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Ontario students should return to schools that look more normal in the fall, with sports and clubs, no lineups for daily health checks at the door, and optional masking – as long as there is not a spike in severe COVID-19 cases requiring hospital admission in the community.

That’s the conclusion of a new report from Ontario’s COVID-19 Science Advisory Table and the province’s pediatric hospitals, which recommends the provincial government do everything it can to avoid a repeat of last year, when in-person learning was shut down for longer than in any other Canadian jurisdiction.

“Schools should not only open in September, but need to stay open,” said Ronald Cohn, the president and chief executive officer of Toronto’s Hospital for Sick Children. He added that closing schools “should not be used as a lever for pandemic control unless we find ourselves in a catastrophic circumstance.”

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Published Monday, the new guidance document was released a few weeks after the end of a controversial academic year in which nearly every decision about the daily lives of students was the subject of fierce argument.

Now, students, teachers and parents across the country are preparing for an uncertain September. Although Canada’s COVID-19 vaccination rate is among the highest in the world, the jabs are not yet approved for children under 12, and the fast-spreading Delta variant continues to pose a threat.

The report strongly encourages vaccination, but stops short of saying shots should be mandatory for students and education workers.

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It also recommends that Ontario students continue to stay home and get tested if they have symptoms of COVID-19, or if they have had close contact with someone who tested positive for the virus, but advises against broad surveillance testing of asymptomatic students when community transmission is low.

Ari Bitnun, a pediatric infectious diseases physician at SickKids and one of the lead authors of the new document, said a key lesson from the last school year is that shuttering schools did more damage to students than the coronavirus itself, considering the vast majority of infections in children are mild or asymptomatic.

“Their general health, their mental health, their socialization skills, and their overall well-being is significantly worsened by not being in school,” he said. “When you compare that to the adverse consequences of COVID in kids, the balance, in our view, is that they should be in school.”

The report notes that of 272,257 confirmed cases in Canadians under the age of 19 as of July 2, 0.06 per cent required intensive care and 14 died. It also notes that some children suffer long-term effects from COVID, something the authors say requires further study.

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It’s too early to say how much of the report the Ontario government and individual school boards will adopt, but Caitlin Clark, a spokeswoman for Ontario Education Minister Stephen Lecce, said Monday that the government’s back-to-school plan “will work to ensure a more normal in-class learning experience, including reinstating clubs, sports, and extra-curriculars.”

“We are following the advice of Sick Kids and pediatric experts on our plan – with $550-million in continued air ventilation improvements underway – and all permanent recommendations made by Ontario’s Science Table already implemented by our government,” Ms. Clark said in an e-mail.

The report’s 35 authors advocate for some permanent changes to school policies and school buildings, such as continuing to keep students home when sick, regular hand hygiene and improving ventilation by updating HVAC systems, opening windows, installing air purifiers and teaching outdoors when possible.

When it comes to temporary COVID-control measures, the report recommends that local decision-makers be guided primarily by the disease burden in the community, not by case counts alone, although they say officials should keep an eye on community transmission levels.

When the risk is low – meaning there are a limited and sporadic number of severe cases in the community requiring treatment in a hospital, as is the case in Ontario today – schools should place few limits on students, the report says.

For example, masking should be “permissive,” a position that means students and staff can wear masks if they like, but don’t have to. In the United States, meanwhile, the American Academy of Pediatrics on Monday came out in favour of universal compulsory masking in schools this fall, regardless of vaccination status.

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When risk is low, physical distancing and daily health checks at school entrances should not be required, the Science Table report says. Assemblies with capacity limits should be permitted; clubs, activities and sports, including games against other schools, should resume; and choir practices should be allowed, preferably outside.

If the risk level rises to moderate or high, the authors say temporary restrictions, such as mandatory masking, should be added. However, the report did not conclude precisely how many people would have to be in hospital with COVID-19 in order for an area to shift from the low-risk into the moderate or high-risk categories.

“I think that’s impossible to define,” Dr. Bitnun said. “That’s why we ended up going with a sort of general outline and then, depending on the scenario, decisions will need to be made in real time.”

The report recommends against rapid antigen tests – which the authors say don’t perform well in asymptomatic cases – and against broad surveillance testing of asymptomatic students, even though some epidemiologists have said such surveillance campaigns could help elucidate the role of silent spreading in schools and neighbouring communities.

Another of the report’s lead authors, Nisha Thampi, a pediatric infectious disease physician at CHEO in Ottawa, said the evidence so far is that when community transmission is low, there isn’t much to be gained in testing children with no symptoms and no known contact with an infected person.

“Studies in the last year out of the United States and in Europe have not shown a benefit of picking up additional cases when contact tracing resources were sufficient,” she said.

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