WILL MY KID BE SAFE?

In March, when world health of­fi­cials de­clared a pan­demic, the kids came home from school — and stayed home. Now, as schools across the GTA pre­pare to re­open, the Star asked a panel of ex­perts what’s likely to go well and what could go wrong

Toronto Star - - FRONT PAGE - PATTY WINSA AND KENYON WAL­LACE STAFF RE­PORTERS

It’s a ques­tion that has been on the minds of thou­sands of On­tario par­ents, stu­dents and teach­ers for some time now: just how safe is it to re­turn to the class­room in the age of COVID-19?

School boards across the GTA have put for­ward plans with a va­ri­ety of mea­sures in­tended to keep stu­dents safe, such as ask­ing stu­dents and staff to stay two me­tres apart, low­er­ing class sizes, block­ing off water foun­tains and re­quir­ing stu­dents in Grade 4 to 12 to wear masks.

But only once stu­dents and teach­ers are back in the class­rooms will we truly know how ef­fec­tive th­ese plans are.

Out­breaks will likely oc­cur. Dif­fi­cult de­ci­sions might have to be made. Pre­mier Doug Ford has said there will likely be “bumps in the road” when school starts up again and that he will “not hes­i­tate for a sec­ond” to close schools down if nec­es­sary.

The Star asked a num­ber of ex­perts — rang­ing from peo­ple who do pan­demic mod­el­ling to doc­tors — for their sci­ence­based per­spec­tives about mea­sures school boards are tak­ing to keep the spread of COVID-19 at bay.

Some com­mon themes emerged. There was agree­ment that the smaller the class size, the bet­ter. Most agreed that run­ning school buses at ca­pac­ity was a bad idea. And while phys­i­cal fitness is im­por­tant, gym class should be held out­side as much as pos­si­ble.

There was some dis­agree­ment over whether it was re­al­is­tic for par­ents to keep their kids home for two weeks at the slight­est symp­tom of ill­ness. And not all be­lieve we will be able to make it through a full school year in class­rooms.

Here then is our panel of ex­perts with their thoughts to help guide us in the com­ing weeks. The com­ments have been edited for clar­ity and space.

Ques­tion: The GTA’s10 English pub­lic and Catholic boards are al­low­ing ele­men­tary stu­dents in class as long as they’re so­cially dis­tanc­ing (in some boards desks are only one me­tre apart) and some are al­low­ing stu­dents to work closely to­gether as long as they’re wear­ing masks. Do you think that is safe or should ele­men­tary class size be re­duced?

An­swer: Dionne Aleman, in­dus­trial en­gi­neer­ing pro­fes­sor and pan­demic mod­eller:

There is ev­i­dence to sug­gest that one-me­tre dis­tanc­ing is al­most as ef­fec­tive as two-me­tre. But, the one-me­tre and two-me­tre radii are de­rived from ex­per­i­ments with peo­ple talk­ing at normal vol­umes and the dis­tances that droplets from their noses and mouths spread. When kids are sit­ting at desks, are they talk­ing in a normal con­ver­sa­tional tone?

They are prob­a­bly rais­ing their hands to loudly ask ques­tions to the teacher at the front of the room (or maybe yelling and hors­ing around with each other), which means that the one-me­tre or even two-me­tre dis­tance may not be enough.

“The On­tario Pub­lic Health rec­om­men­da­tion for other in­door set­tings has con­sis­tently been two me­tres for dis­tanc­ing. Schools should not be an ex­cep­tion.” Dr. Jen­nifer Kwan, fam­ily physi­cian

Su­san Bondy, epi­demi­ol­o­gist: In pub­lic health there are really rarely go­ing to be uni­ver­sally ac­cepted thresh­olds for what is “safe” and “not safe.” Risks are al­ways on a con­tin­uum and what is ac­cept­able to one per­son, or fam­ily, is not ac­cept­able to an­other ... also, even if we had well-re­searched and de­fen­si­ble risk num­bers for a very spe­cific con­text (e.g., dif­fers by school, grade, and time), risk num­bers are the­o­ret­i­cal and ab­stract con­cepts. The fact is, some out­breaks are go­ing to hap­pen in some schools some­where in On­tario. Ray­wat Deo­nan­dan, epi­demi­ol­o­gist: Re­duc­ing class sizes should be the num­ber one strat­egy and fo­cus. Not only does it al­low dis­tanc­ing but also lim­its the num­ber of ex­po­sures ex­pe­ri­enced by any given per­son.

