Adapting infection prevention and control measures used in hospitals and applying them in schools could keep students and educators safer in the classroom, medical experts say.
Those measures include making face masks mandatory for teachers and all but the youngest students.
"If you think about the school environment where physical distancing, I think realistically, is going to be impossible to maintain, especially when we’re dealing with children or we’re dealing with overcrowded schools ... there may be infection prevention and control measures similar to the ones that we use in the hospital that could keep schools as safe as hospitals have been," said Dr. Michael Warner, medical director of critical care at Michael Garron Hospital.
He thinks schools could be a "second safe place for children outside of their social circle."
This comes as Education Minister Stephen Lecce said the government will be sharing its plan for the resumption of classes next week. He said the plan that will include "strong health and safety measures" along with "additional supports and resources" is being finalized with the province's chief medical officer of health.
Face masks in schools
Warner said face coverings should be required in schools for educators and students above a certain age who can tolerate wearing them.
"I think that, at the end of the day, will be demonstrated to be the most important thing to reduce the risk of spreading COVID-19 in congregate settings," he said. "If you’re going to mandate it at Costco, how could you not mandate it at schools, which some will say is a much higher risk environment for spreading COVID-19."
Medically it makes sense, said Warner, adding that children are "highly adaptable."
"If things become part of their routine, whether it be hand hygiene, wearing a face covering, keeping distance from children who aren’t in their cohort, let’s not underestimate their ability to pivot and change in a way that makes schools safer for them," he said.
His call has been echoed by several in the medical community.
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Hospitals have successfully created a safe busy environment for the past 4 months with masks and physical distancing where possible. Schools can do the same. Give the kids some credit, they can do masks just fine!
&mdash; Shady Ashamalla MD (@ShadyAshamalla) <a href="https://twitter.com/ShadyAshamalla/status/1285770642835386368?ref_src=twsrc%5Etfw">July 22, 2020</a></blockquote>
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Lecce's office wouldn't say whether the government is considering mandatory masks in schools.
When the province released its initial reopening plan for schools in June, <a href="https://www.ontario.ca/page/approach-reopening-schools-2020-2021-school-year" target="_blank" rel="noopener noreferrer">guidance</a> accompanying the announcement stated that "in general, masks should not be required for school staff if physical distancing is practised appropriately."
“Our single greatest priority is the safety of students, staff, and their families. That is why we continue to work closely with the best medical and scientific leaders in Canada, to implement health protocols that keep our schools safe," wrote Lecce's spokesperson, Alexandra Adamo, in an email.
Dr. Zain Chagla, medical director of infection control at St. Joseph’s Healthcare Hamilton, said while educators should wear face masks, students — except for toddlers or very young students — could too.
"There’s lots of examples of four-, five-, six-year-olds being able to wear masks," he said, adding that while they might not be able to keep them on all day, they should still be taught how to wear them. This could include developing "techniques where they’re actually engaged with using it, either creating things like superhero masks, something that makes it more interesting that they’re much more engaged in wanting to do it."
Once children reach Grade 5 or 6, it's "quite reasonable" to have them wear masks if they can tolerate them, Chagla added.
Warner stressed the importance of consistency when it comes to school reopening policies, pointing to the patchwork of masking requirements across the province. While some municipalities have decided to mandate face coverings in public indoor settings, others haven't.
"We can’t have schools infection prevention and control policies be that heterogeneous because you could even have children in the same family at different schools where there are different rules, and that doesn’t make sense," he said.
While mandatory mask policies in Toronto and York Region apply to grocery stores, malls and places of worship, they have an exemption for schools.
Asked why, Pat Casey, director of corporate communications for York Region, said schools and other spaces were exempt from the order because "they do not often have unknown people entering or leaving throughout the day." However, mandating masks in schools would be up to the ministry or school boards, he said.
It's expected that staff and students would not attend school if they are unwell, said Casey, adding that "face coverings are one prevention measure but not a panacea." Cohorting, handwashing and physical distancing are "important preventive measures," he said, noting however that parents shouldn't be discouraged if they want to send their child to school with a mask.
Dr. Vinita Dubey, Toronto Public Health's associate medical officer of health, said the health unit has been working with local school boards to provide COVID-19-related public health guidance, but that it "will await additional guidance regarding mask use in schools from the Ministry of Education." The Toronto District School Board said direction on mask use would come from Toronto Public Health and/or the ministry.
