Full document: COVID-19: Guidance for School Operation during the Pandemic

In order to prevent the spread of SARS-CoV-2 infection, students, teachers and other employees who have signs/symptoms of COVID-19 (according to Ministry of Health and local public health guidance) must stay home, and decisions about testing and return to school should be guided by provincial public health authorities. In addition, return to school decisions for those who have had an exposure to SARS-CoV-2 should be in accordance with local public health recommendations.

Consensus Guidance Statement(s):

• It is essential that strict screening and exclusion policies are in place for students and employees who are symptomatic or have been exposed to SARS- CoV-2 and directed to self-isolate by public health.
• Teachers, school staff and principals should be provided with information on symptoms of COVID-19 in children¹²⁶ so that appropriate action can be taken if children develop symptoms during the day.  
• Active screening for students, staff and visitors for signs and symptoms of SARS-CoV-2 infection should occur prior to arrival at school, on site (i.e., at the school) or a combination. 
  • Screening by parents and caregivers prior to arrival at school
    • We would strongly recommend that parents and caregivers be empowered to play an active role in daily screening of their children and youth prior to them leaving for school. A standard checklist should be provided for parents/caregivers/older students for this purpose (language and literacy considerations will be important). Parents/caregivers may require access/support from a health-care provider and/or local public health unit when they are unsure. This is especially the case for children and youth with underlying medical conditions and chronic symptoms. 
    • Provision of an attestation of completion of the daily screening (either virtual, such as a cell phone app, web-based, QR-based or paper for those unable to do so virtually) would add extra assurance, but consideration should be given to ensure that the process is not onerous such that it disadvantages groups with limited technological supports.  
    • Parents/caregivers should be educated around the importance of providing truthful information both for their child and others’ safety. This has been the approach taken by public health for other communicable disease.
  • Screening by school staff at school entry
    • Daily screening on site provides reassurance that the screening has been completed, however, it may result in safety concerns because of increased lines (e.g., crowding and mixing between children, youth and parents/caregivers) and the need to use non-school property (e.g., waiting on sidewalks blocking traffic flow, overflow onto streets). Therefore, it is not practical without significant staggering of start times. Consideration would also need to be given to the process during inclement weather conditions (i.e., very cold weather, rain).  
    • If screening students as they enter the school is selected as a strategy, additional staff and infrastructure resources would be required and appropriate training provided to them to effectively complete the task. 
    • Especially at the high school level, multiple entry points to the school should be considered to reduce crowding, lines and unnecessary interactions between cohorts.  
    • On-site temperature measurement or pulse oximeter checks are not recommended because fever and hypoxia are not consistent symptoms in children and youth (present in only a minority of cases)¹²⁷ and would result in lines and delayed school entry for what has not been shown to be an effective screening strategy to date. 
• The specific symptoms to screen for should take into consideration their positive predictive value as well as community rates of SARS-CoV-2 and other respiratory viruses. In situations where there is moderate to high SARS-CoV-2 community transmission, the threshold for school exclusion and testing should be lower (i.e., screen for any single symptom).¹²⁸   
  • There is large variation in signs and symptoms of SARS-CoV-2 in children. Predominant symptoms have included fever and cough in more than half the cases, followed by rhinorrhea/nasal congestion, myalgia/fatigue and sore throat in 10–20% of cases and gastrointestinal symptoms and headache in fewer than 10% of cases.¹²⁹
  • Using one symptom will be a more sensitive screening approach. However, it will lead to more children being excluded from school. 
• In regions with moderate to high SARS-CoV-2 community transmission, consideration should be given to keeping siblings of symptomatic students home from school until test results are available.  
• Easy access to non-invasive testing is an essential implementation consideration of any screening program as it is likely to promote adherence to recommendations. 
• Employers and the government play a critical role in supporting parents/caregivers who need to stay at home with their child because their child is sick or in isolation due to SARS-CoV-2 infection or exposure. This support is essential to reduce the burden on parents/caregivers and reduce the likelihood parents/caregivers will need to send their child/youth to school with symptoms (e.g., paid sick days available for workers, financial supports for families).  
• Virtual learning or other forms of structured learning should be put in place for children and youth who are required to stay home because they are sick or in isolation due to SARS-CoV-2 infection or exposure. It will be important to continue to work to identify options for students who have limited internet availability or other barriers to online learning. 

