Hand hygiene, no face masks: SickKids experts on how schools can safely reopen in the fall
TORONTO -- While most schools across the country remain closed for the rest of the school year, experts from one of Canada’s leading children’s hospitals are calling for schools to reopen while adhering to a list of safety guidelines.
On Wednesday, an advisory group from the Hospital for Sick Children (SickKids) in Toronto released a series of recommendations on schools reopening, which covered a range of topics, including screening students for symptoms before they arrive at school, encouraging proper hand hygiene, advising against the use of face masks for students, and implementing some physical distancing measures, but allowing children to play with each other.
While the SickKids experts acknowledged that closing schools may have been reasonable during the early pandemic response, they stressed the need for students to return to school in order to avoid adverse health and welfare consequences.
Some of those consequences include, decreased vaccination coverage, delayed diagnosis and care for medical conditions unrelated to COVID-19, impacts on children’s behaviour and mental health, and exposure to child abuse, violence, and neglect.
“We strongly believe that it is of utmost importance that we open schools in September,” Dr. Ronald Cohn, president and CEO of SickKids, told reporters during a webinar on Wednesday.
“The impact on the mental, behavioural, and developmental health of children not going to school, not being exposed to in-person teaching, and not being with their friends and peers is something that myself and many of my colleagues in pediatrics are literally losing sleep over.”
In terms of the risk of coronavirus infection for children, the experts said that multiple reports from around the world indicate that children account for a small percentage of COVID-19 infections and the majority of them are asymptomatic or have only mild symptoms.
What’s more, the group said there have been no pediatric deaths associated with COVID-19 reported in Canada to date.
In Canada, the advisory group said there have been 98,605 COVID-19 cases reported as of June 15 and only 6,824 (6.9 per cent) were in children aged 0 to 19. They said there is mounting evidence to suggest children may be less susceptible to the disease and less likely to transmit it to others.
Dr. Jeremy Friedman, associate paediatrician-in-chief at SickKids, said his experience at the hospital supports these findings. He said of the 5,000 symptomatic children who were tested for COVID-19 at the hospital since March, fewer than 30 children tested positive for an overall incidence of less than 0.8 per cent.
Even severe cases of COVID-19 in children that require hospitalization, such as those with multisystem inflammatory syndrome in children (MIS-C), are relatively rare and treatable, according to the group.
Although the expert group said it’s impossible to remove all risk of infection and disease now that coronavirus has been well established in many communities, it’s possible for schools to mitigate that risk when they reopen by taking extra precautions.
“We have to accept and internalize that this virus will stay with us for a very long time, a year, maybe even longer,” Cohn said. “We have to accept that we will not be able to eliminate the risk from getting infected from the coronavirus. So we have to stop living in fear from the virus. And most importantly, we need to move on with certain activities of our life.”
Here are some of the general guidelines the expert advisory group recommends schools should follow so they can safely reopen in September.
SCREENING FOR SYMPTOMS
In accordance with provincial health ministries and local public health guidance, the SickKids experts said students and staff should stay home if they have any signs or symptoms of COVID-19 and their return to school should be guided by public health recommendations.
For students who develop symptoms during the school day, the group said principals and teachers should be provided with information to recognize those signs in order to take “appropriate action.”
The experts advised against taking students’ temperatures on site before school starts every day because this will lead to lineups, unless there are significant staggered start times. Instead, they said parents and caregivers should be given a checklist to do daily screenings at home every morning.
The SickKids experts also emphasized that virtual learning, or other forms of structured learning, should be put in place for children who are required to stay home because they are sick or in isolation.
The advisory group called proper hand hygiene “the most effective strategy” to prevent the spread of respiratory viruses, including coronavirus, particularly before symptoms emerge. They said children should be taught in a “non-judgemental and positive” manner how to clean their hands and avoid touching their faces and age-appropriate signs on proper hand hygiene should be placed throughout the school.
Students should also be reminded to sneeze or cough into their elbows, the group said.
The group also advised regularly scheduled hand hygiene breaks staggered throughout the day and the use of hand sanitizer during these breaks if sinks aren’t readily available in the classroom.
Hand sanitizer with 60 to 90 per cent USP-grade alcohol should be made available at the entry point of every classroom. Liquid soap and hand sanitizer should be replenished regularly and tissues made available for hand drying.
Schools should also consider providing disposable disinfectant wipes so that commonly used surfaces can be cleaned before each use, the guidelines state.
