Every weekday morning before the school bell sounds, Maé and Ève Corr line up with the Grade 1 and 2 kids at their assigned entrance outside their school in Quebec’s Eastern Townships, taking care to obey the lines marking where they must stand to keep two metres away from their classmates.
Once inside École des Bâtisseurs, the girls sit two metres apart from others. The teacher stays at a distance too. Each class is limited to 15 students and everyone remains in their room during instruction hours. Hand washing and bathroom breaks are on a schedule. The frequent use of alcoholic hand sanitizer at first left the girls with burning hands; their mother, a home-care nurse, soon arranged for milder hand-wipes and cream.
Each group takes turns for recess, avoiding others to prevent infection from spreading from class to class. Ève misses a dear friend in a different class who is also at school, but she’s only allowed to glimpse her from a long distance.
Maé and Ève’s routine may sound like military school compared with the usual joyful chaos of their public elementary school in Granby, Que., but the girls are happy to be back. Their mother, Kim Pomerleau, says that while the kids have adapted, she still hopes the distancing requirement is dropped next fall.
“It’s a bit upsetting for children to have to stay away from their friends and teachers," Ms. Pomerleau says. “They need human warmth for development.”
That sentiment has led pediatricians across Canada to push back against the strict physical-distancing rules for kids that underpin Maé and Ève’s school day. As Quebec’s schools continue to find their feet in the age of COVID-19, and as other provinces plan for September, doctors argue too little attention has been paid to how measures designed to fight the novel coronavirus can cause harm.
In Quebec, 1,066 physicians signed a petition demanding public health drop the two-metre social distancing guideline for young children; the Canadian Paediatric Society released a statement this week urging provincial governments to allow in-person graduation ceremonies, with physical distancing and other safety measures in place.
Toronto’s Hospital for Sick Children has now joined the charge to free the children. An expert group from Canada’s largest pediatric hospital is advising the Ontario government to let children play together again when school resumes in the fall.
“Strict physical distancing should not be emphasized to children in the school setting as it is not practical and could cause significant psychological harm,” the panel argues in a draft of its advice to the Ministry of Education, part of which was viewed by The Globe and Mail. “Close interaction, such as playing and socializing, is central to child development and should not be discouraged.”
The SickKids-led group, which also includes physicians from Toronto’s Unity Health, is not suggesting physical distancing be discarded; desks should still be separated, assemblies banned and line-ups spaced appropriately. Hand-washing, screening for symptoms of COVID-19 and the tracing and isolating of infected children and staff will be imperative.
But when it comes physical distancing outdoors, SickKids president Ronald Cohn doesn’t mince words. “I think it’s impractical,” he says. “I also think it really has the potential to take away some of the positive experiences that our kids need in school.”
The idea of allowing classmates to high-five and hug one another is bound to please some parents and terrify others. And the debate isn’t just about the well-being of students. It also involves protecting the grown-ups they love from illness and death. A frightening amount is known about how the virus can cause harm to adults, particularly the old and chronically ill.
“Unless you’re proposing a Lord of the Flies scenario, there will be adults involved in this, and it’s pretty clear that risk of severe illness takes off very sharply after age 50,” says David Fisman, an epidemiologist at the University of Toronto’s Dalla Lana School of Public Health.
At every turn, SARS-CoV-2, the virus that causes COVID-19, has proven a wily opponent, one not to be underestimated. Much is still unknown about a baffling post-infection inflammatory syndrome known as MIS-C that has killed a handful of young people in New York and London.
But now that most of Canada has brought the first wave under control, Dr. Cohn argues it’s time to figure out how to live with a virus whose risks can be mitigated, but not eliminated. “And we have to balance that with the impact on children," he says.
No Deaths, Many Questions
Back in the second week of March, when governments across Canada began suspending or cancelling school, officials had little choice but to play it safe.
The decision “was the right and necessary thing to do,” says Dr. Cohn, an expert in metabolic genetics and the hospital’s former pediatrician-in-chief. “We didn’t want our health-care system to become overwhelmed."
Although early evidence from China and northern Italy suggested children were less likely to be infected and fall severely ill than their grandparents, nobody knew for certain how a brand-new virus would affect the young.
Four months later, here is what we know: Although more than 6,500 children and teens have tested positive for the virus, only 95, or 1.5 per cent, have been admitted to hospital, according to the Public Health Agency of Canada. Of those, 18 required treatment in an intensive-care unit.