The following points were considered in developing this guidance:

• There is increasing evidence that upwards of 30%-50% of children with SARS-CoV-2 infection are asymptomatic.^{129, 130} As a result, complete case identification in children and youth after an exposure requires testing to better understand transmission dynamics.
• The merits of school-based one-time surveillance testing requires further study, but it may have value as part of a comprehensive public health strategy given the ability to reach out to a large volume of students and families at once.
• Consideration for point prevalence surveillance initiatives:
  • Potential benefits:
    • Identification of asymptomatic cases may lead to more timely and effective contact tracing and improvements in the health and safety measures in schools as well as in households.
    • Epidemiological analysis (in setting of exposure cohorts) may be helpful to clarify transmission in schools.
  • Potential disadvantages:
    • May detect remote cases that are no longer infectious or less commonly false positive results, which could lead to unnecessary quarantine of the children who test positive as well as their families and their classmates. 
    • With point prevalence screening, it can be difficult to identify the timing in the course of illness based on the lab test alone, which may lead to unnecessary class dismissal and school closures. Furthermore, the higher prevalence areas where testing is more likely to be positive are often areas where socioeconomic and educational disparities already exist. Thus, strong educational support for teachers, students and families in conjunction with robust trace-isolate-support measures need to be in place to manage these situations. 
• Routine periodic testing of asymptomatic students, prior to entering the school, is a proposed screening strategy as 30-50% of children with SARS-CoV-2 infection are asymptomatic. However, this strategy is not currently feasible related to the following factors:
  • Multiple tests per week per student and school staff would be required.
  • It is difficult to perform large-scale rapid testing with the current generation of rapid assays. It would require a rapid and simple to use point-of-care assay that utilizes saliva as the specimen type (currently not available).
  • Testing would ideally occur in the home setting as coordination of testing in the school setting at this frequency and volume may prove unfeasible. Additional concerns for sample collection (i.e., obtaining sample and cleaning) and consent, depending on age are also present.
  • The lower sensitivity of the current generation of rapid tests (compared to PCR-based tests) may be overcome by frequent testing.¹³¹ The performance of the tests is not necessarily changing rather capturing a viral load increasing over time. This requires more evaluation in the setting of asymptomatic children.
• Rapid testing:
  • Currently, two broad categories for rapid testing exist based on either molecular detection of viral nucleic acid or antigen detection of molecules on the virus surface.
  • The primary advantage of both forms of rapid testing is their ability to produce results in a short period of time (under 30 minutes) compared to laboratory-based (non-rapid) testing.
  • Rapid tests are often easier to use and deploy and do not require the same degree of expertise that is required of traditional testing methods. However, the downside of this is that there can be operator variability that can impact sensitivity.
  • While it has a rapid turnaround, the current throughput is low partly due to the need to train operators, limiting its use to small volume testing (can do about three to five tests an hour).
  • Rapid tests currently require appropriate oversight and laboratory quality management structure to ensure accurate results. This may include the deployment of qualified personnel to oversee testing and ensure that all quality controls are met. Logistically, this may provide challenges with respect to scalability unless home-based point-of-care testing is developed.
  • Based on current approvals, the rapid molecular test requires nasopharyngeal or nasal swab and rapid antigen tests require nasopharyngeal swabs. Alternative specimens (e.g., saliva) are not currently approved.  
  • Molecular-based rapid testing 
    • Compared to non-rapid based testing, the sensitivity of a single ID Now test has been shown to be as low as 73.9%,¹³² however, with moderate to high viral loads sensitivity increased to 100%.
    • Similar sensitivity rates of 71.7% and 76.8% were found in various systematic reviews.^{133, 134}
    • Specificity is generally very good approaching 100%
  • Antigen-based rapid testing
    • Compared to non-rapid laboratory molecular testing, the sensitivity of a single Panbio assay (rapid antigen) has been shown to be 72.6%, 79.6%, and 81% in symptomatic individuals, while sensitivity is less than 50% in asymptomatic individuals.^{135, 136}   
    • High viral load was associated with a positive test, while low viral loads were not detected. 
  • The use of rapid testing for SARS-CoV-2 remains a developing area in terms of availability of tests, implementation logistics, and performance characteristics in various populations based on age or presence/absence of symptoms and community prevalence of SARS-CoV-2. Recommendations may change as further evidence and experience is obtained. 

