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Ontario’s largest pediatric hospitals say children need to be back learning in classrooms as soon as possible, emphasizing that more robust testing and infection-control strategies will need to be in place for that to happen.

An updated school guidance document, led by Toronto’s Hospital for Sick Children and released on Thursday, said delays to in-person learning “must be as time-limited as possible” given the harmful social, developmental and academic impacts on children.

“I think whatever shortcomings have happened in the past need to be fixed now. There’s really no wiggle room now,” Ronald Cohn, president of SickKids, said in an interview on Thursday when asked about whether the province had done enough to keep schools safe.

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Dr. Cohn added: “There has to be a razor-sharp focus now on these bundled measures, on a testing strategy [so] we can all feel safe and good about sending our kids to school.”

The report made sweeping recommendations including testing for all staff and students exposed to a confirmed COVID-19 case and setting up mobile testing sites for exposed class cohorts so that tests are more accessible. For younger students, it suggests grouping classes, rather than strictly enforcing physical distancing, “because of the centrality of play and socialization to their development and learning.”

Schools in Southern Ontario remain closed to in-class learning, setting them apart from the rest of the country. Northern boards received the go-ahead to resume in-class instruction, and students in a handful of southern boards will return next week. But the province said schools in the hardest-hit regions – Toronto, Peel, York, Windsor-Essex and Hamilton – will remain closed until Feb. 10, and decisions on reopening schools in other southern boards will depend on local numbers.

The issue of closing schools has been polarizing. There is still no conclusive evidence regarding transmission in schools and to what extent children drive the spread of the virus. However, children who contract COVID-19 tend not to get seriously ill.

Doctors and educators have been calling on the Ontario government to lower class sizes, while also implementing a screening, testing and contact-tracing strategy for schools.

A spokeswoman for Education Minister Stephen Lecce said in an e-mail statement on Thursday that the government follows the guidance of medical experts, especially as community transmission increases. “We know how critical it is for children to be in safe, supportive school environments with their classmates and teachers,” Caitlin Clark said.

Andrew Morris, an infectious-diseases physician at Toronto’s Mount Sinai Hospital, said it is “disappointing” that already 4½ months into the school year, the government has failed to implement “many scientifically supported measures to keep schools open.”

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“If we were to treat schools with the same seriousness as we believe other essential settings are treated, we would not even be having a discussion of when to open schools,” Dr. Morris said. “We would make them as safe as reasonably possible with good testing and contact tracing, and everyone would feel quite reassured.”

The guidance document, which was first released over the summer, said that robust testing and contact tracing, along with infection control, such as masking, is needed to keep schools open as community transmission remains high in many parts of Ontario and with the emergence of a new more-contagious variant of the virus.

The experts have recommended against rapid point-of-care antigen testing, because it’s less accurate for either children who are symptomatic, or for asymptomatic children exposed to a confirmed case. The document also said targeted one-time surveillance tests may be useful if the chance of infection is higher, but does not otherwise recommend it.

The report said that grouping classes and using masks in moderate to high-incidence regions are strategies that should be examined for the youngest learners in place of physical distancing. It recommended physical distancing and masks, however, for middle- and high-school students, particularly in the highest-risk regions.

“A daily in-person school model is best as it allows for consistency, stability and equity regardless of the region in which children live,” the document stated. Further, it said that there is “emerging evidence indicating inequalities in the social and economic burden of COVID-19, which may further disadvantage children [and] youth living in areas with higher infection burden where educational inequality and barriers to online learning may be more pronounced.”

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