NON-MEDICAL AND MEDICAL FACE MASKS
While public health officials have urged people to wear face masks when they’re out in public, the experts from SickKids said it’s impractical to expect children to properly wear them for an entire school day.
In fact, if worn incorrectly, the group said children could face an increased risk of COVID-19 infection due to them touching their faces more often to adjust the mask.
The experts said children would require help putting on and taking off the masks during meal times and they would likely be improperly disposed of throughout the day leading to increased risk of infection.
Although the group recognized that some parents and children may choose to wear face masks, the guidelines state that non-medical and medical face masks are not required or recommended for children returning to school.
As for teachers, the guidance states that face masks aren’t required so long as physical distancing can be maintained and that facial expressions are an important part of communication.
However, if prolonged contact with other people can’t be avoided, teachers can wear a mask, but they should explain why they are doing so to their students.
Despite Quebec requiring children under the age of 16 to maintain a one-metre distance from each other and a two-metre distance from adults, the SickKids advisory group didn’t recommend similar measures because they said strict rules are not practical and may cause psychological harm.
Instead, the experts said efforts should be made to arrange classroom furniture to keep as much space as possible between students, and to have smaller class sizes, if possible. They also said schools could consider holding classes and lunch breaks outside, if weather permits.
As for large gatherings, such as assemblies, the SickKids experts said those should be cancelled for the immediate future.
When students are outside for recess or sports, the guidelines said physical distancing should not be required and children should perform proper hand hygiene before those activities. While the group said physical activity should be encouraged, schools should consider whether they should postpone or modify certain sports with a high-degree of contact, such as football and rugby.
The guidelines said that cohorting groups of students may be an advisable option to limit the mixing of students and staff so that if someone becomes infected, the number of exposures would be reduced.
For example, younger age groups and children with medical or behavioural complexities could be cohorted so that students stay in the same class group and there is less mixing between classes and years.
The group stressed that daily school schedules or curriculums should not be disrupted in order to accommodate smaller cohorts.
“Student well-being and mental health should be prioritized, however, such that class or program switching should not be denied on the basis of cohorting,” the recommendations state.
CLEANING AND VENTILATION
Because coronavirus has been detected on a variety of surfaces and it’s possible that infection can be transmitted by someone touching contaminated surfaces and then their face, the advisory group said cleaning and disinfection will be important to prevent infection.
They advised schools implement a regular cleaning schedule with emphasis on high-touch surfaces and toys and equipment should be made of materials that can be easily cleaned.
The experts also said efforts should be made to reduce the need to touch surfaces, such as door handles, waste containers, and students should not share food, water bottles, and cutlery.
As for ventilation, schools should try to increase air flow in classrooms by opening windows and improving ventilation systems.
Children with underlying medical conditions, such as immunocompromised states or chronic medical conditions such as cardiac and lung disorders, should continue to go to school, but the guidance advises parents to work with their child’s health-care provider on their specific case.
The group also said that schools should provide special accommodations for medically and behaviourally complex children upon their return to school. School administrators should liaise with parents for a more individualized and smoother return. These students also should be provided with remote learning opportunities should they choose not to return right away.
The SickKids experts recommend schools take a proactive approach to minimize the potential mental health impact for children who are returning to school under very different circumstances.
Due to the pandemic, school enrollments, class selections, and activity registrations may have been mixed up and schools should be extra flexible in these administrative processes to avoid further stress for students and their families, the guidance said.
Students may also be returning to school at different academic levels due to school closures so extra in-school educational support should be provided to teachers and students to help them identify learning gaps and catch up.
Finally, the advisory group said that it should be expected that some children and youth may experience increased stress and anxiety due to the pandemic. What’s more, physical distancing measures and school closures may have exacerbated the symptoms of students who already have mental health conditions, such as anxiety, depression, and substance abuse.
That’s why schools should provide accessible mental health support services for students, including for diverse groups and at-risk populations, the recommendations said.
Dr. Daphne Korczak, a child and youth psychiatrist at SickKids, said schools should attempt to communicate their reopening plans to students and their families as much as possible before they return to relieve some of their anxiety and uncertainty about what the coming school year will look like.
“Being able to provide information to families as far in advance as possible will be helpful,” she said. “Once parents and kids know what to expect, they’ll be able to prepare themselves and have a greater sense of control over their preparation and their anxiety.”