SARS-CoV-2 and other respiratory viruses are primarily spread by respiratory droplet transmission and should be the focus of preventative measures. As a result, and because virus shedding may occur prior to symptom onset or in the absence of symptoms, routine, frequent and proper hand hygiene (soap and water or hand sanitizer) is important in limiting transmission.¹³⁷

Consensus Guidance Statement(s):

• Children and youth should be taught how to clean their hands properly (with developmentally and age-appropriate material)¹³⁸ and taught to avoid touching their face, eyes, nose and mouth as much as possible. This should be done in a non-judgmental and positive manner and should be reinforced regularly.
• Respiratory etiquette; children and youth who have symptoms of a respiratory tract infection must stay home and should be reminded to sneeze or cough into a tissue followed by hand hygiene, or their elbow/sleeve if no tissue is available. In the event a mask is worn and becomes soiled, it should be changed.  
• There should be age-appropriate signage placed throughout the school to remind children and youth to perform proper hand hygiene.
• Students and staff should perform hand hygiene upon entering and before exiting the building, after using the washroom, before and after eating, and before and after playtime with shared equipment/toys. In addition, a regular schedule for hand hygiene, above and beyond what is usually recommended, is advised. Possible options would be to have regularly scheduled hand hygiene breaks based on a pre-specified schedule. For practical reasons and to avoid excess traffic in the hallways, the preferred strategy for these extra hand hygiene breaks would be hand sanitizer unless sinks are readily available in the classroom.   
• If masks are worn, students and staff should be instructed to perform hand hygiene before putting on and after touching or removing their mask.
• Access to hand hygiene facilities (hand sanitizer dispensers and sinks/soap) is critical with consideration for ensuring accessibility for those with disabilities or other accommodation needs (See Section 9 for additional considerations). Hand sanitizer (60-90% USP grade alcohol, not technical grade alcohol) should be available in all classrooms. Safety precautions to avoid toxic exposure (e.g., ingestion) from hand sanitizers should be in place. 
• Adequate resources and a replenishment process need to be in place to ensure supplies are available to perform hand hygiene frequently. Liquid soap and hand sanitizer will need to be replenished and paper towel available for drying. No-touch waste receptacles should be available for disposal of materials. Electric hand (air) dryers can be used.¹³⁹  

The objective of physical distancing is to reduce the likelihood of contact that may lead to SARS-CoV-2 transmission and has been a widely used strategy during the pandemic.¹⁴⁰ In the school setting, several control measures can be put in place to encourage physical distancing, especially when prolonged exposure is expected (e.g., in the classroom). However, while physical distancing and its role in the prevention of infection transmission should be discussed with students of all ages, it is likely not justified or practical to enforce strict physical distancing in kindergarten and elementary school children, especially during periods of play. 

Interaction, such as playing and socializing with other children, is central to child development and should not be discouraged in younger children. Cohorting (discussed in Section 6) and consideration of masking in moderate to high-incidence regions is a strategy that should be strongly considered in place of strict physical distancing in order to allow for close interactions, while minimizing the number of potential exposures.

