• Susanna Lehtimaki

School re-opening and COVID-19

In this brief, we explore the current evidence around school closures in Europe and North America and provide an update on practice from different countries regarding school re-opening. We caution that there is a dearth of studies on the effects of current guidelines vis-à-vis educational or wellbeing outcomes for students. In preparation for the 2020-2021 school year, we note with urgency the need to understand these effects to enable policymakers to consider trade-offs and plan

appropriately.


Current evidence

There are less reported COVID-19 cases in children and adolescents than in adults, and they are also at lower risk of severe illness, hospitalization, and death from COVID-19.(1) Emerging evidence suggests also that the role of children in spreading the SARS-CoV-2 virus is small.(2,3,4) With school-based transmissions mainly related to social events and likely derived from staff or other adults, (5) schools have had only a marginal impact on transmissions. (4) Compared to other control measures, school closures were estimated to prevent only 2–4% of COVID-19 deaths.(6)


Despite the lack of supporting evidence, in the beginning of April 2020, 194 countries had implemented country-wide school closures affecting over 90% of the world’s children and adolescents enrolled in school. (2) While many countries have implemented home-based schooling during the pandemic, school closure will likely continue to negatively impact on children and adolescents’ learning and wellbeing, disproportionally affecting those already disadvantaged.(7) School closures during previous epidemics are associated with poorer academic performance and learning, food insecurity,(8) increased vulnerability to violence and child abuse,(9) adolescent pregnancy and school drop-out.(10) Further, evidence of the ongoing COVID-19 epidemic suggest increased anxiety, depression and loneliness among children and adolescents that will likely continue after social isolation (11,12) as this age group is also disproportionately

affected by social deprivation due to physical distancing measures.(13)


During the pandemic, most countries implemented nationwide school closures and only a few a

localized closure based on the epidemic situation. While a majority of countries have not yet reopened the schools, 65 countries have plans for full or partial opening (14) and as of June 12, around 20 countries had fully opened. Only a few countries, including Sweden, Iceland and Taiwan, maintained schools at primary and lower secondary levels open during the epidemics.


Global guidance

While most countries have not yet made a decision when and how to reopen schools,(14) several

guidelines have been put forward to support the effort. A Framework for Reopening Schools (15) by UNESCO, UNICEF, the World Food Programme and the World Bank as well as Preparing the Reopening of Schools (16) guide with webinars by UNESCO support national and local authorities in decision-making process; Guidance for Covid-19 prevention and control in schools (17) by UNICEF, WHO and IFRC outlines key messages and actions for staff, parents, community members, and children on safety measures at school; and Considerations for school-related public health measures in the context of Covid-19 (5) by WHO provides authorities with concrete measures how to ensure safety at school. According to these guidelines, reopening should be informed by risk assessment, based on local epidemiology and conditions, including schools’ ability to maintain COVID-19 prevention and control measures and on assessment of potential harm to children and adolescents due to closure.


Of note, these guidance were developed when evidence on susceptibility and transmissions in school-aged children and adolescents was nascent and without an implementation research agenda on feasibility or effects on health and wellbeing of school-aged children. As such, the approach to date has been “learning by doing”. We did not identify any research in the published literature that have yet studied the effects of these guidelines in practice.


Description of current practice: countries where schools did not close (as of June 15)

In Sweden, where primary and lower secondary schools have remained open, schools have not been found to be a driver of the epidemic. In most cases with children with COVID-19, symptoms have been mild and infection was acquired from an adult. There has been no deaths among children 0-19 years, only 0,3% of the total cases in need of ICU have been in this age group, and COVID-19 cases among the school staff have not been greater than in other occupational groups.(18)


During the epidemic, Swedish schools have implemented intensified handwashing and cleaning, increased distance in seating and activities outdoors, avoided organizing large gatherings, and supported communication and information sharing. These measures are recommended by public health authorities; however, the school principal can decide the extent to which they are implemented. Children in risk groups (e.g. with diabetes) have been expected to attend school as normally. In case a child or staff member gets symptoms related to COVID-infection, they should stay home for seven days and return to school only after two days without symptoms.(18) Only few schools have been closed or have reduced school hours as there have not been enough teachers.(19)