Jen­nifer Kwan, fam­ily physi­cian: The On­tario Pub­lic Health rec­om­men­da­tion for other in­door set­tings has con­sis­tently been two me­tres for dis­tanc­ing. Schools should not be an ex­cep­tion. Camille Lemieux, physi­cian: The more mea­sures a school can take the bet­ter. Re­dun­dancy that al­lows for in­creased safety should be what schools are aim­ing for, mean­ing it should not be ei­ther mask­ing or dis­tance but rather both.

Abdu Sharkawy, in­fec­tious dis­eases ex­pert Every ef­fort should be made to keep classes as small as pos­si­ble. Mask­ing will help re­duce the risk of trans­mis­sion but is not a sub­sti­tute for dis­tanc­ing and this is very dif­fi­cult to ac­com­plish if class sizes are large. Work­ing to­gether less than two me­tres apart is in­ad­vis­able in my opin­ion, and cre­ates un­nec­es­sary risk, es­pe­cially if it is done for pro­longed pe­ri­ods of time.

Ques­tion: Does ar­rang­ing all the desks fac­ing for­ward (as some boards are do­ing) really make a dif­fer­ence?

Dionne Aleman: It prob­a­bly helps some, but prob­a­bly not as much as wear­ing a mask dur­ing class. Stu­dents will still turn around in their desks to talk with their neigh­bours even if they are told not to.

Cyn­thia Carr. epi­demi­ol­o­gist: We con­tinue to learn about the role of the larger droplets (cough­ing, sneez­ing) vs. droplets from talk­ing and singing vs. the pos­si­bil­ity for in­fec­tiv­ity by much smaller mi­cronu­clei that can stay air­borne longer and float far­ther than then heav­ier cough or sneeze droplets (think spray­ing water from a Win­dex bot­tle vs. putting that water in a hu­mid­i­fier for ex­am­ple). How­ever, this has not been de­fined as an air­borne virus like the measles, so we are still learn­ing and with that look­ing at harm re­duc­tion.

Camille Lemieux: I don’t be­lieve there is any ev­i­dence that sup­ports desk ori­en­ta­tion hav­ing any im­pact.

Abdu Sharkawy: Not really. In re­al­ity, stu­dents are not fac­ing for­ward 100 per cent of the time. They will be turn­ing at all an­gles as a mat­ter of habit and ne­ces­sity.

At least one school board is al­low­ing stu­dents to sing in class as long as they’re phys­i­cally dis­tanc­ing. Do you think this is safe?

Dionne Aleman: Ab­so­lutely not. We have al­ready seen at least two doc­u­mented cases of COVID clus­ters aris­ing from choir groups: one in Washington and one in Ger­many.When you sing, you are open­ing your mouth much wider — both in­hal­ing and ex­hal­ing more air — and the ev­i­dence sug­gests that you are send­ing far more droplets at a longer dis­tance. Su­san Bondy: Any time one is speak­ing or ex­hal­ing force­fully there will be risk of spread — should the speaker be in­fected and in the in­fec­tious pe­riod. I doubt this has been stud­ied so in­tensely as to sep­a­rate the im­pact of those be­hav­iours, but my ex­pec­ta­tion would be that ban­ning singing com­pletely, and only singing, isn’t go­ing to make a clin­i­cally sig­nif­i­cant — or pub­lic health sig­nif­i­cant — dif­fer­ence in risk. Masks ver­sus no-masks rep­re­sents a far greater dif­fer­ence in risk than singing ver­sus lec­tur­ing or laugh­ing.

Cyn­thia Carr: I would not sup­port singing right now even with a mask on. We know that the closer we are to­gether, the more like­li­hood of spread. But there are cases of out­breaks in call cen­tres where peo­ple were dis­tanced. The more we talk or sing, the more like­li­hood for re­s­pi­ra­tory droplets. Ray­wat Deo­nan­dan: The ev­i­dence around singing is un­clear. So far it seems that singing pro­duces more aerosol trans­mis­sion than sim­ple talk­ing. Given that, singing should be al­lowed only if, in ad­di­tion to dis­tanc­ing, a good ven­ti­la­tion sys­tem re­duces the chances of aerosol spread.