No Canadian under the age of 19 is known to have died of COVID-19.
“I think it surprised everyone,” Stephen Freedman, a pediatric emergency doctor at Alberta Children’s Hospital. “We had expected more disease in children and more severe disease in some subgroups, like kids with asthma and the really young, and we have not really seen that.”
At SickKids, Canada’s largest pediatric hospital, the emergency department has been unusually quiet during the pandemic.
Of the approximately 5,000 children that SickKids has tested for COVID-19, fewer than 1 per cent have come back positive. Only six COVID-positive patients have been admitted to the hospital since March, “and the majority of those children, actually, were admitted for reasons not related to their COVID infection,” says Jeremy Friedman, the hospital’s associate chief of pediatrics.
The frightening exception to the COVID-doesn’t-hurt-kids rule is a baffling new illness that first emerged in Britain at the end of April. Known as multisystem inflammatory syndrome in children, or MIS-C, the syndrome is a cross between toxic-shock syndrome, gastrointestinal illness and Kawasaki disease, a rare childhood illness that inflames blood vessels, most dangerously in the heart.
In Canada, where several dozen suspected cases of MIS-C are under investigation in four provinces, none of the children have tested positive for active infections of COVID-19. This means they aren’t part of the country’s official COVID-19 tally. But all have had blood samples taken to search for antibodies that would show the children fought off a coronavirus infection in the past – the working theory is that MIS-C is a post-infection phenomenon.
Reassuringly, the cases in this country of possible MIS-C have been much milder than some of the severe cases documented elsewhere and no Canadian children have died.
As for why SARS-CoV-2 affects the vast majority of children mildly or not at all, "there are hypotheses, but nobody actually knows,” says Jesse Papenburg, a pediatric infectious-disease specialist and medical microbiologist at the Montreal Children’s Hospital.
One theory involves a cell receptor called ACE2, which the coronavirus’s now-famous spike protein binds to before entering cells and beginning to replicate. The ACE2 receptor expresses itself at a lower level in children than adults which could help explain why they are less likely to catch the virus, according to a study published last month in JAMA.
Another theory is that children enjoy some protection thanks to recent bouts with the other benign coronaviruses that cause the common cold. Other experts speculate it could have something to do with children’s immune systems.
In photos: Inside a reopened B.C. school
A more pressing question for decision-makers is what role children play in the transmission of the coronavirus.
At the beginning of the pandemic, infectious-disease experts and epidemiologists presumed that children would be major spreaders of SARS-CoV-2, as they are for so many other contagious illnesses.
Every parent knows that children – especially toddlers – are adorable germ-factories who can’t keep their fingers out of their mouths and noses. Children are so vital to the spread of influenza that studies of Canadian Hutterite colonies have found that vaccinating a majority of kids and adolescents leads to a significant drop in flu cases among the wider, unimmunized community.
To the surprise of many, the coronavirus seems to be different. It’s not that children don’t transmit SARS-CoV-2 – they have and they do – it’s just that they appear less likely to pass it on than adults, according to preliminary research from Iceland, the Netherlands and the Australian state of New South Wales.
Children also appear to be less likely to be the first, or index, cases in household clusters, according to an analysis from China and Australia.
Others, including Dr. Fisman, say it’s too early to draw conclusions on the part children play in COVID-19 outbreaks. With their tendency toward mild or asymptomatic illness, many infected children were probably missed by restrictive testing policies early on.
Modelling studies have pointed out that, even if children are less likely to catch and pass on the virus, they could spark a rebound in cases by the sheer number of contacts involved in a return to class.
All of these suppositions are now being tested in real time as schools around the world open their doors again, often with smaller classes, masking and physical distancing in place. Officials in Denmark and Finland say the return to class hasn’t sparked a resurgence in cases, but in Israel, dozens of recently reopened schools have been shuttered again because of COVID-19 outbreaks.
In the village of Port-Daniel in Quebec’s Gaspé Peninsula, a tiny English primary school reopened – but only one of 70 students showed up. Many parents in the village were concerned about the virus and had options to have a parent or grandparent care for children. When they heard about planned school restrictions, they stayed home.