In Iceland, primary schools remained open and secondary schools opened after six weeks of lockdown. Schools have implemented intensified handwashing and cleaning, maintained two meters distance in class, transportation and other places, and applied reduced school hours. The limitations for social gatherings have been relieved gradually, from 20 to 50 and finally, to 200 people (primary schools have been operational without limitations).(20) Children under ten years have not been largely affected by COVID-19 and those positive with the virus, have not infected adults.(21) Since the end of April, the new cases in Iceland overall have been close to zero.(22)


In Taiwan, schools closed only for a 10-day winter break. Measures put in place include daily

temperature screening, disinfections and handwashing. Children also wear masks and some schools have introduced plastic screens on desks. There have been relatively few COVID-19 infections in Taiwan overall, with most cases in March 2020.(23)


Description of current practice: school reopening

Norway closed schools for 1,5 months and initiated phased reopening at the end of April by starting with lower primary years and afterschool clubs and two weeks later, upper primary and secondary schools. Universities, colleges and vocational schools remain in distance education.(24) Norway public health authorities have developed detailed guidance that applies a risk-based “traffic light approach”, determined by the national health authorities. Overall recommendations include handwashing and intensified cleaning. In low risk situation (green), school operates normally; in intermediate risk situation (yellow), classes cannot mix with others, but teachers can switch between classes; and in higher risk (red), classes remain together with a designated teacher. Currently, schools have implemented physical distancing during classes, meals and transportation, including by having desks two meters apart, holding classes outside, and dividing into smaller groups with designated teacher (max 15 kids).(25) While children with weakened immune system (e.g. due to cancer treatment) can stay home, chronic conditions, such as asthma and diabetes are not a reason for absenteeism.(26)


In mid-April, Denmark, the first country in Europe to reopen schools, had similar measures in place.

Compared to Norway, it has had smaller class size (around 10 kids) with a designated teacher. It also implemented phased reopening, starting from 1-5th graders and a month later, for older children.(27)


In Finland, class sizes have not been reduced and school reopened for primary and lower secondary years at the same time.(28) During the two weeks that schools were open before the summer break, only a few schools were partially or to lesser extent, fully closed due to children or school staff’s confirmed COVID-19 infection.


Different countries have prioritized “back to school” for different age groups. While Estonia opened

schools exclusively for children above 3rd grade, Germany and Portugal started with older students. In Germany, school opening and safety measures vary by state. As in Norway, France has divided the country into “zones.” While schools in “red” and “orange” zones implement stricter measures (e.g. no recess outside, “one-way” walk lines at school), schools in “green” zone can have less restrictions. Throughout the country, however, class sizes are reduced (max 15 kids) and children have less school hours and contact learning. Since the reopening, attendance has been voluntary and children have been able to continue with home-schooling if the parents so decide. As of 22 June, attendance will be mandatory in France for all primary and secondary school students. The guidelines for this are yet to be shared publicly.


In Europe, only a few countries require masks at schools. In some states in Germany, masks are used at school (29) and in France, masks are required for teachers, children over 11 years and staff.(30)



Conclusions

As countries and cities consider how best to reopen schools, plans must also consider how the proposed mitigation measures at school impact on learning outcomes and child and adolescent health and wellbeing more broadly. Review of the applicability and evidence of currently proposed measures such as two meters of distance, temperature checks and mask wearing in school should be prioritized. Selected measures need to be based on real-time updates of the evidence of these effects, with a clear objective and an end goal.


Further, while research on impact of school closure to children and adolescents’ health and wellbeing is being conducted, a broader research agenda with a monitoring framework for intermediate and longterm should be established to track the impact of school closures and other COVID-19-related measures on children and adolescents.


Finally, for the current COVID-19 as well as comparable pandemics in future, the global community

should develop age-specific standard policies and procedures, based on different risk scenarios, to

determine when and how - if at all – schools should closed and if they are, what needs to be in place to mitigate the effects of those closures on children and adolescent health, development and wellbeing.


References

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2. Munro APS & Faust SN. Children are not COVID-19 super spreaders: time to go back to school. Arch Dis Child. Published online May 5, 2020. doi:10.1136/archdischild-2020-319474

3. National Centre for Immunisation Research and Surveillance (NCIRS). COVID-19 in Schools – the Experience in NSW. NCIRS; 2020. http://ncirs.org.au/sites/default/files/2020-04/NCIRS%20NSW%20Schools%20COVID_Summary_FINAL%20public_26%20April%202020.pdf