Asked if the Ontario English Catholic Teachers’ Association would support making masks mandatory in schools, union President Liz Stuart said in a statement to QP Briefing that "everything possible should be done to protect students, teachers, education workers, other school staff, and their families."
"Given how difficult it is to maintain appropriate physical distance in schools, this means everyone in the building should be wearing a mask, unless they have a legitimate medical reason not to do so," Stuart said, adding that for schools to reopen safely, proper screening protocols and additional investments for smaller class sizes and hygiene and cleaning products would be needed.
The Elementary Teachers’ Federation of Ontario also supported the idea, saying "a requirement for masks and personal protective equipment (PPE) makes sense, particularly in those situations where effective physical distancing will be challenging." But there would need to be variation in requirements based on the educator's role, the union stated, adding that it would expect school boards to provide staff with the necessary masks and PPE.
The Ontario Secondary School Teachers' Federation said it would support the advice of health authorities.
"I think parents are looking for certainty, parents are looking for standards, teachers are also looking for this and we need to set the maximally safe standards and work backward from those if they’re not necessary," said Warner.
Learn from hospitals, say doctors
Chagla said there's a "wealth of infection control experience" in communities and hospitals that can serve as a prototype for what should be done in schools.
One of the ways to do this, said Warner, is to deploy infection prevention and control experts to school settings as was done with long-term care homes.
He said several measures were put in place at his hospital where it is often difficult to physically distance including screening staff every day, having handwashing stations around the hospital and requiring masks for workers and visitors. There is also a "culture of trust" among staff that when they leave the hospital, they'll adhere to public health guidelines, Warner added.
"Because of those things ... COVID-19 outbreaks among health-care workers are exceedingly rare, and I actually feel safer at the hospital where COVID is present than in any other public venue around, that means safer than the grocery store, safer than going to get gas and it’s because of those things," said Warner, who has a social circle of 10 people.
Without such measures in place in schools, children "will be exposed to the social circle of 150 other people right away," he said. "Having partnerships formed between health-care infection prevention and control experts and educators ... will not only facilitate school reopening, but also allow us to have full-time school."
Chagla and Warner agreed that school five-days-a-week makes the most sense for infection control. The government has told school boards to prepare for three scenarios: remote learning, in-person classes and a hybrid model. While the government initially said school boards should expect to roll out the hybrid model in September, Lecce and Premier Doug Ford have said their preference now is to have kids in school every day.
A hybrid model would mean that some children requiring child care would be exposed to more people on the days they are not in school, increasing the risk of bringing COVID-19 into the classroom, said Chagla.
He said there are many other lessons learned from the health-care system from the first few months of the pandemic.
Space and small class sizes are needed, Chagla said, pointing to the long-term care sector which showed that rapid transmission occurs in homes where space and cohorting isn't adequate.
It's also important staff are able to physically distance from their colleagues when in school, including when they're taking breaks, he said.
"As we learned in health care, health-care workers are as much a threat to other health-care workers as patients are to health-care workers because health-care workers tend to let their guard down among their colleagues and not wear their PPE appropriately," Chagla said, adding that whether it's in the school office, copy room or break room, staff should wear PPE and ensure they are distancing, or if the weather is nice, consider outdoor breaks.
And while a deep clean of a classroom might be necessary if someone gets infected, having a checklist of "high touch surfaces" like doorknobs and bathrooms that need to be cleaned each day should suffice, he said, stressing that frequent handwashing should accompany this.
Screening at school entrances will also be important, Chagla said, noting that parents should also be taught how to properly screen their children.
And while the government has said its pumping more money into the sector than previous years, both doctors joined educators and boards in saying more funding will be needed to ensure schools can reopen full-time and safely. This would include funding for more teachers so that class sizes can remain low and using "unconventional spaces" outside of schools so physical distancing can be maintained.
"I think the goal should be to be to have 100 per cent school with 200 per cent of the investment, not 50 per cent school with 100 per cent of the investment," said Warner. "This is going to involve new money, but I think from an economic perspective, there’ll be a return on investment because parents will be able to go to work and the economy will be able to reopen."

Doctors, education unions call for mandatory masks in schools

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