sick Kids Hospital updated its guidance document on school operation during the pandemic, and the Council of Ontario Medical Officers of Health wrote a letter to Ontario’s Ministers of Education and Health – both groups point to evidence that in-person learning is better for students’ development and their physical and mental health.

The Medical Officers of Health emphasized that schools should begin to reopen before other sectors reopen.

However, both groups also warn that effective testing, control of community spread, reduction of risks for staff, and enhanced physical distancing are among the keys to successfully and safely keeping schools open.

The ongoing safe operation of schools is the primary responsibility of the Ministry of Education and should include input from several key stakeholders, including the Chief Medical Officer of Health, Ministry of Health, Ministry of Labour, public health authorities, teachers and other educators, principals, other school-related authorities, parents and children.

Sick Kids Report includes 17 key takeaways:

1. Active screening to prevent symptomatic individuals from entering the school: 

• There are a wide range of symptoms for COVID-19. For this reason, temperature-taking at school entry is no longer recommended. Parents should be provided with a screening checklist, and in areas where there is moderate to high community transmission, students with even one symptom (and their siblings) should be asked to stay home.
• The report also says support from employers and the government is essential and points to paid sick days and financial support for families as key to reducing the burden on families.

Employers and the government play a critical role in supporting parents/caregivers who need to stay at home with their child because their child is sick or in isolation due to SARS-CoV-2 infection or exposure. This support is essential to reduce the burden on parents/caregivers and reduce the likelihood parents/caregivers will need to send their child/youth to school with symptoms (e.g., paid sick days available for workers, financial supports for families).

2. SARS-CoV-2 testing for schools:

• All children with symptoms should be tested (rapid tests are not recommended).
• Targeted large-scale one-time school-wide asymptomatic testing is not recommended.
• Twice-weekly testing of asymptomatic students could be considered during periods of moderate to high community transmission, but it is not currently feasible because of available testing options. The report says this recommendation should be re-evaluated as new tests become available.

3. Hand hygiene

• Schools should have age-appropriate teaching about hand hygiene and a schedule for frequent hand hygiene. Hand sanitizer should be available in all classrooms.

4. Physical distancing

• Physical distancing is difficult to enforce with young children and may be detrimental to their development, so the focus should be on maintaining small group “cohorts” and masking.
• Physical distancing is recommended for middle and high school classrooms, but there was no consensus on the exact distance.
• The report says smaller classes should be a “priority strategy,” however there was no consensus on the ideal size.
• Encourage outdoor activities as much as possible.

Schools should endeavour to offer as many of their usual clubs and activities as possible during periods of low community transmission. Most clubs and activities, with the exception of choir/band, should involve less crowding than regular classes, and so should be feasible inside or outside.

5. Non-medical and medical facemasks for children

• While the experts recommended mask-wearing should be mandatory for middle, and high-school students, they did not agree on mask-wearing for younger students, except to say that it should not be mandated for Kindergarten students.

6. Cohorting

• The report says that cohorting – limiting the mixing of students and staff – should be a priority in younger grades, so that students “stay mostly with the same class group and there is less mixing between classes and years.”
• There were no specific recommendations for cohort size, but the report recommends that resources to support smaller cohorts should be prioritized for areas with higher community transmission.
• At times of high community transmission, rotating staff between multiple cohorts should be minimized.

7. Environmental cleaning 

• Cleaning and disinfecting should occur but not be the main focus for reducing transmission.

8. Ventilation

• Well ventilated classrooms are important for reducing transmission.  The report recommends keeping classroom windows open at all times if possible and encourages using outdoor learning environments as often as possible.
• The report says HEPA portable air cleaning units could be used in poorly ventilated classrooms, but there is insufficient evidence to recommend them for all classrooms.

9. Mitigation of risk for students at higher risk for severe disease

• With appropriate measures in place, most children with underlying medical conditions should be able to go to school but this should be discussed with their doctor.

10. Special considerations for children and youth with medical, physical, developmental and/or behavioral complexities

• The report notes that many families with children who require intensive supports “have had a prolonged period of time in home isolation compounded by a lack of respite and/or homecare supports.”
• Transitioning these students back to school should be a priority.
• It is important to mitigate the infection risk for the educational and medical assistants that sometimes support students with higher needs.

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.

11. Mental health awareness and support for all children

• Approximately 70% of children and adolescents report their mental health has worsened since the start of the pandemic. The report recommends increased support for students and teachers to support early identifications.
• Report recommends that all students with IEPS should be given new diagnostic assessments, and that these students should be tracked during the 2020-2021 school year with ongoing formative assessments.
• School Mental Health Ontario has a tip sheet for families about supporting young people’s mental health during the pandemic.

12. Protection of teachers and school staff

• Safety for teachers and school staff should be paramount and there should be an emphasis on physically distancing staff from students.
• School staff should be among those prioritized during vaccine
• Assign supply teachers to one school for longer periods of time to minimize exposures between schools.

13. Protection of at-risk persons or families

• A separate document is being prepared by SickKids with guidance for families on mitigating risks in the home.

14. Management of suspected and confirmed SARS-CoV-2 cases and their contacts

• There should be clear processes for management of students or staff who test positive.
• Schools should have clear guidance from public health for students returning to school after testing negative, positive or who do not get tested.

15. Communicating about COVID-19 to children, youth and parents/caregivers 

• Parents and children should be provided with clear and age-appropriate information and updates.

16. Opportunities to improve evidence-based decision making 

• The report lists priority areas for more research into COVID-19 transmission in schools to determine effectiveness of mitigation 

17. Additional considerations 

• More guidance is needed concerning the safety of staff beyond teachers who have significant exposure to students and other staff – this refers in particular to school bus drivers.

Letter from Ontario Medical Officers of Health emphasizes importance of opening schools first

In their letter to the Ministers of Health and Education, the Council of Ontario Medical Officers of health says it is imperative that schools begin to reopen before other sectors reopen. They told the Ministers that they recommended that “schools be opened first, while other non-essential businesses or sectors remain closed, especially if community transmission rates in certain areas remain high.”

“Upon careful review and consideration of local indicators, we believe it is possible, and in fact, imperative, that schools begin to open before the reopening of other sectors, as the Stay-at-Home orders are lifted provincially. Safe reopening of all schools in Ontario is essential.”

The letter also emphasized that it was crucial that public health units have the capacity to conduct contact tracing and follow ups.

Like the Sick Kids experts, the Medical Officers of Health said that more needed to be done to reduce risks for staff, including cancelling in-person staff training and reducing staff interactions during breaks and in staff rooms. They also recommended that boards restrict staff from moving between schools and that teachers not provide instruction to multiple cohorts.

They too pointed to the need for same day access to testing for COVID-19 and reiterated that early identification and contact tracing are critical.

Read the Sick Kids report.

Read the letter from the Council of Ontario Medical Officers of Health.