Jen­nifer Kwan: Singing is a high-risk ac­tiv­ity due to the for­ma­tion of aerosols and droplets dis­trib­uted in the in­door space. It would only be con­sid­ered safe if done out­doors, with masks and with two-me­tre dis­tanc­ing. Singing in an in­door class­room would be an un­nec­es­sary risk. Abdu Sharkawy: I don't think this is ad­vis­able. If the ven­ti­la­tion is not op­ti­mal, it is con­ceiv­able that some de­gree of aerosolize­d virus could travel from some­one singing and be trans­mit­ted to some­one more than two me­tres away.

The Toronto Catholic board is fix­ing win­dows so that in some schools they open 12 inches. Other schools have win­dows that only open a few inches. How im­por­tant is good ven­ti­la­tion?

Dionne Aleman: Ev­i­dence sug­gests that good ven­ti­la­tion is im­por­tant to pre­vent COVID spread, but it is not clear what makes ven­ti­la­tion good enough. I doubt that win­dows open­ing only a few inches makes much of a dif­fer­ence, but 12 inches might not be suf­fi­cient ei­ther.

Su­san Bondy: There is some ev­i­dence, and a few out­break stud­ies, which sug­gest this virus can be moved by air in ven­ti­la­tion sys­tems and so be trans­ported to an­other per­son who be­comes in­fected. It is a bit beyond be­ing merely a the­o­ret­i­cal pos­si­bil­ity but still may be a rare oc­cur­rence. Good ven­ti­la­tion is an es­sen­tial el­e­ment of in­fec­tion con­trol where the risk is high and so the costs of a pur­pose-built ven­ti­la­tion sys­tem must be in­curred.

Cyn­thia Carr: Re­cir­cu­lated air could be a pos­si­ble fac­tor in spread­ing the virus so ven­ti­la­tion is ab­so­lutely key. Even with­out abil­ity to in­stall an up­dated ven­ti­la­tion sys­tem, hav­ing doors and win­dows open will help bring in fresh air and po­ten­tially dis­burse the virus as op­posed to a closed room with re­cir­cu­lated air. There should be no fans in the class­room re­cir­cu­lat­ing air if win­dows are closed. Ray­wat Deo­nan­dan: Good ven­ti­la­tion is very im­por­tant for mit­i­gat­ing that frac­tion of trans­mis­sion that is caused by aerosols. I would say it's the fourth-most im­por­tant strat­egy af­ter low­er­ing com­mu­nity in­ci­dence, mak­ing class sizes smaller and en­forc­ing phys­i­cal dis­tanc­ing.

Colin Fur­ness, epi­demi­ol­o­gist: Ven­ti­la­tion is key and fresh air is very safe – much bet­ter than re­cy­cled fil­tered air. You don’t want stu­dents sit­ting in a row such that air cur­rents from the win­dow will blow droplets from one per­son to the next. Some Plex­i­glas or other kind of dif­fuser in front of the win­dow would help to dis­si­pate air cur­rents. Re­ly­ing heav­ily on fresh air in the win­ter may make a class­room un­com­fort­ably cold, how­ever – and viruses thrive in cold dry air. I would not want to see cold dry air in class­rooms for this rea­son, so I would rec­om­mend lim­it­ing open win­dows to a rea­son­able level in win­ter and us­ing an air scrub­ber and a hu­mid­i­fier.

Dr. Camille Lemieux: Ven­ti­la­tion has been shown to have a pos­i­tive im­pact with re­spect to other vi­ral and bac­te­rial in­fec­tions. The num­ber of times air is ex­changed in an in­te­rior space can re­duce trans­mis­sion of droplet and air­borne trans­mit­ted in­fec­tions, a higher num­ber of ex­changes be­ing bet­ter.

Abdu Sharkawy: Good ven­ti­la­tion is crit­i­cal. And any ven­ti­la­tion is bet­ter than no ven­ti­la­tion.

Some school buses will be op­er­at­ing at ca­pac­ity. What are your thoughts on the safety of this? How can par­ents keep their kids safe on buses?