Gillian O’Rourke-Garrett, the Grade 1 teacher, is still teaching her seven students online. “It’s a huge, huge challenge,” she says. The children are too young to sit still or read instructions. Teaching them to read online is a lost cause. Directives from the province have shifted constantly. “It’s the biggest challenge I’ve faced in 17 years of teaching.”
The kids are lonely and bored, Ms. O’Rourke-Garrett says. “They desperately need social interaction for healthy development,” she says. “A huge part of the school program, especially at younger ages, is social interaction and development. Learning and listening skills, responding to others’ emotions. You can’t learn that online.”
With so much attention devoted to fighting a new virus, not enough consideration has been given to how the fight itself is harming the educational prospects and mental health of children, some experts say.
Formal evaluations of at-home learning during the pandemic are scarce, but some American and British researchers predict learning loss could be substantial. One paper from the non-profit NWEA and academics at the University of Virginia and Brown University projected that the average student returning in the fall may have lost about a third of their previous year’s learning gains in reading and close to half in math. However, the researchers also projected that the top third of students could potentially make small or moderate gains in reading despite being out of school.
Carol Campbell, an associate professor of leadership and educational change at the Ontario Institute for Studies in Education at the University of Toronto, says that unlike a summer break, children are still receiving formal instruction during this period, and more evidence on the impact of COVID-19 on students in Canada is needed. “Inequities are really going to be exacerbated here, and that’s going to need attention,” Prof. Campbell says.
Aside from school struggles, some children are suffering in other ways, says Catherine Birken, a pediatrician at SickKids and co-leader of TARGet Kids, a long-running study of childhood development that has pivoted to look at how the coronavirus spreads among children and their families. Dr. Birken and her team have also been conducting surveys and focus groups with parents in the study.
“I can tell you, anecdotally,” Dr. Birken says, “that parents are really concerned about their children’s behaviour and emotions and their health.” Not long into their confinement, she says, many noticed the kids were at sea without their routines, sleeping poorly, lashing out and clinging to screens for comfort and distraction. Some felt the opposite – that the slower pace of life and extra family time made children calmer, less anxious.
As for parents, Dr. Birken adds, they’re drowning without childcare.
The Test Case
As many parents struggled, one type of childminding was available in Quebec and other parts of Canada throughout the pandemic: Group care for the children of essential front-line workers.
Geneviève Bélisle, executive director of the association of Quebec’s public early childhood centres, says the province’s experiment in pandemic-era childcare has “flown a little under the radar.” The government worked with daycares and unions to produce a detailed guide for opening daycares, which included children being dropped off at the door, frequent disinfection of toys and other material, and mandatory masks for caregivers. Two-metre distancing was not practical with small children, Ms. Bélisle says, and never enforced.
Quebec’s emergency daycares ran for 10 weeks and saw 50 COVID-19 cases among 3,000 daycare workers and 23 cases among 7,000 children. Two workers and no children spent time in hospital. The cases were mainly isolated and most occurred near the start of the pandemic among those who travelled during the province’s early March school break. In the two weeks since the full reopening started, at least four cases have surfaced among at least 130,000 children and 20,000 workers.
In British Columbia, where about 5,000 children of essential workers attended slimmed-down classes before the province began a broader reopening at the start of June, no outbreaks have been declared at schools.
In Alberta, where 902 children attended 183 daycare centres that were allowed to remain open to serve front-line families, a single staff member at one centre tested positive. In the Greater Toronto Area, where just more than 1,100 children in Toronto and the neighbouring regions of Peel, Durham and York, attended daycares, there was a single outbreak.
In that case, Toronto Public Health believes that, based on the timing of symptoms, a staff member in late April brought the virus to the Jesse Ketchum Early Learning and Child Care Centre, where 15 staff and seven children ultimately tested positive. All recovered at home and the daycare reopened on May 14, according to Vinita Dubey, Toronto’s associate medical officer of health.
At most of the emergency daycares, staff-to-child ratios were high, which likely provided staff extra time to focus on infection control.
“Overall, our recipe worked,” Ms. Bélisle of the Quebec association says. “Maybe we can reassure people in the rest of Canada that our children didn’t grow an extra arm from their foreheads.”
Back to School
At Maé and Ève’s school, 300 children are back in class, about 63 per cent of full attendance. Twenty-five students returned after their parents saw how well things have gone since Quebec’s grand reopening started May 11. Back in April, Granby was in the hottest area for COVID-19 infections outside greater Montreal but the presence of the virus has declined rapidly since then.
