This is an excerpt from Second Opinion, a weekly roundup of health and medical science news emailed to subscribers every Saturday morning. If you haven’t subscribed yet, you can do that by clicking here.
Lots of fresh air, plenty of space for physical distancing and a comprehensive plan to keep sick students out of the classroom to prevent outbreaks.
That might sound like a parent’s wish list for reopening schools in 2020, but they’re actually tactics that worked to keep kids healthy during disease outbreaks over a century ago.
Open-air learning environments, or “forest schools“, were places where students could attend classes while at a lower risk of infection from diseases like tuberculosis and the Spanish Flu.
After first emerging in Germany in the early 20th century, the concept came to Toronto in 1912 when hundreds of kids spent their days learning and socializing outdoors, as detailed in this in-depth TVO story.
But with less than a month to go until schools reopen across the country in the current global pandemic, experts say Canada’s plans to get kids back in the classroom safely are missing some key lessons from history.
Low COVID-19 numbers in community key
Canada currently has a relatively low number of COVID-19 cases circulating in the community, which is an essential precursor to reopening schools safely, but ignoring proven strategies to reduce the spread of the virus in classrooms could put that in jeopardy.
“The single best way to make schools safe is by driving the caseload in the community as low as possible,” said Raywat Deonandan, an epidemiologist and associate professor at the University of Ottawa.
That’s important context for understanding a widely discussed recent study from the U.S. Centers for Disease Control and Prevention that has major implications for reopening schools.
Researchers looked at an outbreak of COVID-19 at an overnight summer camp in Georgia that resulted in 260 kids infected. Campers were not required to wear masks, slept 15 per cabin, and windows weren’t kept open to ensure proper ventilation.
But at the time the camp took place, there were still hundreds of new COVID-19 cases reported in the state daily.
“A lot of panic right now is coming from people looking at data from places where there’s an uncontrolled epidemic,” said Dr. Lynora Saxinger, an infectious diseases specialist and an associate professor at the University of Alberta’s faculty of medicine.
Israel may provide a more relevant cautionary tale for jurisdictions where community spread is low. Israel moved to reopen schools quickly in late May, when the coronavirus epidemic had been successfully controlled, but cases exploded soon after, largely because it didn’t limit class sizes, prioritize physical distancing, mandate mask wearing or ensure proper ventilation.
“Closed, crowded, and close-contact spaces are high risk for COVID transmission – and schools meet all those criteria,” said Ashleigh Tuite, an infectious disease epidemiologist and assistant professor at the University of Toronto’s Dalla Lana School of Public Health.
“We’ve known for a while that we want to have a return to school in the fall, and we’ve had time to prepare for that.”
But Tuite said she’s frustrated that with less than a month to go, there isn’t a comprehensive plan in place to prevent potential outbreaks in schools.
“I think we’re setting ourselves up for failure,” she said. “We really need to set up our schools in a way that parents and children and staff feel safe to return and that minimize the potential for these outbreaks to happen.”
Keeping sick kids out of school essential to stopping spread
“The most important things to do are actually before the kids and adults are in the building,” said Dr. Andrew Morris, an infectious disease specialist and medical director of the antimicrobial stewardship program at the Sinai Health System and the University Health Network in Toronto.
“Almost all the discussion and effort has been around what happens once kids are in the school, but we need to have a strategy that keeps infected kids out of the school.”
Many jurisdictions, including Ontario, B.C. and Alberta, are telling staff and students (with help from their parents or caregivers) to self-screen for COVID-19 symptoms daily, and stay home or seek medical attention if sick.
But Morris, who helped with revised Ontario guidelines from the Hospital for Sick Children in Toronto, said schools need to have extensive surveillance systems in place beforehand to ensure students and teachers are not infected with COVID-19.
From no plan to facilitate contact tracing from bars & restaurants, to no extra effort to mitigate school risk, the Ontario govt is proving itself to lack the administrative sophistication and desire to tackle complexity when we need it most. This doesn’t bode well. <a href=”https://twitter.com/hashtag/onpoli?src=hash&ref_src=twsrc%5Etfw”>#onpoli</a>
One way of doing that is through what’s known as syndromic surveillance, where kids who miss classes are assessed, tested and isolated by local public health officials if they’re infected before they can cause wider outbreaks in schools.
Pooled surveillance is another tactic that can be used to detect transmission in schools before it becomes apparent, which is when entire classrooms are tested at random in order to find unseen COVID-19 cases.
