Reopening schools safely during the pandemic

A recent interview in the Canadian Medical Association Journal cautioned that reopening schools should be delayed until more robust data are available, and that school attendance should, therefore, remain voluntary.[1] This would provide an option for high-risk students and staff who may suffer from severe complications if they were to contract COVID-19.[2]

Research, however, shows that the prolonged school closure has negatively impacted the social and emotional well-being of school-aged children due to social isolation and increased screen time.[3,4] Schools provide critical educational and health benefits to children, and education is an important social determinant of health. 

There is a national debate among parents, caregivers, policymakers, and the teachers’ union over whether BC schools should reopen amid the COVID-19 pandemic, but students’ voices are largely missed in that dialogue. Meanwhile, the National Academies of Sciences, Engineering, and Medicine; Toronto’s Hospital for Sick Children (SickKids); and the American Academy of Pediatrics’ guidelines urge in-person full-time instruction, especially for kindergarten through grade 5 and for students with special needs because they benefit from an environment where they have to maintain attention and regulate their own behaviors and emotions.[5,6] 

SickKids has published new guidelines on how to safely reopen schools. The report, along with other guidelines, reiterates the importance of weighing the risks of COVID-19 transmission among children against the harm of keeping them out of schools in September.[6]

As public health organizations look to reopen schools, understanding transmission potential in children will be important to guide public health measures. The Centers for Disease Control and Prevention issued a Morbidity and Mortality Weekly Report in early August based on data from an overnight camp in Georgia where 260 of 344 children and staff tested positive for COVID-19.[7] As BC makes plans to reopen school in September, we think that it is important to have closer look at this incident and learn from it:[7,8]
1.    Masks weren’t required for the campers.
2.    Spaces were not ventilated consistently (i.e., windows and doors kept open).
3.    Extensive group-based indoor activities were common, including singing and clapping.

We strongly believe it is important to disseminate this information widely to attract attention from school educators before we restart schools. It is necessary to increase appropriate mask-wearing, frequent hand washing, and physical distancing; keep class sizes small; conduct classes outside whenever possible; and make special accommodations for high-risk students, teachers, and other school staff.

It is equally important to pay close attention to the findings in two other research studies; it has been demonstrated that young children can be potential drivers of SARS-CoV-2 spread in the general population.[9,10] With the publication of these two studies, it cannot be assumed that children are incapable of spreading the virus.

The mitigating factors that we recommend above should be strictly enforced using additional staff. On the first day of school all students must receive school-reopening hygiene guidelines, disinfection protocols, and instructions. This should include comprehensive but short educational instructions on the best way to prevent SARS-CoV-2 through good respiratory hygiene, regular hand washing, and covering of the mouth and nose whenever they sneeze or cough. It is also important to make students understand their social obligation to wear masks to protect themselves and those around them.  
—Ediriweera Desapriya, PhD
—Yuan Wei Peng, BSc
—Marie Maddumage, MBBS
—Sarah Yassami, MD
—Jay Herath, PhD

References
1.    Vogel L. Into the unknown. CMAJ News. Accessed 2 September 2020. http://cmajnews.com/2020/05/01/id-panel-1095869.
2.    Yousif N. Reopening schools safely is now Canada’s most urgent task. Maclean’s. Accessed 2 September 2020. www.msn.com/en-ca/news/canada/reopening-schools-safely-is-now-canadas-most-urgent-task/ar-BB17Eri0.
3.    Wang G, Zhang Y, Zhao J, et al. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020;395(10228):945-947. 
4.    Xie X, Xue Q, Zhou Y, et al. Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China. JAMA Pediatr 2020. doi: 10.1001/jamapediatrics.2020.1619
5.    National Academies of Sciences, Engineering, and Medicine. Reopening K-12 schools during the COVID-19 pandemic: Prioritizing health, equity, and communities. National Academies Press; 2020.
6.    The Hospital for Sick Children (SickKids). COVID-19: Guidance for school reopening. Accessed 2 September 2020. www.sickkids.ca/PDFs/About-SickKids/81407-COVID19-Recommendations-for-School-Reopening-SickKids.pdf.
7.    Szablewski CM, Chang KT, Brown MM, et al. SARS-CoV-2 transmission and infection among attendees of an overnight camp — Georgia, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1023-1025.  
8.    JAMA Network. AMA COVID-19 daily video update: What’s behind the continuing high number of new cases? Accessed 2 September 2020. www.ama-assn.org/delivering-care/public-health/ama-covid-19-daily-video-update-what-s-behind-continuing-high-number.
9.    Moreira LP, Watanabe ASA, Camargo CN, et al. Respiratory syncytial virus evaluation among asymptomatic and symptomatic subjects in a university hospital in Sao Paulo, Brazil, in the period of 2009-2013. Influenza Other Respir Viruses 2018;12:326-330.
10.    Heald-Sargent T, Muller WJ, Zheng X, et al. Age-related differences in nasopharyngeal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) levels in patients with mild to moderate coronavirus disease 2019 (COVID-19). JAMA Pediatr 2020. doi: 10.1001/jamapediatrics.2020.3651.