Current distancing recommendations in Canada and the U.S. are two metres and six feet, respectively. The WHO has recommended a distance of at least one metre.¹⁴¹ A one metre separation does provide a degree of protection¹⁴⁰ which may approach that of two metres particularly in the school setting where children should be asymptomatic,⁹ and especially for younger children as they are likely less efficient transmitters of SARS-CoV-2.^{6, 19, 23, 26, 27, 85-88} However, risk reduction from physical distancing is likely on a continuum with larger distances (≥ two metres) potentially providing additional protection in high-occupancy indoor settings, such as classrooms. In middle and high school students, physical distancing is an important strategy, especially during periods of prolonged exposure indoors (e.g., the classroom), and they are more likely able to adhere to distancing recommendations. We emphasize that distancing is not an all-or-nothing proposition and optimizing distancing in as many indoor school settings as possible will likely diminish SARS-CoV-2 transmission.

Transmission of the virus will likely be attenuated in outdoor settings and outdoor play and learning opportunities have many benefits for children and youth. Therefore, school boards and educators should incorporate outdoor learning activities into the curriculum wherever possible.

There was not full agreement among contributors on the need for and role of physical distancing in children depending on age and specific circumstances. The guidance statements below were drafted based on the updated survey of the contributing paediatric care providers (n=32) completed in December 2020. Where there was less agreement the percentage of the more common positions are provided.

Consensus Guidance Statement(s):

Education:

• The role of physical distancing to prevent infection transmission should be discussed regularly with elementary, middle and high school students.
• Students should be informed about how physical distancing is being implemented in the school (e.g., desks separated, expected behaviours) and the expected practices in the school environment.
• Physical distancing will be difficult to strictly enforce in kindergarten and younger elementary school children, and is likely detrimental to their well-being. As such, a cohorting strategy and consideration of masking in high-incidence regions should be strongly considered in place of physical distancing within the classroom.
  Developmentally and age-appropriate education can emphasize the importance of hand hygiene, avoiding body fluid exposure, avoiding putting their hands and toys in their mouth, good respiratory etiquette and avoiding close contact especially for long periods of time (e.g., touching, hugging, hand holding).

Classrooms:

• Smaller class sizes should be a priority strategy as it will aid in physical distancing and reduce potential spread from any index case. Several jurisdictions reopened schools with maximum class sizes ranging from 10-15 students.¹¹⁵ However, there is limited evidence on which to base a pre-specified class size. Decisions should take into account the available classroom space in addition to the number of exposures that would occur should a student or staff test positive (agree 81%, neutral 16%, disagree 3%). Smaller class sizes reduce the upper bound in terms of outbreak size and result in fewer students impacted by quarantine if an introduction occurs.
• The use of non-traditional spaces should be explored to accommodate smaller class sizes in order to allow daily school attendance. This may necessitate additional teacher/educational resources and needs to be given priority especially in school regions of higher community transmission and vulnerable populations. 
• When students are in the classroom, efforts should be made to arrange the classroom furniture to leave as much space as possible between students.¹⁴²
• Physical distancing recommendations should be age-specific:
  • For kindergarten students, strict enforcement of distancing is not recommended. Emphasis should be placed on separating cohorts, not students within cohorts (agree 69%, neutral 25%, disagree 6%).
  • For elementary school students, there was a lack of consensus on the need for and the degree of physical distancing. The majority favoured some degree of physical distancing (22% favoured two metre separation between students, 19% favoured one metre separation between desks if possible or students if not possible, 16% favoured one metre separation between students, 12% favoured two metre separation between desks and 6% favoured a minimum of one metre separation between desks). A significant minority (25%) felt that physical distancing should not be enforced.
  • For middle school students, physical distancing is recommended. There was a lack of consensus regarding the degree of physical distancing required; 38% recommended a separation of two metres between students, while 34% recommended a minimum of one metre separation between desks or if impractical a one metre separation between students.
  • For high school students, physical distancing is recommended. A separation of two metres between students is preferred given the transmission risk may be higher in this age group (53%).  A significant minority (28%) recommended that there should be a minimum of one metre separation between desks in the classroom or if impractical a one metre separation between students.
• Classroom set-up:
  • Remove any non-essential furniture.  
  • Utilize all available space (including desks against walls and at the back of the class).
  • If class sizes are not reduced, alternative classroom set-ups should be explored to promote physical distancing.
• Educators should be encouraged and supported by school administrator to explore outdoor learning opportunities as weather permits. This will likely require specific programming and resources to optimize learning activities. 
  • Accommodations for outdoor learning should focus on making the outdoor learning environment as comfortable as possible to support the well-being and learning environment of students, teachers and staff.  
  • Outdoor learning environment could consider using some of the current local recommendations for outdoor spaces.¹⁴³