“If you’ve got a kid that’s sick in the class, there’s a very high likelihood that if they’re there every day for five days they’re going to infect at least one other kid,” he said.
“To some degree, you almost can’t overreact when you have a case in a classroom and if you think you’re overreacting, you’re probably doing the right thing.”
Saxinger said while there’s no way to ensure zero risk of COVID-19 cases in schools, it’s important to clamp down on potential outbreaks and isolate infected students and classes quickly to prevent entire schools shutting down.
“That’s something people have to wrap their heads around – that having a class being quarantined because someone was positive is going to be kind of normal and that in fact picking that up is good, versus not picking it up.”
Ventilation overlooked in Canadian schools
Another key area experts say is lacking in the gear up to reopen schools across the country is a focus on adequate ventilation, despite new federal guidelines from the Public Health Agency of Canada that call for increased air circulation and outdoor classrooms whenever possible.
Schools are notorious for having minimal access to windows and for using antiquated HVAC systems that can rely on recirculated air – leaving unanswered questions as to how schools are expected to ensure a steady flow of fresh air in classrooms.
“I haven’t seen any discussion of that at all in Ontario context,” said Tuite. “You hear stories about schools where the windows are painted shut.”
WATCH | Dr. Tam discusses risks of sending kids to school, and keeping them home
Linsey Marr, one of the top aerosol scientists in the world and an expert on the airborne transmission of viruses at Virginia Tech, said ensuring proper ventilation is crucial to successfully keeping COVID-19 out of schools.
“It’s important to get kids back to school in person, but I think we also need to do everything possible [to prevent transmission],” she said.
“And even if it just means opening windows, or upgrading an HVAC filter, or putting an air purifier in the room – that you’re doing something that is going to reduce the risk.”
Marr said the move to push classrooms outdoors whenever possible would also drive down the risk of COVID-19 infection dramatically and should be done while the weather permits – even if temperatures drop and students need to bundle up.
“It’s worth it for the education of a generation,” she said. “Because it will be so much safer to go outdoors than to stay indoors.”
Marr said ventilation is one of four essentials that need to be prioritized in the reopening of schools in order to successfully navigate a return to the classroom; the others being ensuring enough space for physical distancing, mask wearing and avoiding crowds.
“In the cars we drive we have seatbelts, we have airbags, we have anti-lock brakes and we try to drive carefully,” she said. “Would you get in your car if the airbags are broken?”
Mask policies in schools a ‘hodgepodge’ across Canada
Mandating students to wear masks while in the classroom is another strategy that could help curb the spread of COVID-19, but some provinces don’t have strict policies in place for doing so.
In B.C., students won’t be required to wear masks, while Ontario’s plan will see masks required only for students in grades four to 12.
Alberta will also require students of those ages to wear masks, but only while in hallways, common areas and when working closely with others.
Saskatchewan will send students back to class without either requiring students to wear masks or reducing class sizes.
“The reason it’s a hodgepodge is because we know that in different places, combinations of those things have worked,” Saxinger said, referencing schools in Europe and Asia that have since dialled back strict reopening policies.
“You’re trying to find this balance of what is feasible and what’s the range of reasonable and how can we learn from this? Because frankly, there’s a lot of pandemic left and if we’re not learning from what we’re doing, we’re missing a really big opportunity.”
The new federal guidelines also say that consideration should be given to the use of masks and face shields, because the “evidence is evolving on their benefits to the wearer to reduce their risk of infection.”
But they stop short of recommending widespread mask use and say non-medical masks should not be worn by anyone who is “unable to remove the mask without assistance, due to age, ability or developmental status.”
Deonandan says that while he agrees there is an age cutoff for children who can effectively wear masks, he thinks more students should be required to wear masks in schools across the country.
“We could look into masks and face shields, the two of them together … that added layer of … self protection through a face shield, I think would pay extraordinary dividends,” he said.
Deonandan said the arguments against mask wearing for younger students in schools focus on the fact that they will fidget with them, risk exposure by touching their face, or not wear them consistently throughout the day.
For those kids incapable of wearing a mask, instead of saying, ‘Well then, masks are impossible,’ have them wear face shields only. It’s not as good as a mask for outward mitigation, but it’s better than nothing.”
“It won’t be perfect, but … don’t let perfect be the enemy of good.”
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