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Updated: September 15, 2020

What are the potential implications and precautions for my family, including elderly parents with medical conditions, when my child returns to school?

Summary

The following is a summary of evidence sources that provide high quality information from Ontario and other jurisdictions on the implications and precautions for families, including elderly parents with medical conditions, when children return to school.   For additional information about each of the sources, see the Table below.

In Ontario, most schools are scheduled to re-open September 8, 2020. The Guide to reopening Ontario’s schools provides a detailed outline to facilitate reopening of schools in a safe manner [6]. Public Health Ontario has noted  in COVID-19 Infection in Children that children, aged 19 years and under, between January 15 and July 13, 2020 accounted for only a small number of confirmed cases in Ontario, although it must be noted that these observations were within the context of school closures [8]. The question of transmission of the coronavirus and susceptibility of infection for children remains an important focus for current research. The authors of A Chinese study of 391 cases and 1286 of their close contacts reported that household contacts are at a higher risk of being infected with SARS-CoV-2 than other close contacts [10]. Two systematic reviews note that infected children, excluding infants, are more likely to be asymptomatic and present less severe symptoms than infected adults resulting in a lower frequency of sneezing and coughing, however there is still a risk of transmission even among asymptomatic or milder symptoms [1,2]. Public Health Ontario states in COVID-19 and Severe Outcomes in Ontario that elderly family members, those aged 60 years and over, are at an increased risk of severe disease associated with SARS-CoV-2 infection [7]
 
The Government of Canada and the Centers for Disease Control and Prevention (CDC) in the United States state that the risk of infection in students is associated with the following: 1) communal transportation; 2) asymptomatic transmission; 3) situations where the use of masks is not feasible (i.e., exempted individuals, lunchtime, recess, music related activities, physical education); 4) mask wearing and physical distancing adherence; 5) hand-washing frequency; 6) duration of social interactions with other students and staff during and after school; 7) frequency of disinfecting surfaces; 8) access to personal protective equipment; and 9) education on symptom reporting [3,4]. To address these risks the following mitigation strategies have been recommended by the Government of Canada in its COVID-19 guidance for schools Kindergarten to Grade 12 and by the Hospital for Sick Children (SickKids) in Toronto in its COVID-19: Guidance for School Reopening: 1) increasing frequency of disinfecting surfaces; 2) reducing class sizes; 3) offering alternative means of education delivery (i.e. small groups, virtual); 4) improving ventilation in classrooms; 5) providing frequent reminders to promote healthy behaviours (i.e., announcements, infographics); 6) staggering school entrance times; 7) organizing one-way corridors; 8) putting the child’s initials on their mask to prevent them from being exchanged; 9) packing hand sanitizer in children’s backpacks 10) checking for signs and symptoms; 11) providing role models of transmission-reducing behaviour; and 12) encouraging children to ask questions to increase their engagement [3,9]. In an Israeli study of A large COVID-19 outbreak in a high school 10 days after schools’ reopening, Israel, May 2020 , the authors recommend testing and isolating individuals with mild symptoms, reducing class sizes with physical distancing measures in place, using masks in indoor settings and ensuring adequate ventilation in indoor spaces [11]. The CDC recommends that parents should also consider taking extra precautions to separate their child from elderly or other high-risk family members in the home by limiting their duration of contact as much as possible [5]. In situations where the high-risk family member is taking care of the child, one should ensure that their child limits contact with others as much as possible [5].   

Evidence

What‘s Trending on Social Media and Media

This CBC article discusses Ontario’s back to school plan having no mandatory COVID-19 testing. Students may be advised to go for testing, but it is never an absolute requirement. One reason why experts agree with this is because of the inevitable false positive results and a lack of research on how the virus spreads among children.  
 
This CP24 article reports that the Toronto District School Board recently switched 700 high school teachers to online learning after more than 14,000 students opted for remote learning this September. As a result, the average class size will be 20 students.  
 
BrainPOP recently released a video which helps to explain to children how to prepare for the 2020 school year. This video clearly and effectively communicates many Do’s and Dont’s in an engaging cartoon!  

