This Briefing Note was completed by the Research, Analysis, and Evaluation Branch (Ministry of Health) based on a COVID-19 Rapid Evidence Profile provided by McMaster Health Forum, a member of the COVID-19 Evidence Synthesis Network. Please refer to the Methods section for further information.
This note provides a summary of scientific evidence and a jurisdictional scan on the re-opening, operation, and monitoring of schools during the COVID-19 pandemic.
*The full version of the Briefing Note including the Appendix can be accessed in the PDF file at the top of the page*
- Before Re-Opening Schools: Guidelines and systematic/rapid reviews emphasize the importance of basing decisions on the local situation and current COVID-19 epidemiology. Schools are recommended to re-open only when community transmission is low.
- Operation of Schools: Evidence sources emphasize, to some extent, the need to adopt remote-learning arrangements, but also note the limitations with remote learning (e.g., poorer educational outcomes for those from a lower socioeconomic status).
- Accompanying Public-Health Measures: Measures for infection-prevention (e.g., cohorting, hand washing, face masking) and infection-control (e.g., screening, testing, isolation) were identified by most of the evidence sources, which emphasize the need for a multifaceted approach to preventing COVID-19.
- Monitoring Measures as Re-Opening Is Being Implemented: The identified literature suggested that it is rare for children to be the index case in a COVID-19 outbreak and do not appear to be a major source of transmission for COVID-19. However, these findings are based on studies conducted prior to children returning to schools and while stay-at-home orders were still in place.
- Clinical Outcomes among Children: While children can get COVID-19, it is rare to see severe symptoms or require hospitalization, and it is suggested, although debated, that younger children tend to be infected less than adolescents and adults.
- Jurisdictional Review: While approaches to re-opening schools and accompanying public-health measures may vary, there were similar themes that emerged across jurisdictions such as the prioritization of younger grades and those in need of particular credits to move forward with post-secondary education. To date, Quebec is the only Canadian jurisdiction to allow children to go back to school, while the remaining provinces and territories have developed plans for returning to school in September 2020.
Analysis for Ontario
- There are innovative approaches to re-opening schools in Ontario which include, but are not limited to:
- Mix of home and campus-based education; school spaces with enhanced or new ventilation; creating adaptable plans for future waves; establishing a COVID-19 program coordinator at schools; permitting flexibility to the school day to allow for cohorting of students; rotation between online and in-person schooling; implementing exam-style seating where students are seated individually; enhancing online and remote learning through increasing access to devices and the internet; and creating social-distancing measures for the maximum capacity in a room.
The section summarizes scientific evidence and lessons learned from international and Canadian jurisdictions on re-opening schools during the COVID-19 pandemic. The findings were organized according to the following framework:
- Indicators to monitor before re-opening schools
- Rate of community spread
- Rate of community adherence to public-health measures
- Changes to the operation of schools
- Online instruction (whole or partial)
- Student supports
- Instructor supports
- Staffing ratios
- Classroom changes (e.g., limiting number of students; increasing distance between students)
- Facility changes (e.g., expanding classroom size by using additional facilities; providing class outside)
- Skill re-development programs
- Accompanying public-health measures
- Infection prevention
- Washing hands
- Wearing masks
- Disinfecting surfaces and facilities
- Physical distancing (e.g., cohorting, limits to class size, desk spacing)
- Temporal distancing (e.g., holiday staggering, time of day staggering)
- Ventilation maximization
- Public-focused behaviour change supports
- Infection control
- Quarantining of exposed or potentially exposed individuals
- Isolation of suspected or confirmed cases
- Contact tracing
- Infection prevention
- Indicators to monitor as re-opening is being implemented
- School outbreaks
- Transmission among students
- Transmission between students and school employees
- Transmission to families at home
- Rate of community adherence to public-health measures
- Rate of community spread
- Reported challenges implementing any of the measures above
- School outbreaks
Indicators to Monitor Before Re-Opening Schools
- The identified guidelines and systematic/rapid reviews all emphasized the importance of basing decisions on the local situation and current COVID-19 epidemiology, with school reopening being recommended to take place only when community transmission is low.
- The World Health Organization’s guideline emphasizes the need to consider the potential harms due to school closure, such as the potential for widening disparity in educational attainment.
- A guideline from the Scottish government noted the importance of considering other indicators such as COVID-19 incidence and swab positivity for the entire population and specifically for school-age children, as well as the proportion of case among school workers, outbreaks in specific regions and in educational settings, and antibody prevalence among children and school workers.
