The Sri Lanka College of Paediatricians (SLCP), the foremost academic professional organization of all the Consultant Paediatricians in Sri Lanka, forwards this Position Statement regarding the reopening of schools to optimize adaptation of children to the new normal situation during and following the COVID-19 pandemic and to prevent the spread of the disease when mobilization of children accelerates alongside the reopening of schools and other educational institutions.The exact timing would depend on many considerations and the status of COVID-19 in the country at various times.
1.Background:
More than three quarters of the schools of the world remain closed at this moment. Since this has gone on for a considerable length of time, many countries are now beginning to open their schools. There are many different issues for and against the need to reopen schools soon and a careful look at those will be helpful in arriving at the best decisions.
Experience from many parts of the world has shown that even in the countries best prepared for e-learning, such as South Korea, virtual schooling is less satisfactory than the real thing. In normal times schools help to level the playing field. Without it, the achievement gap between affluent and the less privileged children will grow.
1.1Effects of Covid-19 on school children
Reaching nearly 6 months since it was first reported, the world is still in a big learning curve about Covid-19 and the knowledge we have is changing almost daily. Many national and international bodies including the World Health Organisation (WHO) or the Centers for Disease Control and Prevention (CDC) in the USA also had to change their stand or advice accordingly. The best example is the advice given by health authorities about the place of face masks for the general public. It would be best to remain alert about emerging evidence and be ready to make necessary changes without being dogmatic. As paediatricians who meet and treat many children as our primary day-to-day duty, we believe that we should play a key role in guiding the policy makers on this subject.
Here are some important findings/emerging evidence for consideration to formulate strategy.
1.1.1. The Case Fatality Rate (proportion of deaths out of the total number of patients) for children in school going age is extremely low. (0.0148% versus 1.38% in other age groups overall)
1.1.2. Most of the Covid related childhood mortality is in young infants and younger pre-schoolers.
1.1.3. Since schools were shut down and children had less opportunities for exposure, the availability of data about spreading of this virus in children is limited. However, it is generally believed that unlike influenza, Covid-19 does not seem to be infecting children more readily. Their chances of transmitting it to others may also be less compared to adults. Two research studies from China that trace the contacts of infected people find that children are, at worst, no more likely to catch the disease than adultsand possibly are likely to be less so. If they do get it, they are 2,000 times less likely to die than someone over 60 years of age.
1.1.4. Eradication of Covid-19 or wide availability of an effective and affordable vaccine against it seem to be unlikely possibilities for a significant period of time in the future.
1.1.5. The most infective period for Covid-19 is in the very early stages of infection, or even before symptoms develop and within the first few days of the onset of symptoms.
1.1.6. There is sufficient documented evidence that transmission of this virus can occur from completely asymptomatic contacts too. Current epidemiological data reveal that significant proportion of people who are infected with the virus does not show any symptom at any stage or show only mild symptoms. This asymptomatic or very mildly symptomatic proportion is even substantially higher among children. In fact, two thirds of Sri Lankan children and adolescents less than 18 years who had confirmed COVID-19 were totally asymptomatic. Published studies show this asymptomatic fraction of cases could be between 30-80%. Further evidence suggests that among the symptomatic children, only 50% will be mildly symptomatic and often may not even be identified as Covid-19 or other respiratory cases.
1.1.7. The transmission dynamics of Covid-19 is highly variable. Case clustering emerges as a key pandemic puzzle, where some patients infect many others, while many do not spread the virus at all. This explains the differences of some local observations too. Eg. Spread of Covid inside a navy camp versus the lack of spreading from many other index cases such as the pilot who attended the big match. Some evidence suggests that probably about 10% of cases lead to 80% of the spread in Covid-19.
1.1.8 While the containment of the virus we have observed so far in the country is a great relief for all, it should not be a reason for complacency to take measures like social distancing or the use of face masks lightly.
1.1.9. It is important to plan and implement measures to prevent potential spread of the disease among school children and the spread of it to and from adults as well. Sri Lanka’s social structure has an extended family system with grand parents often living with children in close vicinity and school re-opening can have a direct effect on our elderly vulnerable population.
1.1.10. Social distancing and hand hygiene were considered the only evidence-based measures available to reduce viral transmission until recently. However, the amount of new evidence emerging almost daily in favour of the benefits of face masks for the general public has made many countries in the world to newly adapt this practice, making it possibly the most consistently and widely used preventive measure. Evidence also suggests that countries which widely implemented mandatory mask wearing have done better than those who did not. Some modelling ventures suggest that 80% of the community wearing masks could be as effective as a total lockdown in preventing the spread of Covid-19.
1.1.11. The ideal effective social distancing is 6 feet or 1.8 metres, though 1 metre is considered as the more practical application, which by itself alone is inadequate to be effective without the other measures being implemented.
1.1.12. The transmission of the SARS-CoV-2 virus, which causes COVID-19 infection, mainly happens with inhalation of infectious particles (aerosol droplets) of variable size which contain the virus. In addition, touching of the nose, mouth or eyes with contaminated hands also leads to viral entry into the body. These infectious particles are released to the environment mainly through coughing or sneezing by infected people.
1.1.13. The current evidence on transmission dynamics of the virus has revealed that in addition to coughing and sneezing, viral shedding and hence the spread of COVID-19, could happen even with speaking and normal breathing. In addition, live viruses could remain viable in the air for several hours and may have the potential to spread the infection to contacts beyond a distance of even more than one metre in enclosed spaces.
