COVID19: Some Last Words for Parents Before Schools Open
by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)
Unless you’ve been on a long meditation retreat and are unaware of what’s going on in the world, the topic on most people’s mind right now is how to open schools safely in the era of COVID. I’ve written about this in the past, but there have been a lot of developments since then. Many prominent scientists have come forth with new analyses and data; and many governments have spent time and effort putting together plans for safe re-openings.
Some plans are better than others. I’ve been on several media outlets discussing them, as best I can. On Monday I’ll be part of a live national broadcast on CBC radio, taking questions from across the country the day before most public schools open. I’m definitely feeling the pressure to present the best scientific information in a balanced way, while simultaneously being transparent about the risks but not fomenting panic. It’s a narrow needle to thread.
My goal today is to write down some quick additional thoughts to cover some topics that I think parents might be worrying about, focusing on things that parents can do for themselves and their children.
As always, if anyone –particularly other scientists with more experience in these matters than I– sees an error in something I’ve written, please let me know in the comments below. I see my role here as an interpreter of science for the masses, not necessarily as a purveyor of expertise. So I’m likely to get some things wrong.
Before we begin, someone smarter than me broke down the school protection strategy in a very simple way that I will now simplify even further. Our goals in descending hierarchy of importance are: (1) to keep the disease out of the community, because then it can’t get into the schools; (2) once it’s in the community, to keep it from getting into the schools; (3) once it’s in the schools, to keep it from spreading within the school; (4) once it’s spreading within the school, to keep it from spreading back to the community.
(1) Keep It Out of the Community
I’ve talked about this one before, and it should be our number one priority as a society right now. Simply put, even if you don’t have a child or don’t work in education, you have a role to play in keeping schools open. And it’s in your best interest to do so. Open schools mean parents can go to work, which means businesses can stay open, which means our economy keeps humming along, which means we can all enjoy some semblance of normality.
What this means for the common person, you and I included, is that we must each do our part to physically distance, to wear a mask when we can’t distance, and to avoid unnecessary socializing, especially that which takes place indoors with large numbers of people.
Everyone has a role to play. Everyone.
(2) Keep It Out of Schools
i. Checking For Symptoms
Some school boards are asking/requiring parents to monitor children for symptoms. This is a little confusing for many people. So let’s see if I can make some sense of it.
First, it’s becoming clear that children with COVID are more likely than adults to be asymptomatic. Or they will have symptoms so mild that most people will miss them. This is a scary thought to many, because it means that children in our midst might be silent “plague vectors.” But it’s not so simple.
See, it’s often the symptoms that drive transmission. Sneezing and coughing are what tend to project respiratory droplets the furthest. Talking and breathing do so, as well, but with lesser force. As a result, all other things being the same, symptomatic people are more likely to infect others than are non-symptomatic people.
This does not mean that an asymptomatic COVID-infected child is safe to be around. It means that she is safer to be around than is a fully symptomatic COVID-infected child, especially when distancing and mask-wearing are not enforced.
As a result, it’s important to regularly check for symptoms. This should be done daily by parents. But teachers and school staff have a role to play in this, as well.
What symptoms? There are no hard and fast rules with this virus. But infected children present most commonly with a slightly elevated fever and a cough. Some will also have a runny nose, and a few will have gastrointestinal symptoms, like diarrhea.
If we can keep those kids with symptoms at home, then we reduce the probability of having transmission in the classroom. Remember, we don’t eliminate the risk; we just reduce it.
ii. But Kids Are Always Having Runny Nose and Diarrhea
Yep. This is the issue. Allergies are common. Eating weird stuff or too much can cause stomach issues. Mind you, if your child has diarrhea for whatever reason, they probably should be staying at home anyway. But runny noses and coughs are common with colds.
Now, I fully expect a lighter than typical flu season this coming year, due to the fact that mask-wearing, distancing, and hand hygiene have been deployed for COVID. Certainly, in the southern hemisphere , their flu season has been remarkably mild. So I don’t expect a lot of flu cases here in North America, especially if the vaccine uptake is good, as I expect it to be.
But the common cold is another matter, as I’ve been recently learning about. It spreads in slightly different ways and is more susceptible than COVID to fomite transmission. So kids will probably be getting colds.
How do we distinguish between COVID and the common cold? The answer is that we don’t. We keep symptomatic kids at home regardless.