Changes to the Operation of Schools
- The identified guidelines and systematic/rapid reviews all emphasized (to some extent) the need to adopt remote-learning arrangements, but several also identified important limitations with remote learning. In particular:
- A low-quality rapid review that was focused on the Australian context found that remote-learning arrangements have the potential to result in poorer educational outcomes for almost half of Australian primary and secondary students if used for an extended period, and that combinations of face-to-face and remote learning may be as effective as only classroom learning for some students;
- The review noted that those most at-risk for poorer outcomes are those of low socioeconomics status, with English as a second language, with special learning needs, and those in rural and remote areas;
- The review also highlighted that Indigenous peoples were more likely to face challenges with remote learning given lack of internet service and device availability, reduced opportunities for interaction with Indigenous teacher assistants, and challenges in incorporating culturally appropriate teaching approaches into online resources.
- In addition, a guideline from the Department of Education in the United Kingdom (UK) highlighted the importance of online education support, along with efforts to enhance staff recruitment, deployment, and training; and
- Lastly, a guideline from the American Academy of Pediatrics highlighted the need to utilize outdoor spaces, support students with disabilities, and address the mental health needs of students and staff as part of the school re-opening process.
Accompanying Public-Health Measures
- Each of the infection-prevention and infection-control measures listed in the framework above were emphasized by most of the guidelines and literature which underscores the need for a multifaceted approach to preventing COVID-19.
- The findings from some of the included literature provided contradictory recommendations about how to implement such measures, including different ages to require masks (although the challenges for young children to wear masks was consistently acknowledged), and whether masks need to be worn at all times or just in common spaces.
- In addition, several of the single studies provide important insights about the implications of not implementing robust infection-prevention and infection-control measures. In particular:
- UK: A recent modelling study conducted in the UK examined six scenarios that included the combination of two school re-opening strategies (i.e., a full-time and a part-time rotation system with 50% of students attending school on alternate weeks) and three testing approaches (i.e., 68% contact tracing with no scale-up in testing, 68% contact tracing with sufficient testing to avoid a second COVID-19 wave, and 40% contact tracing with sufficient testing to avoid a second COVID-19 wave). Based on these scenarios, the study found that prevention of a second wave of COVID-19 infections following the relaxation of physical distancing and re-opening of schools must be paired with large-scale, population-wide testing of symptomatic individuals and effective contact tracing, followed by isolation of diagnosed individuals;
- France: Another modelling study from France found similar results (including the need for large-scale tracing and testing) and indicated that opening schools will result in an increase in COVID-19 cases. It also predicted that the burden on the health system is manageable by opening only pre-schools and primary schools, and that a second wave of COVID-19 would be triggered if full attendance in secondary school is pursued.
- Israel: A recent study reporting on an environmental assessment conducted on the outbreak of COVID-19 cases following school re-opening in Israel provides additional insight about how implementation can affect outcomes. Specifically, the study found that distancing and other personal protective measures among students and teachers was not possible due to crowded classes and an extreme heatwave that involved exemption from facemasks and continuous air-conditioning.
- Sweden: In contrast, results of a study of pediatric COVID‐19 admissions in Sweden during two months of its open-school policy during the pandemic point to low incidence of severe illness due to COVID‐19 among Swedish children despite day‐care centres and primary schools being open, which suggests that the Swedish strategy of allowing day cares and schools for children under age 15 to remain open as of April 2020 did not worsen the course of the pandemic for children in Sweden. However, the study did not assess the impact of the open-school strategy on societal transmission of COVID-19.
Monitoring Measures as Re-opening is being Implemented
- All of the identified systematic/rapid reviews focused on transmission of COVID-19 among children and were all in agreement that it is rare that children are found to be the index case in an outbreak and that children do not appear to be a major source of transmission for COVID-19.
- One rapid review found a linear relationship between age and likelihood of contracting and transmitting COVID-19, which may mean that the risk of transmission is relatively low among early elementary school children but increases in later elementary school and in secondary school.
- Despite the positive findings from the literature reviews related to the likelihood of transmission, it should be noted that many of the studies included in the literature reviews were conducted prior to children returning to schools and while stay-at-home orders were still in place.
- Additional research is needed to understand the extent to which returning to school increases the potential for transmission.
Clinical Outcomes Among Children
- 10 systematic reviews related to clinical outcomes among children were identified.
- In general, the reviews found that though children can get COVID-19, it is rare to see severe symptoms or require hospitalization.
- The reviews further suggested that younger children tend to be infected less than adolescents and adults, however, there remains some debate about this, particularly given that their experience of mild or no symptoms may result in fewer tests having been conducted.