1.1.14. The argument that ‘wearing face masks will give a false sense of security’ is not justified when weighed against its potential benefits.
2. Key measures and important considerations in each measure
Reopening of schools should be a gradual stepwise process following a systematic and well-thought out plan to prevent or minimize children acquiring COVID-19.
The SLCP emphasises that a sufficient period of time following the immediate reopening of schools should be used to train children about these measures and gradually make them adopt these measures as daily routines of the new normal situation in the world. Therefore, teachers should be given very clear guidelines to focus on these measures during the initial period, rather than resorting to immediate resumption of teaching activities exclusively.
Teachers should be empowered to teach children about the proper hygienic practices, cough etiquette, proper use of face masks and other relevant aspects of prevention of COVID-19 spread among students because teachers do play the main role in teaching and training students regarding those measures. Teachers should act as role models to train schoolchildren on these practices. Parental support is also essential in this process and the final aim is to get maximum cooperation of each child without forcing the child to practice these measures.
In addition, it would be necessary to appoint suitable and experienced teachers into committees in each grade and train them to identify the educational, psychological, social, economic and any other relevant issues of students due to long school holidays, quarantine, curtailment of family income etc. and then to address them if possible at school level or refer them to relevant parties.
SLCP also supports and suggests to implement the following three main measures at schools to prevent the spread of COVID-19 among children and adults.
1. Maintaining social distancing
2. Hand washing
3. Wearing face masks
2.1. Maintenance of social distancing
Although, sometime it may be difficult to do so, maintaining a social distance of at least one metre between each person and another in the community is the single most important measure to prevent the spread of COVID-19.
Suggested measures to maintain social distancing at schools
2.1.1 Reduction of the number of students staying in a classroom at any given time and re-arranging classrooms to facilitate social distancing among students.
There are about 30-50 children in a classroom in most of the schools in the country and many schools have limited overall space. This is particularly significant in almost all national schools. Hence, maintaining a social distance among students while classroom teaching is going on would be a serious practical issue.
How to reduce the number of students in a class room to facilitate social distancing?
2.1.1.1 Divide students in a particular class in to 2-3 groups (depending on the number of students per class and the size of the classroom) and bring them to school on different days of a week.
For example, one set of students will come on Monday, Wednesday and Friday and the other set will attend on Tuesday and Thursday (and Saturday if authorities decide) of a particular week if they are divided in to 2 groups. Then this rotation will be implemented in the other way round in the following week.
The essential and difficult parts of the syllabus should be taught at classrooms and the rest could be covered as assignments and homework given for days in which they do not physically attend school.
According to this plan, only half or one third of children would attend schools on a given date. Hence, congestion in schools buses, vans and on the roads will be reduced and further facilitate social distancing during transport as well. In addition, this will reduce the number of adults coming on to the roads accompanying school children, thereby supporting the maintenance of social distancing among them in public places as well.
2.1.1.2 Commence schools only for senor grades during the initial phase and divide each class in to 2-3 groups to keep them with adequate distancing in a classroom.
Use the rest of the available classrooms of the juniors to accommodate divided groups of each of the classes and teach them separately. However, this might be practically difficult because the number of teachers might not be adequate to be allocated to each divided class. Nevertheless, if facilities are available, one teacher can do the lessons to all classes using a virtual classroom facility and this could be rotated in a manner that each student gets the opportunity to participate in real classes as well as virtual classes.
2.1.2 The SLCP strongly opposes the idea of extending school days or hours to compensate for the lost time, or to cover the syllabi fully.
We, the Consultant Paediatricians of the country, firmly believe that the present school child is over-burdened with subjects of excessive volume in their school curriculum. We strongly feel that most age groups are challenged over their age-related abilities while being deprived of other essentials. Even previously, the SLCP has made representations to the state educational authorities about this, on several occasions.
We consider this COVID-19 pandemic as a window of opportunity for the application of the concept of modifying the syllabi as a solution to overcome the undesirable effects of lost school time and the implementation of the new school timetable we must adapt to promote social distancing.
The present school curriculum consists of content that include core knowledge which is ‘Essential to know’ and additional stuff which is ‘Good to know’ and ‘Nice to know’. Classroom teaching should be prioritized to give core-knowledge which should be what needs to be tested at examinations than the other components which the child can be encouraged to research and learn, especially using their ‘days-off from school’.
While getting ready to re-open schools, the educationists should identify those different parts of their curriculum and advise teachers to use classroom teaching time to teach what is essential only. With this the need for ‘extra time to cover the syllabus’ can be completely eliminated.
An ideal curriculum should be one that achieves 10 essential human factors equally or at least in substantial proportions. Imbalance between expectations of knowledge over mental efficiency or social relationships is not healthy. While waiting to decide on the timing of schoolsreopening, relevant parties should immediately start revisiting excess volume in the curriculum to decide on the essentials.
2.1.3 Avoid keeping children in enclosed classrooms as much as possible.
Make necessary adjustments to keep classrooms open and well-ventilated. Keep the windows of classrooms well-opened to enhance ventilation and air circulation at all times.
If schools have adequate outdoor space, encourage them to have open air classes with adequate social distancing as much as possible.
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