Organizational Scan

The Government of Ontario has released a guideline for the reopening of schools, which aligns with the province’s Stage 3 mandate for social gatherings where indoor gatherings cannot exceed 50 people. Elementary schools will reopen with in-person delivery of teaching following the full range of elementary curriculum, provincewide. Students will remain in one cohort for the full day with one teacher whenever possible and maintain social distancing. Recesses, lunches, and bathroom breaks will be staggered to support cohorting. Secondary schools will reopen with class cohorts of 15 students on alternating schedules with at least 50% of in-class instructional days and the remaining completed remotely through an online experience [12]
 
Ontario schools will require students in grades 4-12 to wear non-medical or cloth masks indoors in school. Outdoor times like recess can be used as opportunities to provide students with a break from wearing masks within their cohorts. Students in kindergarten to grade 3 will be encouraged but not required to wear masks in indoor spaces. Non-medical masks and alcohol-based hand rub will be accessible for students where appropriate. Furthermore, additional custodial staff have been hired to facilitate frequent disinfection of surfaces in schools [12].  
 
All students will be given the opportunity to attend school remotely. Students will be provided with a daily schedule of subjects/courses according to a 5-hour instructional day with opportunities for frequent, live contact with a teacher and expectations for synchronous learning. Students with special needs should consult with their school and health care providers to determine a safe Individual Education Plan (IEP) to support a smooth transition [12]

Review of Evidence

Resource Type/Source of Evidence Last Updated
Systematic review of covid-19 in children shows milder cases and a better prognosis than adults
— Jonas F. Ludvigsson
Systematic Review

This systematic review found that children have accounted for 1%-5% of diagnosed COVID-19 cases thus far. Compared to adults, severe pneumonia, elevated inflammatory markers and lymphocytopenia were less common. Common symptoms among children included cough, wheezing, pharyngeal erythema, and fever. 

Last Updated: March 22, 2020
Children are unlikely to be the main drivers of the COVID-19 pandemic – A systematic review
— Jonas F. Ludvigsson
Systematic Review

This review states that children may have lower viral loads than adults, however data is scarce. Children often have fewer symptoms than adults, which should decrease the transmission risk. The review states that children seldom caused outbreaks, but that it is highly likely that children can transmit the SARS-COV-2-virus, even if asymptomatic. Further research of viral loads of asymptomatic children are suggested. 

Last Updated: May 18, 2020
COVID-19 guidance for schools Kindergarten to Grade 12
— Government of Canada
National Guidance

This guidance is for administrators and public health authorities to consider potential risks and mitigation strategies when re-opening schools including: 1) the possible interactions that may occur in a school setting; 2) the risks associated with many people gathering indoors for extended periods of time;3) situations that may make it difficult to maintain physical distancing; and 4) mask wearing.     This guidance notes that since physical distancing is not always possible in schools, it is important to “layer” multiple measures to reduce the risk of COVID-19 spread. For example, 1) physically separating from each other through physical distancing and physical barriers; and 2) practicing respiratory etiquette, hand hygiene and wearing non-medical masks.     The guidance recommends promotion of personal preventative practices for all ages: 1) teaching children about why, how and when to clean hands and to cover coughs, sneezes; 2) implementing a schedule for frequent hand hygiene; 3) reinforcing “no sharing” food and drink policies; 4) having children bring filled water bottles to school rather than drinking directly from water fountains; 5) for younger children, reminding them not to touch others or put toys or objects in their mouths; 6) assisting/supervising when performing hand hygiene, and incorporating fun strategies to encourage compliance (such as humming songs while handwashing); and 7) encouraging older children to leave personal items such as cell phones and head phones in lockers or at home, and not to share these items.  

Last Updated: August 11, 2020
Operating Schools During COVID-19
— CDC: Centers for Diseases Control and Prevention
National Guidance

The CDC has noted several considerations for operating  schools during COVID-19  including: 1) promoting behaviours that reduce the spread of COVID-19 (e.g., staying home when appropriate, hand hygiene and respiratory etiquette, masks, signage); maintaining healthy environments (e.g., cleaning and disinfecting frequently touched surfaces, discouraging the sharing of objects, improved ventilation) and operations (e.g., offering options to staff or students with higher risk of severe illness, cohorting, alternate or staggered scheduling); and for when someone becomes sick (e.g., self-isolation and testing).     The CDC states children are less likely to have severe COVID-19 symptoms than adults or are more likely to be asymptomatic.     The CDC recommends families and staff be educated about when children should stay home, and families should be made aware of policies that encourage sick staff and students to stay home and to notify school officials of illness without fear of reprisal. Students and students’ families should be provided with information on proper use, removal and washing of cloth face coverings or masks.  