Large gatherings/assembly

• Large gatherings/assemblies should be cancelled for the immediate future. Any gathering size should be in accordance with local public health guidance.
• Choir practices/performances and band practices/performances involving wind instruments pose a higher risk of transmission.^{144, 145} As such, it is recommended that these be cancelled for the immediate future. When the situation allows, special consideration should be given to safely resuming such activities (depending on local epidemiology and performance venue).
• When and if band practices/performances involving wind instruments resume, ideally instruments should not be shared between students. If sharing is required due to limited supply of instruments, it is essential that the instruments be thoroughly cleaned and disinfected between use.

Lunch and recess breaks

• Stagger breaks and lunch times (or have lunch in classrooms) to reduce larger crowds in cafeteria settings and keep groups of students together (see cohorting below).
• Hand hygiene should be performed prior to eating and after lunch breaks, with easy access to hand sanitizer.
• If weather permits, lunch and nutrition breaks could be held outside.
• Shorter lunch breaks with more frequent nutrition breaks may help reduce the length of less supervised interactions.

Outdoor and other activities

• The affordances of outdoor play and learning opportunities is linked to a plethora of physical, mental, social, and developmental benefits for children and youth.¹⁴⁶ 
  • Regularly embrace the outdoors for learning, socialization, and physical activity opportunities, in various weather conditions—including rain and snow. Outdoor active play is an important part of childhood and should not be eliminated from the school yard. 
    • The Council of Chief Medical Officers of Health recommends access to active play in nature and outdoors – with its risks – is essential for healthy child development and recommends increasing children's opportunities for self-directed play outdoors in all settings, including at school.¹⁴⁷ 
    • When children are outside they move more, sit less and play longer — all of which is associated with improved cholesterol levels, blood pressure, body composition, bone density, cardiorespiratory and musculoskeletal fitness and aspects of mental, social and environmental health. 
    • Extreme weather limiting outdoor learning and play is infrequent in Ontario. Children and staff should have adequate clothing for the changes in temperature and parents/caregivers should be encouraged to send their child to school with a change of clothes and shoes/boots.  
    • Outdoor play should be avoided if the temperature or the wind chill falls below -25°C (-13°F). At this temperature, exposed skin can freeze in a few minutes.^{148, 149}
• During outdoor activities, such as recess, physical distancing should not be strictly enforced, especially in kindergarten and elementary school children. A cohorting strategy (see Section 6) is preferred. 
• All students should perform hand hygiene before and after sports activities/outdoor play/playground use.
• Schools should endeavour to offer as many of their usual clubs and activities as possible during periods of low community transmission. Most clubs and activities, with the exception of choir/band, should involve less crowding than regular classes, and so should be feasible inside or outside. In the context of moderate to high community transmission, these activities should be suspended, in part due to mixing of cohorts.  
• Sports and physical education classes should be encouraged and continue with risk mitigation strategies in place (including NMMs, as appropriate). Close contact sports (e.g., wrestling, rugby, football), as well as indoor team sports (e.g., basketball, volleyball), should be cancelled for the time being. When the situation allows, based on regional epidemiology, consideration should be given to their safe restart. We note that physical education classes will be much easier to have outside on a regular basis than other pedagogic activities. 
  • Sports equipment (e.g., balls, hockey sticks etc.) should be cleaned at the conclusion of the activity.  
  • Sharing of personal sports equipment should not occur. 