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5. WHO. Considerations for School-Related Public Health Measures in the Context of COVID-19. Annex to Considerations in Adjusting Public Health and Social Measures in the Context of COVID-19. WHO; 2020. https://www.who.int/publicationsdetail/considerations-for-school-related-public-health-measures-in-the-context-of-covid-19

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14. UNESCO. Reopening Schools: When, Where and How?; 2020. Accessed June 4, 2020.

https://en.unesco.org/news/reopening-schools-when-where-and-how

15. UNESCO, UNICEF, WFP & the World Bank. A Framework for Reopening Schools. April 2020. UNESCO, UNICEF, WFP, WBG; 2020.

16. UNESCO. COVID-19 Education Response: Preparing the Reopening of Schools: Resource Paper. 5 May 2020. UNESCO; 2020. https://unesdoc.unesco.org/ark:/48223/pf0000373401

17. UNICEF, WHO & IFRC. Guidance for Covid-19 Prevention and Control in Schools. March 2020. UNICEF; 2020.

18. Folkhälsomyndigheten/The Public Health Agency of Sweden. Covid-19 hos barn och unga – en kunskapssammanställning. Folkhälsomyndigheten; 2020. https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/c/covid-19-

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19. Hedman E. Flera grundskolor stänger helt eller delvis efter påsk. Skolvärlden. Published online April 7, 2020. Accessed June 5, 2020. https://skolvarlden.se/artiklar/flera-grundskolor-stanger-helt-eller-delvis-efter-pask

20. Government of Iceland. Q&A about school restrictions due to COVID-19. Published June 2020. Accessed June 5, 2020. https://www.government.is/topics/education/q-a-about-school-restrictions-due-to-covid-19/

21. Highfield R. Coronavirus: Hunting down COVID-19. Interview with Kari Stefansson, CEO deCODE genetics. Published April 27, 2020. Accessed June 5, 2020. https://www.sciencemuseumgroup.org.uk/blog/hunting-down-covid-19/

22. The Directorate of Health, Iceland. COVID-19 in Iceland – Statistics. Published June 5, 2020. Accessed June 5, 2020. https://www.covid.is/data

23. Johns Hopkins University & Medicine. COVID-19 Dashboard. Published June 5, 2020. Accessed June 5, 2020. https://coronavirus.jhu.edu/map.html

24. The Norwegian Directorate of Health. Barnehager og skoler. Published May 11, 2020. Accessed June 5, 2020. https://helsenorge.no/koronavirus/barnehager-og-skoler?redirect=false

25. Utdanningsdirektoratet/Norwegian Directorate for Education and Training. Veileder om smittevern for skoletrinn 1.–7. trinn under covid-19 utbruddet 2020. Published 5 2020. Accessed June 5, 2020. https://www.udir.no/kvalitet-ogkompetanse/

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26. What you need to know about Norway’s schools reopening. The Local. Published online April 22, 2020. Accessed June 5, 2020. https://www.thelocal.no/20200422/what-you-need-to-know-about-norways-schools-reopening

27. Cavanagh E. How 6 countries are opening up schools again, with temperature checks, outdoor classes, and spaced out desks. Published May 4, 2020. Accessed June 5, 2020. https://www.insider.com/how-china-denmark-japan-reopeningschools-2020-4

28. Finnish Institute for Health and Welfare & Ministry of Education and Culture. Terveyden Ja Hyvinvoinnin Laitoksen Ja Opetus- Ja Kulttuuriministeriön Ohje Opetuksen Ja Varhaiskasvatuksen Järjestäjille Koronavirusepidemian Aikana. THL & OKM; 2020. Accessed June 5, 2020.

https://valtioneuvosto.fi/documents/10616/22150002/THL+OKM+ohje+kouluihin+04052020.pdf

29. Das Deutsche Schulportal. Wie Schulen die Hygienevorgaben einhalten. Published April 27, 2020. Accessed June 12, 2020. https://deutsches-schulportal.de/schulkultur/coronavirus-wie-schulen-die-hygiene-vorgaben-einhalten/

30. Back to school: what lessons can UK learn from rest of Europe? Guardian. Published online June 10, 2020. Accessed June 12, 2020. https://www.theguardian.com/world/2020/jun/10/back-to-school-what-lessons-can-uk-learn-from-rest-ofeurope

31. The United Nations. Convention on the Rights of the Child. General Assembly Resolution 44/25 of 20 November 1989. The UN; 1989. https://treaties.un.org/doc/Treaties/1990/09/19900902%2003-14%20AM/Ch_IV_11p.pdf

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