Last Updated: August 20, 2020
School Decision-Making Tool For Parents, Caregivers, and Guardians
— CDC: Centers for Diseases Control and Prevention
National Guidance

The CDC notes the risks and benefits of re-opening schools including the risk to household members and how household can evaluate a school’s plan to mitigate these risks.    The CDC recommends that parents should consider taking extra precautions to separate their child from elderly or other high-risk family members by limiting their duration of contact as much as possible. In situations where the high-risk family member is taking care of the child, one should ensure that their child limits contact with others as much as possible. 

Last Updated: July 22, 2020
Guide to reopening Ontario’s schools
— Government of Ontario
Provincial Guidance

This guidance states that to ensure students and families are supported and respected, in-person school attendance will be optional for the 2020/21 school year in the United States.   School boards should provide parents with a checklist to perform daily screening of their children before arriving at school. Schools are being asked to significantly limit or even prohibit visitors, including parents.     Active forms of travel (e.g., walking and cycling) and private transportation by parents and caregivers, are encouraged where possible, to ease pressure on transportation demand. 

Last Updated: August 27, 2020
COVID-19 and Severe Outcomes in Ontario
— Public Health Ontario
Provincial Guidance

This report states that individuals aged 60 years and older account for the highest proportion of all hospitalizations, ICU admissions and deaths in Ontario as of May 14th, 2020. Few hospitalizations and ICU admissions were among those 19 years and younger.  

Last Updated: May 13, 2020
COVID-19 Infection in Children: Jan 15, 2020 to July 13, 2020
— Public Health Ontario
Provincial Guidance

This report states that children account for a small number of COVID-19 cases in Ontario, despite representing 21.1% of the Ontario population. The rate of infection among children was dramatically lower than adults, and among children rates were highest among 15 to 19-year old children. The most frequently reported acquisition exposure type in children was close contact with a confirmed case. Children were more likely to be asymptomatic than adults, and less likely to experience severe outcomes.  

Last Updated: July 12, 2020
COVID-19: Guidance for School Reopening
— Sick Kids Hospital
Professional Organization

This guidance recommends: 1) screening to prevent symptomatic individuals from entering schools; 2) teaching proper hand hygiene; 3) discussing the importance of physical distancing with children; 4) using non-medical masks based on local epidemiology; 5) considering cohorting classes; 6) implementing regular cleaning schedules; 7) improving ventilation; 8) discussing with children’s healthcare providers for high risk students; 9) consulting with healthcare providers for children with medical, physical, developmental and/or behavioural complexities; 10) paying attention to mental health of staff and students,; and 11) ensuring awareness of COVID-19 signs and symptoms. 

Last Updated: July 28, 2020
Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzen, China: a retrospective cohort study
— Bi et al.
Individual Study

This study states that children are at a similar risk of infection to the general population, although less likely to have severe symptoms, and this should be considered in analyses of transmission and control. Household contacts were at higher risk of infection than other close contacts.  

Last Updated: April 26, 2020
A large COVID-19 outbreak in a high school 10 days after schools’ reopening, Israel, May 2020
— Stein-Zamir et al.
Case Study

This paper describes a major COVID-19 outbreak in a high school in Israel upon opening in May 2020, involving approximately 260 people infected across students, staff, relatives and friends. The authors recommend for students to study in small groups, minimize student mixing in activities and transportation, wear face masks, practice hand hygiene, and keep physical distance. The paper suggests school attendance should be avoided at any sign of illness. Improved ventilation systems to increase air exchange rate and outdoor air use to decrease air recirculation are also suggested.  

Last Updated: July 22, 2020
Guide to reopening Ontario’s schools
— Government of Ontario
Organizational Scan Last Updated: August 27, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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