The use of NMMs in the school setting is a complex and nuanced issue, especially in younger children.Given the current moderate to high community transmission, we recommend the use of masks for high school and middle school students at all times while indoors (provided there is no contra-indication for developmental, medical or mental health reasons). It is important to try to find periods in the day where NMMs can be safely removed. For elementary school students, there was a lack of consensus around a masking recommendation, but most agreed that in areas of moderate to high community transmission, NMMs should be recommended in this age group. There was agreement that masking should not be mandated in kindergarten.

The considerable disagreement between authors reflects differences in opinion on the evidence for NMM use and the potential downsides of mask use in children, particularly young children where the strict enforcement of both NMM use and physical distancing will preclude close interaction and play between children. It will be important to assess the use of masks on an ongoing basis throughout the school year and adjust accordingly based on new evidence and SARS-CoV-2 epidemiology. The following paragraphs highlight some of the important complexities of using masks in children, in particular as it relates to kindergarten and elementary school students.

The main benefit of NMMs and medical masks is that they can reduce transmission from individuals who are shedding the virus, as they help to prevent the respiratory droplets from the wearer from coming into contact with others, if worn correctly.¹⁵⁰ While NMM use has been recommended and/or mandated for use by public health authorities in Ontario in indoor spaces,¹⁵¹ it is important to note that their use is recommended primarily for source control (i.e., preventing infectious particles from spreading from the wearer), not as PPE. In children and youth, there are limited data on the effectiveness of NMM use for source control, but there remains a theoretical benefit especially for older children and youth. However, in order to be effective, NMMs would need to be worn correctly, which for many otherwise healthy children and youth will be difficult to do for a full school day; even more significant barriers exist for children and youth with underlying medical, developmental and mental health conditions.

In some countries, particularly in Asia where masking culture is more ingrained and longstanding, children have worn NMMs upon return to school. However, during the first wave of the pandemic several European countries had children successfully return to school without NMMs (often with reduced class sizes).^{6, 118} Evidence specific to children and youth on NMMs is extremely limited. There have been four cluster randomized trials that evaluated mask use for prevention of influenza virus transmission in the household setting that included children as the index case.^152-155 Two studies (with 33% and 96% children) found a possible benefit of hand hygiene and masking as a combined intervention, when implemented within 36 hours of symptom onset,^{152, 153} while the other two studies (with ~50% children) demonstrated no protective effect.^{154, 155} In all four studies, adherence to mask wearing was poor, and in three of four studies mask wearing was also promoted for the contacts and, as such, the beneficial effects may have been related to mask wearing by the contacts. In the one study that evaluated masking for source control, where 33% of index cases were children, no protective benefit was demonstrated.¹⁵⁴

Decisions around NMM use in schools should take into consideration the benefit from source control (which may vary by age) balanced with the negative consequences/risks (e.g., impact on communication) of NMM use. As noted above, the practicality of wearing a NMM for prolonged periods of time is an important consideration. Other factors to consider include availability of other risk mitigation strategies, local epidemiology and community public health directives. Finally, the perspective of educators on the front lines has to be taken into account when deciding on policy and implementation considerations relating to masking. Preferences in this regard might well vary across jurisdictions in relation to local epidemiology and perceived risks.

Of note, the most recent Ministry of Education guidance updated on Jan. 15, 2021, indicates that NMMs must be worn by children in Grades 1-12 while indoors, on school transportation and outdoors during recess when physical distancing cannot be maintained, provided there are no contraindications.¹²³ For kindergarten students NMMs are encouraged, but not required.

