Massive outbreaks in Israeli schools a 'cautionary tale' for Canada
Israeli school children wear face masks to help prevent the spread of the coronavirus as they walk in Tel Aviv, Israel, Monday, July 6, 2020. (AP Photo/Sebastian Scheiner)
TORONTO -- When Israel opened its schools May 17 after just two months in pandemic lockdown, it seemed the novel coronavirus had been brought under control.
But the confidence was temporary and the results were disastrous. The experience of the tiny Middle Eastern nation is serving as a “cautionary tale” for Canadian provinces and school boards ramping up plans for a return to school in September.
New cases among Israel’s nine million people had dropped from more than 750 a day in the early spring to low double digits in May.
After a couple of weeks of small groups of students returning to school, the day everyone was invited back without any class size restrictions, there were just 10 confirmed cases in the country. Leaders had shifted from talking about staying home to getting people back to work.
In just 10 days, an outbreak was underway at a Jerusalem high school and soon it was joined by dozens of others.
Eventually, hundreds of schools were closed and tens of thousands of students and teachers were in mandatory quarantine.
Experts in Israel and around the world say overconfidence, a lack of enforcement of preventative measures, including physical distancing and masks, and inadequate ventilation all combined to create a disaster that could have been prevented. As of Thursday, Israel’s per capita cases are among the highest in the world, currently just ahead of the United States.
The chair of the team advising Israel’s National Security Council on the pandemic, Eli Waxman, told the New York Times that the move was a “major failure” and that other nations should learn from the mistakes made.
It’s not like Israeli leaders didn’t impose some restrictions on schools. It required masks for students in Grade 4 and above, said windows had to be kept open, handwashing should be frequent, and students kept two metres apart wherever possible.
All of that sounds much like what Canadian provinces are mandating or recommending. Provincial plans are being finalized, but at this point, no province has committed to cutting the size of classes to accommodate physical distancing, but are recommending students be spaced out as much as possible.
Some are arranging cohorts and only some are requiring masks for staff and students, while others are not.
Back in Israel, while guidelines were put in place, execution was not universal. And when a heat wave hit an already very hot nation, the government nullified the mask rule for four days and many schools shut the windows to let air conditioning do its work.
A local epidemiologist said instead of cancelling school for those stifling days, officials had created the “ideal circumstances for an outbreak.”
The initial Jerusalem school in outbreak shut down after discovery of the second case. All staff and students were tested and told to quarantine for 14 days. Some teachers had to be hospitalized.
In all, before school ended for the summer break in late June, more than 240 schools were shut down, more than 22,000 teachers and students were quarantined and about 2,000 of them had contracted COVID-19.
But community transmission was escalating, too, with new daily cases hitting the 800 mark by late June and more than 2,000 a month later. Those numbers were also driven by large gatherings and the reopening of restaurants, bars, gyms, hotels and wedding venues.
Israel has grappled since with how to get kids back to school with much better results. A new coronavirus czar signalled a new approach by shifting responsibility for testing and investigation from the health ministry to the military.
The government has announced that only students in Grade 2 and lower will return to full-size classes, based on evidence that younger children are at less risk of serious illness and seem to be less adept at transmitting the virus.
Older students will be split into “capsules” of 18 and those in grades 5 and above will get mostly online teaching.
NO PERFECT SOLUTION
Marina Milner-Bolotin, an education professor at the University of British Columbia, told CTVNews.ca that there are many differences between Canada and Israel, that both may help to explain what happened in schools there in May and why Canada might have a different outcome.
First, typical classroom sizes are larger than what is found in Canada, sometimes up to 36 children in lower grades, making physical distancing an even greater challenge in Israel.
Next, local municipalities hold much of the decision-making power for schools, leading to much more decentralized policy-making and widely varied enforcement of health regulations.
There are also cultural differences, with Israeli families usually having more children and often living in smaller homes or apartments. There was a lot of pressure on officials to get kids back to school, which they attend from Sunday to Friday afternoon.
“A lot of parents were overwhelmed (during lockdown) with trying to handle schooling their kids. Many families might not have enough computers,” said Milner-Bolotin, who was born in Ukraine and immigrated to Israel in 1991, teaching in middle and secondary schools in that country for six years.
She says there are skeptics about the success of enforcing mask rules, especially given the heat in Israel (she says her nephew’s classroom reaches above 40 C), and overcoming its people’s cultural penchant for hugging, kissing and other touchy-feely displays.
“Canadians have a much different idea of personal space. A lot of teachers in Israel don’t think it will be enforceable to keep kids separated because they haven’t grown up that way.”
What isn’t different between the two countries is the angst of parents – grappling with whether it’s safe to send their kids back to school – and the worry among educators about staying healthy while guiding students through a time of crisis.
“There are a lot of questions out there and not many answers yet. But there is no perfect solution until there is a vaccine.”
A ‘CAUTIONARY TALE’
Canada must learn from the “discouraging” outcome in Israel, says Dr. Lynora Saxinger, an infectious diseases specialist and an associate professor at the University of Alberta.
She says officials there seemed to get a “little overconfident” about case numbers and the extent to which children and teens transmit the disease. Mistakes were made in not dealing with overcrowded classrooms or cohorting students into groups to minimize their exposure to others. Then a heat wave created the perfect conditions to abandon masks and crank up the air conditioning, which could have amplified the transmission of the virus by extending the range of infectious droplets.
“I think it’s a cautionary tale of a rushed, naïve and overconfident start-up.”