Dionne Aleman: School buses at ca­pac­ity is a ter­ri­ble idea. You have kids from dif­fer­ent grades and dif­fer­ent classes in a tight, con­fined space, yelling across to each other. If any­one has COVID, it will spread, and it will spread to mul­ti­ple classes and grades.

Sue Bondy: There have been some out­breaks in which trav­el­ling to­gether in buses ap­pears to have been an op­por­tu­nity for trans­mis­sion. The risk, though, is really driven by the rate of in­fec­tion in the com­mu­nity and that is im­pos­si­ble for real peo­ple to know on a day-to-day ba­sis beyond fol­low­ing gen­eral trends.

Cyn­thia Carr: Buses have risk fac­tors: close prox­im­ity of sit­ting to­gether, kids walk­ing up and down the aisle get­ting on and off the bus and then the re­cir­cu­la­tion of air for both heat­ing and cool­ing. I would want bus win­dows open and all kids wear­ing masks.

Ray­wat Deo­nan­dan: This is not an ideal sce­nario and I'd pre­fer if we'd in­vest in more buses and driv­ers to lower the den­sity of peo­ple on each bus. How­ever, in this cir­cum­stance we can lower risk by man­dat­ing both masks and face shields on the bus, hav­ing adult su­per­vi­sion on each bus to limit shenani­gans and hav­ing re­served seat­ing so that kids are al­ways ex­posed to the same per­son, es­pe­cially if that per­son is a class­mate or sib­ling.

Colin Fur­ness: That is very con­cern­ing be­cause that is a lot of peo­ple in a small air space for a sus­tained pe­riod of time. More­over, in my ex­pe­ri­ence kids en­joy shriek­ing on buses, which in­creases droplet shed­ding. I would also worry about mask com­pli­ance on a bus given a propen­sity for bois­ter­ous be­hav­iour. I’d like to see buses at about 25 per cent ca­pac­ity.

Jen­nifer Kwan: School buses should re­quire masks for all stu­dents (who can wear them), and also re­quire two-me­tre dis­tanc­ing be­tween stu­dents. Ca­pac­ity may need to be re­duced to al­low for ap­pro­pri­ate two me­tre dis­tanc­ing. Win­dows should be opened if pos­si­ble, de­pend­ing on the weather. A phys­i­cal par­ti­tion to pro­tect bus driv­ers should be con­sid­ered. Abdu Sharkawy: I have ma­jor con­cerns about school buses. Driv­ers are go­ing to be at risk in par­tic­u­lar and should be masked with a bar­rier in place and win­dow open if pos­si­ble. But kids will be hard-pressed to dis­tance, es­pe­cially if a bus is even half full in many cases. Even with masks, this wor­ries me when we con­sider a ride could last an hour or longer in some cases.

Ques­tion: Is it re­al­is­tic to ask par­ents to keep their kids home for two weeks at the slight­est symp­tom of cold or ill­ness, a re­quire­ment in some boards?

Dionne Aleman: I think some par­ents will flout this re­quire­ment, but it’s a rea­son­able re­quest given that we are in the mid­dle of a global pan­demic emer­gency. Pub­lic health has to su­per­sede in­di­vid­ual con­ve­nience. Su­san Bondy: In a pan­demic? Yes, I think this is rea­son­able. The ben­e­fit to the pub­lic, in re­duc­ing ac­tual risk and anx­i­ety and the pos­i­tive ben­e­fit of so­cial mod­el­ling are con­sid­er­able. We also know the re­quire­ment may have large im­pacts on some fam­i­lies.

Ray­wat Deo­nan­dan: It prob­a­bly isn't re­al­is­tic in the long run. But in the ini­tial weeks it helps to as­suage some con­cerns; and panic man­age­ment is part of this en­deav­our. Ul­ti­mately a more com­pre­hen­sive symp­tom-based di­ag­nos­tic tool will have to be de­vel­oped and shared with par­ents.

Colin Fur­ness: That seems ex­ces­sive.

ISTOCK GETTY IMAGES PLUS

RENÉ JOHN­STON TORONTO STAR

Hand san­i­tizer is be­ing sup­plied out­side some class­rooms, in­clud­ing this one shown at Wex­ford Col­le­giate School for the Arts.

BOB TYM­CZYSZYN TORSTAR

Staff at Ni­a­gara schools have blocked off water sta­tions as stu­dents re­turn to school.

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