There was not full agreement among contributors on the need and role of NMM use in children in different circumstances. The guidance statements below were drafted based on the updated survey of the contributing paediatric care providers (n=32) completed in December 2020. Where there was less agreement the percentage of the more common positions are provided.

Consensus Guidance Statement(s):

• The use of NMMs in the school setting should be driven by local epidemiology with age-specific considerations (agree 94%, neutral 3%, disagree 3%).
• Kindergarten students: 
  • Regardless of community transmission, NMMs should not be required (agree 59%).  
    • When community transmission is moderate to high, the majority indicated that NMMs should not be recommended or required (34%), or should be recommended, but not required (25%). Others recommended that NMMs be worn at all times while indoors and outdoors (16%), or at all times when indoors, but not outdoors (16%).  
    • When community transmission is low, the majority indicated that NMMs should not be recommended or required (47%), or should be recommended, but not required (13%). Others recommended that NMMs be worn when physical distancing is not possible indoors, but not outdoors (16%), at all times while indoors, but not outdoors (13%), and at all times while indoors and outdoors (6%). 
• Elementary school students:
  • When community transmission is moderate to high the majority favored NMM. 
    • 31% indicated that NMMs should be mandatory when physical distancing cannot be maintained indoors, but not outdoors, 28% indicated they should be mandatory at all times indoors, but not outdoors and 25% indicated that NMMs should not be mandatory.  
  • When community transmission is low, a higher proportion were against mandatory NMMs (41%) 
    • Others recommended that NMMs should be worn when physical distancing is not possible indoors, but not outdoors (31%), and at all times when indoors, but not outdoors (19%) 
• Middle school students:
  • When community transmission is moderate to high, the majority supported NMM use at all times when indoors, but not outdoors (53%). A minority recommended that NMMs be worn at all times indoors and outdoors (19%), when physical distancing is not possible indoors, but not outdoors (13%), and when physical distancing is not possible indoors and outdoors (9%). 
  • When transmission in the community is low, the majority recommended that NMMs should be mandatory only when physical distancing is not possible indoors, but not outdoors (34%). Others recommended that NMMS be worn at all times indoors, but not outdoors (31%), when physical distancing is not possible indoors, but not outdoors (19%), and NMMs should be recommended, but not required (9%). 
• High school students:
  • When community transmission is moderate to high, the majority supported NMM use, but there was a lack of consensus around timing. The majority recommended that NMMs be mandatory at all times when indoors, but not outdoors (56%). A minority recommended that NMMs be worn at all times while indoors and outdoors (22%), when physical distancing is not possible indoors and outdoors (9%) or only when physical distancing is not possible indoors, but not outdoors (9%).  
  • When transmission in the community is low, the majority recommended that NMMs should be mandatory only when physical distancing is not possible indoors, but not outdoors (34%). Others recommended that NMMs be worn at all times indoors, but not outdoors (31%), when physical distancing is not possible indoors, but not outdoors (19%), and NMMs should be recommended, but not required (13%).  
• It is important to try to find periods in the day where NMMs can be safely removed.
• Any recommendation or requirement to wear NMMs needs to address issues around equitable access to masks.
• School-aged children and youth who are not able to remove their NMM without assistance should not wear a NMM due to safety concerns.¹⁵¹ NMMs should also not be worn by children or youth who cannot tolerate a NMM due to cognitive, sensory or mental health issues. 
• Rationale should be provided to children and youth to reconcile any differences in guidance between school and other indoor spaces (if public health mandates exist in their region). This could be accomplished by discussing the other safety measures in place (e.g., screening, hand hygiene, physical distancing, cohorting) that are being used to protect students and teacher/staff. 
• In the winter months, students and staff should be recommended to bring several masks, as they may need to be changed more frequently if worn outside.¹⁵⁶
• Face shields as a mitigation strategy are not routinely recommended for students of any age group.