- Experiences with re-opening schools were examined in 12 countries, namely Australia, five European countries (i.e., Belgium, Finland, France, Germany, and Sweden), Israel, New Zealand, Singapore, South Korea, Taiwan and the United States (with a focus on California, Georgia, Indiana, Minnesota and New York) as well as all provinces and territories in Canada. The focus was specifically on the unique or particularly innovative approaches.
- All of the examined jurisdictions have already opened some or all of their schools, except California and New York, which plan to re-open at the beginning of September.
- Relatively little information was identified on the indicators that triggered the re-opening of schools. However, in the cases of both Australia and New Zealand, schools re-opened based on pre-defined rates of community transmission.
- Though approaches varied to school re-opening as well as in the accompanying public-health measures used, there were similar themes that emerged from across countries including the prioritization of younger grades and those in need of particular credits to move forward with post-secondary education.
- The recent guideline released by the Public Health Agency of Canada for school re-opening recommended a layered approach to reduce the risk of COVID-19 in school, with core risk-mitigation measures including decreasing interactions with others and increasing the safety of interactions (e.g., through the use and promotion of personal preventive practices such as requiring the use of masks for children 10 years of age and older, and increased ventilation).
- Experiences with re-opening schools were examined in all provinces and territories in Canada. The focus was specifically on the unique or particularly innovative approaches.
- Quebec has been the only province or territory to have allowed children to go back to school. The rest of the provinces and territories have developed plans for returning to school in September.
- Nunavut and Alberta have both specified triggers for re-opening and closing schools, which are both dependent on community virus transmission rates and school transmission and outbreaks.
- Innovative approaches from Canadian provinces and territories include:
- Assigning primary students to a fixed classroom to act as their primary learning environment;
- Focus curricula on the teaching of core subjects to students to allow for greater flexibility with attendance and in-person teaching;
- Cohorting middle school and secondary school students who take the same core extracurricular subjects;
- Reducing elementary class sizes to create a ‘bubble’ of students who are assigned to stay together – however, no details were provided on the number of students in a given bubble;
- Making additional mental health and student supports available for all grades;
- Standardized entrance and exit doors and increased use of emergency exits to reduce crowding;
- Altering transportation measures for school buses including increasing the number of school buses, requiring masks, using seating plans and putting in place physical barriers; and
- Disinfecting high-touch areas twice within a 24-hour period.
- In addition to the common approaches to school re-opening that were identified across the examined jurisdictions (i.e., prioritization of younger grades and those in need of particular credits to move forward with post-secondary education), there were a number of particularly innovative solutions that build on those planned for in Ontario. These include:
- Developing additional guidance for schools where large populations come from another geographic area (e.g., where there may be a higher community transmission of COVID-19);
- Continuation of daycare/preschool and early primary school for children of parents who are essential workers or students requiring additional supports throughout the pandemic and any next waves;
- Creating adaptable plans for future waves that may include students attending school but not full-time or during typical school hours;
- Allocating discretionary funds to schools for purchasing of equipment to enhance safety measures (e.g., hand sanitizing stations, PPE) or contracting additional personnel where needed;
- Establishing a COVID-19 program coordinator who will serve as the point of coordination for the school;
- Adding flexibility to the school day to allow for cohorting of students and staff for drop-off and pick-up times as well as lunch breaks and recesses at school to avoid mixing with other students;
- Eating outdoors (with staggered times) or in classrooms to avoid the use of cafeterias or lunch rooms;
- Moving lessons indoors (where possible) or in spaces with enhanced ventilation, and investing in new ventilation systems to enable this change;
- Establishing designated routes of entry and exit for specific groups of students to avoid mixing;
- Providing a mix of home- and campus-based education to allow for smaller class sizes;
- Creating social-distancing measures for the maximum capacity in a room;
- Rotation between online and in-person schooling;
- Enhancing online and remote learning through packages of supports that focus on increasing access to devices and the internet (e.g., ordering laptops and mobile devices), providing students with hard-copy learning materials, and using local television stations to broadcast educational material;
- Implementing exam-style seating where students are seated individually, staggered from one another and using privacy boards or screens between desks; and
- Supporting parents of children who are unable to attend school by ensuring flexible working arrangements are available.
The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following member of the Network provided an evidence synthesis product that formed the basis for this Evidence Synthesis Briefing Note:
- What evidence could support modeling scenarios related to the re-opening, operation and monitoring of schools? Hamilton: McMaster Health Forum, 17 August 2020.
For more information, please contact the Research, Analysis and Evaluation Branch (Ministry of Health).