This post has not been peer reviewed by the BCMJ Editorial Board

Ediriweera Desapriya says: reply

This is an important public health issue with heavy burdens on our children and their foreseeable future, parents and caregivers worldwide. Almost every major medical journal has dedicated at least one specific article on the important theme “school reopening safely during the pandemic” and “school closure and children health and well being” (1, 2, 3, 4, 5). Indefinite school closures have affected our vulnerable children’s safety, welfare and wellbeing in different ways. As reported, 1 in 3 child abuse and neglect incidents are investigated and bought in to the attention of authorities by the school counselors and social workers (6). School closures may have prevented reporting these incidents in a timely sensitive manner (5). Reports show that the suspected child abuse or neglect is down as much as 40 per cent recently (6).
In contrast, a recent UNICEF report further highlights that the economic instability during the pandemic and lack of access to schools and associated supports, and increased confinement at home with potential exposure to domestic violence (7).
Improving child and youth well-being in Canada is a utmost important matter of Canada’s 8 million children. Unfortunately, Canada ranks 30th out of 38 wealthy countries in child and youth well-being (7).
REFERENCES:
(1). Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet. 2020;395(10228):945-947. doi:10.1016/S0140-6736(20)30547-X
(2). Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep. 2013;7(1):105-110. doi:10.1017/dmp.2013.22
(3). Xie X, Xue Q, Zhou Y, et al. Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China. JAMAPediatr. Published online April 24, 2020. doi:10.1001/jamapediatrics.2020.1619
(4). Martin EG, Sorensen LC. JAMA Network Health Forum-Protecting the Health of Vlnerable Children and Adolescents during COVID-19–Related K-12 School Closures in the US-https://jamanetwork.com/channels/health-forum/fullarticle/2767411
(5). Sharfstein JM, Morphew CC. The Urgency and Challenge of Opening K-12 Schools in the Fall of 2020 [published online ahead of print, 2020 Jun 1]. JAMA. 2020;10.1001/jama.2020.10175. doi:10.1001/jama.2020.10175
(6). Rabson M. Advocates worry coronavirus pandemic putting more children at risk for abuse-https://globalnews.ca/news/6851290/coronavirus-child-abuse-risk/
(7). UNICEF REPORT CARD 16 (2020) -https://www.unicef.ca/en/unicef-report-card-16

Ediriweera Desapriya says: reply

In a 2020 systematic review, Viner et al., showed that there is no data on the relative contribution of school closures to SARS-CoV-2 transmission control (1). Based on this data and the recent systematic review evidence, the UNICEF warns that school closings are both harmful and ineffective. UNICEF, the United Nations agency for children, weighed in on school closures across the globe. Its verdict is damning: Keeping children at home is causing significant, long-lasting harm, and has not been effective in curbing the spread of the virus (2).
When schools closed in the spring, some 463 million students worldwide could not access any remote learning. As of November, according to the study, school closures still affect nearly 600 million students (2).
Children have tended to have milder symptoms during the COVID-19 pandemic than adults and multisystem inflammatory syndrome (MIC) has been a rare complication. However, restrictions implemented to reduce transmission have directly affected children, as most countries closed schools during the first wave, despite a lack of strong evidence (1). Strong policies to encourage adherence to mitigation policies including mask wearing, physical distancing, frequent hand washing, outdoor classrooms and stable cohorting and additional, infection control measures need to be strictly enforced (3, 4).
“Unless the global community urgently changes priorities, the potential of this generation of young people may well be lost,” (2) Furthermore, missed instruction during the first wave of pandemic 2020, has been associated with an estimated 5.53 million years of life lost. This loss in life expectancy was likely to be greater than would have been observed if leaving primary schools open had led to an expansion of the first wave of the pandemic (4).
Based on this evidence, the JAMA study favored schools remaining open during the second wave and future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children’s health (4). As our children’s daily lives and routines continue to be disrupted unprecedentedly by the pandemic, we must remember the value of in person schools providing much needed support for children’s overall well being, active lifestyles, while creating opportunity for their learning and growth together.
REFERENCE:
(1). Viner RM, Russell SJ, Croker H, et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. 2020;4(5):397-404. doi:10.1016/S2352-4642(20)30095-XPubMedGoogle ScholarCrossref
(2). UNICEF-Averting a lost COVID generation A six-point plan to respond, recover and reimagine a post-pandemic world for every child-https://www.unicef.org/media/86881/file/Averting-a-lost-covid-generation...
(3). Pierantoni L, Lenzi J, Lanari M, De Rose C, Morello R, Di Mauro A, Lo Vecchio A, Valentini P, Buonsenso D. Nationwide COVID-19 survey of Italian parents reveals useful information on attitudes to school attendance, medical support, vaccines and drug trials. Acta Paediatr. 2020 Oct 12:10.1111/apa.15614. doi: 10.1111/apa.15614. Epub ahead of print. PMID: 33047328; PMCID: PMC7677859.
(4). Christakis DA, Van Cleve W, Zimmerman FJ. Estimation of US Children’s Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020;3(11):e2028786. doi:10.1001/jamanetworkopen.2020.28786.

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