There are two reasons for this: (1) we don’t know that it’s not COVID until the child gets tested, so it’s best to err on the side of caution; and (2) an annoying thing happens when a child with asymptomatic COVID gets infected with something like the common cold…. the sneezing and coughing caused by the cold could actually propel the COVID-containing respiratory droplets further. This means that any transmission advantage garnered by being asymptomatic is negated by the coughing and sneezing brought on by the cold.
Bottom line: if you’ve got symptoms, stay home. This goes for adults, too.
iii. What About Temperature Checks
I’m of the opinion that temperature checks in most parts of society are largely hygiene theatre (more on that later).
As noted, the most common COVID symptom among children is a slightly elevated temperature, that actually might be difficult to measure or even notice. Now, not all cases will present with a fever. And not all fevers are COVID-related. Kids get fevers for all sorts of reasons. And what do most of us do when we have a slight fever? We take some over-the-counter drug (like ibuprofen or acetominophen) to suppress that fever. So a temperature check at the school’s door, or heat-sensitive camera, probably have limited utility.
However, it is my position that it cannot hurt. The time and resource investment of checking your child’s temperature every morning is miniscule. The downside of keeping a non-COVID febrile child home is effectively zero; that child likely needs some recovery time anyway. So I support a strategy used in some Asian countries, wherein children maintain a morning temperature log so they can note (and report) any deviations that might suggest a burgeoning infection.
If this low-cost, low effort activity succeeds in keeping a single case out of the school, then I say it’s worth doing.
(3) Keep It From Spreading Within the School
To keep spreading at bay within a school, we need: (a) reduced number of exposures and (b) masks.
Reduced exposures we get from small class sizes. I know that not all school boards have been able to accomplish this. But we work with what we have. In addition to small classes, we have staggered hours, so that fewer classes of children are interacting with one another. Some people call this combined approach “cohorting.”
The other advantage of cohorting is that, in the event of cases being detected, contact tracing is much easier since the contacts of those cases will be better known. As well, we can remove just that one cohort from the system for a week or so while everyone is tested, and the rest of the school can continue on uninterrupted.
ii. My Child Can’t Wear A Mask Properly
Masks are well discussed everywhere these days. Masks are tools for transmission mitigation, not self-protection. Some kids can’t be relied upon to wear a mask regularly or properly. That’s okay. I’m an advocate of universal masking in schools. Not all provinces and schools boards are requiring it, which is unfortunate. As noted above, while asymptomatic transmission is less likely, it is not impossible. A mask and distancing really help to reduce that risk further.
But as well all know, kids touch their faces a lot and sometimes tear off their masks. This is understandable, expected, and okay. I wrote a whole thing about masks, and followed it up with another article.
The takeaway is this: when talking about masks, we got stuck in the clinical paradigm. Doctors and nurses are trained in proper mask discipline because they work in high disease prevalence environments where a mask or gloves can be vectors for disease transmission. But their use in the wider community is in a low prevalence situation where a mask’s only function is as a wind break to reduce –not eliminate– the distance that respiratory droplets travel.
They won’t always work, and they won’t always work well. But when used by most people most of the time, the aggregate effect is that transmission is reduced.
So it’s okay if your kid isn’t great with masks. As long as he’s trying, and keeping it on much of the time, he’s doing his part. My mantra of the last few weeks has been: Don’t let perfect be the enemy of good.
I’m also a fan of face shields. Whereas masks offer outward (source) mitigation, shields offer inward protection. Layer a face shield over a mask, and your child is both better protected and much less likely to infect others. For children incapable of wearing masks for any number of reasons, a face shield can be an adequate alternative, in my opinion.
iii. Will There Be Cases In The School?
Yes. Absolutely we will hear of cases found in schools. And I predict it will happen very quickly. This is not a reason to panic. I’m hoping that school boards have invested in a good communication platform to keep parents well informed. In these times of distrust, it’s important that we be as transparent with stakeholder as we can be, by informing the community whenever cases are detected, but without revealing any identifying information about the infected persons.
It’s the second half of the message that I think is most important. So case was discovered. Okay, now what? What did public health do to detect, isolate, trace, and contain that case? The second half of the message should be sufficiently comprehensive that we are calmed by the rigor of the public health response.
That response might entail removing the entire class from the system, or the entire cohort, while an investigation happens. If so, this should not be alarming. We should celebrate the fact that the system is working as it should.
Unfortunately, it does mean that there is a risk that your child might be sent home, or his class might be sent home for a period of a week or more. This can create some stress in the household, especially when one parent must then take time off from work. I hope that governments are giving employers incentives to allow this to happen.