Parents, teachers and school administration have adapted to the new regime. To encourage individual play, the school purchased scooters, skipping ropes and Pogo balancing balls, all of which school staff clean several times a day. Animators put on shows including circus and magic tricks.
Maé and Ève favour the Pogo balls and supervised walks in a nearby wooded area.
At the end of the day, supervisors in the schoolyard summon children by walkie-talkie when parents, who aren’t allowed inside the school, arrive for pickup.
Principal Mathieu Brodeur, says he believes the most effective control measure was keeping classes separate.
“We work in cells, much like the family unit during lockdown. By keeping classes, lunch and recess in their own separate cell, we limit potential spread,” he says. "It’s pretty realistic for a September return.”
Schools in the region that includes Trois-Rivières, Que., have faced the most serious challenge yet to the system, with 14 children and eight staff infected at three schools. The hardest-hit school, école Louis-de-France, saw nine of 12 children infected in one class in a single outbreak in early June.
Regional health officials conducted contact-tracing on the children and concluded they could simply shut-down the class while the school remained open. All nine children, along with the cases of infection at the other schools, are recovering at home, according to Guillaume Cliche, spokesman for the regional health authority. The nine children are expected back in class on Monday.
“We were expecting to have cases, but it’s been a month and the curve in schools is still well below the general population,” Mr. Cliche says. “The science said children were less susceptible and so far that’s what we are observing.”
Others provinces are watching Quebec’s reopening closely as they sketch out their plans for September. Alberta, which released its fall reopening plan this past week, outlined three possible scenarios: An extension of at-home learning, a partial return and a resumption of “near normal” conditions with health measures that include avoiding assemblies, reorganizing classrooms for more physical space and practising “some” physical distancing when possible.
In Ontario, Education Minister Stephen Lecce is expected to announce a back-to-school plan in the coming days. The province has faced criticism from child-care operators this week for its daycare plan crafted without consulting advocates. It includes avoiding any singing activities indoors, staff holding infants and toddlers with blankets or cloths and then changing those items between children and not having plush toys in the classroom because they can’t be cleaned and disinfected.
Sources say proposals for the back-to-school plan include having students in both elementary and high school attend on alternating days, meaning young people wouldn’t be in school five days a week. One of the sources says the government is looking to limit students to bubbles with their own classmates and one teacher. It’s unclear how that would work in high school, where students move between classes for different subjects.
The advice from the SickKids group is in line with the government’s thinking, one source says, although it will consider recommendations from all stakeholders, including school boards and unions. (The Globe and Mail granted the sources anonymity because they were not authorized to speak publicly on plans that are still in flux.)
The teacher unions in the province say they have yet to be consulted on reopening plans. Harvey Bischof of the Ontario Secondary School Teachers’ Federation says his members have questions around how the school days would be structured, what happens to staff who are older or have compromised immune systems. He also questions how education would be delivered to those families who choose not to send their children to school.
“Of course I’m worried about the health risks for students and educators,” Mr. Bischof says. “We’ll do everything we can to keep them safe.”
Even in B.C., where the province announced a “dry run” for June, the union president described the plan as a “hodge-podge.” Not all school districts have buses running. Not all of them have hand sanitizer in classrooms.
The return-to-school this month for B.C. students offers just 20 per cent of normal in-class instruction for grades six to 12. Primary school students are receiving half of their regular instruction hours. The return is voluntary.
Jordan Tinney, superintendent of schools for the Surrey School District, says about 15 per cent of his students returned this month. He says the province has different scenarios in place for the fall, but he’s worried that school boards won’t find out until the end of August.
New Brunswick Education Minister Dominic Cardy, whose government was one of the first in Canada to shut down schools, says his government has different approaches based on the age of children. He acknowledges that for younger children physical distancing in schools will be a challenge. Students in kindergarten to Grade 8 will attend school full-time, while those in Grades 9 to 12 will be taught using a combination of online and in-class instruction.
“We have to respond to the pandemic, but we can’t stop living life while it’s still around. And we can’t let it dictate how we drive our society forward. So we have to take advantage of the times when the virus is under control, as it certainly is now in New Brunswick, and carry on,” he says.
“As long as things are good, we stay open,” Mr. Cardy added. “If they get bad, we go online.”
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