She says it’s important for Canadians not to be unduly swayed by the situation in the United States, because the reality north of the border is much different.
She says there are plenty of examples worldwide where countries have managed to reopen schools (or never closed them in the first place) and that hasn’t contributed to what experts call the virus’s overall attack rate.
Students at some German schools self-administered COVID-19 tests when they went back to school in May. A negative test was rewarded with a green sticker that meant no need to wear a mask.
In parts of Australia, students only come to school one day a week and in Denmark, students are in “enclaves” with one teacher. They are to have no interaction outside of that group.
“The situation in the Netherlands or Switzerland presents a much more reassuring message but knowing the extreme outcomes on the other side, what we want to avoid is important, too,” said Saxinger.
“We have to have realize it can happen in schools and anticipate what we need to do to prevent that.”
In Sweden, which didn’t close schools, research has shown that teachers had the same rate of infection as the general population, while other workers, including taxi drivers and transit operators faced a much higher risk.
“That showed that schools were not an amplifying hotbed, but rather reflected the community situation,” said Saxinger.
In other words, what is achievable is not zero risk in reopening schools, but a risk of contracting the virus that mirrors that out in the general community.
It’s inevitable that schools will see COVID-19 cases and protocols must be in place that govern contact tracing, testing, self-monitoring and quarantining as they crop up, says Saxinger. Keeping kids in cohorts or bubbles that minimize their exposure to others makes that process simpler and quicker when positive cases arise.
“The school scenarios in many jurisdictions have been reasonable. There will be cases, there’s no doubt. But I do think, with appropriate measures, it’s possible to keep students and teachers safe,” she said.
SCHOOL BEYOND SCHOOLS
There are a range of tools health authorities can use to monitor schools. For instance, syndromic surveillance would test and isolate students who called in sick, while pooled surveillance is used to uncover transmission by randomly testing classrooms.
But Toronto pediatrician Dr. Anna Banerji says any system that is built around COVID-19 testing is doomed to fail because there are too many false negatives and testing capabilities are already stretched.
She says testing should only be a “supplementary” part of a multi-pronged strategy aimed at prevention and isolation of suspected cases. That includes having as many children and staff as possible wearing masks and repeatedly reinforcing hand hygiene either through washing or sanitizing.
She says teachers should find a way to teach outside as much as possible and classrooms should be spread beyond schools to unused portions of community centres, sports complexes and churches to allow for necessary physical distancing and proper cohorting of groups.
“We have got to be creative. This is not the time to be stuck with the ways we’ve always done things,” said Banerji, who specializes in infectious diseases and is an associate professor at the University of Toronto.
That would also address another issue, she says.
“A lot of schools are old and have inadequate ventilation or the windows don’t open. If students are in portables, there is poor ventilation and they are crammed inside together.”
And parents need to understand it’s vital that whenever their child displays a new symptom – anything from a runny nose to diarrhea – and even in the absence of a temperature, they should not be attending school or any other activity outside the home.
“Isolation is everything in managing this virus,” she said. “If we depend on taking temperatures and testing alone, we will fail.”
For Saxinger at the University of Alberta, the keys to success for Canada are focusing on measures that work and can be sustainable over a long road ahead, constantly assessing the situation, and being prepared to shift courses as the need arises.
She wants to see schools in Canada focus on reducing class sizes, using blended learning wherever possible, staggering arrival and departure times to prevent gatherings, and having school personnel screen students as they arrive each day.
She worries that relying on harried parents to do a self-screening will rely too much on the honour system.
“Anyone who has kids knows how mornings go,” the mother of two children, 4 and 15, told CTVNews.ca. “It could be easy to be not mindful about that checklist.”
Public health needs to ensure testing capacity is in place to quickly respond to potential school outbreaks and education authorities need to clearly communicate to parents and students that responsive structures are in place to minimize risk and handle cases.
Equally important is ensuring that students displaying any symptoms of illness, no matter how mild, stay home and that parents have the ability to stay home from work to care for them, says Saxinger.
“That stiff upper lip mentality has to go. When kids are sick, they have to stay home and so do adults. We can’t just power through anymore and that means a massive shift in thinking in the fall for workplaces.”
STRUGGLING WITH A DECISION
Grade 8 teacher Laura Howe is “conflicted and struggling” with the decision about whether she will go back to her Pickering, Ont. classroom. She only wants to teach in person and knows that’s where she belongs, but at 63 and with a tendency towards asthmatic allergic reactions that require inhalers, she worries about her health.
Reading about what happened in Israel and the death of a 64-year-old preschool teacher in July doesn’t help any. She frets that schools here are just as lacking in expertise and resources to handle both preventing outbreaks and dealing with them when they happen.
Howe told CTVNews.ca in a phone interview from her Toronto home that she’s baffled why Ontario didn’t reduce classroom time for intermediate students to allow more physical distancing.
The province has not committed to lowering class sizes and parents in her school district haven’t yet had to declare whether they will send their kids to school or opt into online learning.
So as it stands, her classroom will be filled with 28 students come the first day of school. She says that will mean no possibility of 2 metres of physical distancing.
She rhymes off a list of questions and concerns and says nothing provided the ministry of education or the Durham District School Board answers any of them.
Howe worries about the inevitable hot days that will make her second-storey classroom uncomfortable and masks unbearable. She worries that special needs kids aren’t going to get supports, and she doesn’t know what she’s supposed to do if a student displays symptoms.
“I don’t think any of us have an idea of what we are going to be facing.”
Graphic by Mahima Singh, edited by CTVNews.ca producer Phil Hahn