Proper ventilation is important, especially for that fraction of cases that typically result from aerosol (airborne) transmission. Hopefully, schools are investing in good filters for their HVAC systems. At the very least, windows should be opened, weather permitting. But public health is the art of the possible. We do what we can.
v. What About Deep Cleaning?
Cleaning can’t hurt. Kids drop saliva and snot and vomit and other body fluids everywhere. That stuff should be cleaned up. However, unlike some other respiratory viruses, it doesn’t look like touching stuff is how many people get COVID. We call this “fomite” transmission. And it probably does happen to some extent, but is not the major way that it spreads. Droplets and aerosol is where we should focus our efforts.
So if the school board is spending more time and effort on deep cleaning than on improving ventilation, I would argue that this is more of a case of hygiene theatre again.
Mind you, much like hand washing, deep cleaning can be useful in preventing other diseases, like the flu an the common cold. As noted above, keeping those infections out of the classroom is useful in preventing co-infected people from pushing COVID droplets further. So there is an indirect argument to be made in favour of deep cleaning.
(4) Keep It From Getting Back Into the Community
This is where a proper in-school surveillance system can be helpful. I don’t know what investments have been made in terms of infrastructure for school-based monitoring, but I think some attention here would be useful.
As noted above, “cohorting” allows us to pull classes or cohorts out of the system without having to close down the system. This enables us to keep both schools and the economy running without necessarily reinfecting the community.
Parents and families can help by not sending their children to unnecessary extracurricular activities where cross-infection can occur. I understand that some parents must send their kids somewhere because they won’t get back from work in time. But for the others, please choose activities that limit additional exposures, perhaps by maintaining contact with the same children from during the regular classroom sessions.
The goal of public health is to prevent the inevitable school cases from becoming genuine outbreaks that bleed into the community. This means that in addition to checking the kids for symptoms, unfortunately parents must monitor everyone in the household for any COVID-like symptoms and take appropriate action.
An important step is to get the flu vaccine. The vaccine won’t prevent COVID. But it helps to keep flu cases out of hospitals, freeing up capacity, and helps to reduce the confusion caused by having to monitor two separate but similar disease curves. As well, there’s a special kind of suffering in store for people who get both COVID and the flu simultaneously.
And despite what you’ve heard, there is no evidence that the flu vaccine either prevents or increases your chances of getting COVID. On the other hand, not getting the flu keeps you strong and healthy and more likely to fight off a case of COVID if you contract it.
So get the bloody flu shot already.
And Of Course…
Do not panic. It’s easy for me to say, because my child is too young to go to school. But seriously, don’t panic.
This is, and always has been, a crisis about population risk, not individual risk. Overwhelmingly, children and families will be fine. It’s just that when scaled up to tens of thousands of schools and millions of kids, it’s inevitable that someone’s going to get it and possibly spread it. But it’s almost like winning the lottery: someone’s going to win, but it probably won’t be you…. but it might be, especially as the odds of “winning” increase over time.
Here’s one way to look at it. Take the number of known active cases in your community. In Ottawa right now, it’s 200. Multiply that by a factor to estimate the number of actual cases walking about. Let’s say it’s twenty times that number, so 20 x 200 = 4000 active COVID cases in Ottawa. There are about 1 million people living here, so 4000/1000000 = 0.4%. So it’s defensible to say that any random person you encounter has a 0.4% chance of having COVID. This is a small number. And just because you encounter this person, it doesn’t mean you will be infected by them, especially if you keep your distance and/or wear a mask.
(Obviously, this assumes homogeneous distribution of cases, which is not realistic, and is valid for a particular sliver of time, etc. So don’t take this analysis to the bank. It’s just to make point.)
So why should I care if the probability of something bad happening to me personally is so small? Because schools are pandemic accelerators. We want to keep the school situation well-controlled so that the pandemic doesn’t explode out of control –as we know it can. If that happens, then our individual risk goes up tremendously –like rapidly increasing the odds of winning the lottery– and an argument for panic becomes more salient.
So as individuals, we should proceed with confidence. But as a population, we should be wary and vigilant. See the distinction? It’s a delicate argument to make, and I hope I’m making it well.
Canadian immunologist Dr Dawn Bowdish has made this very accessible video to explain the susceptibility of kids in schools.
Apropos of Nothing
I do like to keep track of all the nasty things people now say about me in public. I guess it means I’m making a difference. Here’s a taste:
Until next time, this is Deonandan, “King of the Fuking [sic] Stupid Left.” All glory to His Majesty.