The following points were considered in developing this guidance:  

• Public NMM wearing is likely beneficial as source control when worn by persons shedding infectious SARS-CoV-2 virus when physical distancing is not possible in public spaces (e.g., public transit, grocery store).¹⁵⁰ 
• There is a lack of evidence that wearing a NMM prevents SARS-CoV-2 transmission in children and youth, though it is likely for older children and youth. The benefit for younger children is uncertain, both because they are probably less likely to transmit the virus and because of their higher likelihood of improper NMM use. This may evolve as more information is obtained on transmissibility of the new SARS-CoV-2 variants in children. 
• Children’s and youth’s social development hinges upon their interactions, facial expressions and body language. Though important for all age groups, this is particularly so for younger children. 
• Several school boards have mandated masks in kindergarten to Grade 3 and anecdotally children appear to have adapted well. However, it is impractical to expect all children and youth to wear a NMM properly for the duration of the school day and this should not be relied on as the only measure to prevent transmission.  
• The NMM may not be tolerated by certain populations with underlying conditions (e.g., neurodevelopmental disorders, mental health problems) and especially during warm/humid weather conditions. 
• The addition of NMMs may increase anxiety, interfere with the therapeutic learning environment, and increase inattention or distraction in children and youth, particularly for those who may already struggle with attention, such as those with attention deficit hyperactivity disorder (ADHD) or other developmental disorders.  
• Children and youth with expressive communication difficulties (including those with articulation problems, neurologic issues), those who are learning the primary Canadian language of instruction (English or French) as a second language, and many others may be disproportionately adversely affected by having to wear a NMM at school. 
• The school setting is different from most settings where indoor masking is mandated where large numbers of strangers interact (e.g., shopping malls), physical distancing is difficult and contact tracing is not possible. 
• Masks should be made of three layers and be large enough to cover the nose, mouth and chin without gaping.¹⁵¹
• Face shields have been suggested by some as an alternative to face masks as they may block expelled droplets. However, there is currently no evidence that face shields alone are effective as source control.¹⁵⁷  

The purpose of cohorting is to limit the mixing of students and staff so that if a child/youth or employee develops infection, the number of exposures would be reduced. It also allows for more timely case and contact follow-up. For example, a single class in Grade 1 could represent a cohort and they should avoid close mixing with individuals from other classes/grades in confined indoor spaces. Cohorting is likely most beneficial in kindergarten and elementary school children where physical distancing is less practical. For high school students, the need to take different classes may make strict cohorting difficult and, as a result, physical distancing should be emphasized. We recognize that this poses a significant infrastructure challenge for many schools. The benefits of cohorting will be attenuated in many, such as those who require bus transport to school and those who require after-school care; such children could potentially be present in several cohorts (e.g., class cohort, bus cohort, after-school cohort).

Consensus Guidance Statement(s):

• Cohorting classes should be considered a priority strategy for the younger age groups and for children and youth with medical and/or behaviour complexities (see Section 10), so that students stay mostly with the same class group and there is less mixing between classes and years. This applies to both indoor as well as selected, prolonged outdoor activities with close physical interactions.
• Cohort size should take into consideration local epidemiology, prioritizing resources required for smaller cohorts to regions with higher community transmission.  
• Student well-being and mental health should be prioritized, however, such that class or program switching should not be denied on the basis of cohorting. 
• Cohorting and mixing should take into consideration the number of children/youth that would be exposed should a student or staff test positive for SARS-CoV-2 with the goal of minimizing the number of contacts.  
• Especially at times of high community transmission, the need for rotating staff teaching multiple cohorts should be reconsidered so that the number of students a teacher is exposed to is minimized and a single staff case would not lead to the dismissal of multiple student cohorts.  

SARS-CoV-2 has been detected on a variety or surfaces¹⁵⁸ and survival depends on the type of surface. It is possible that infection can be transmitted via fomites by touching contaminated surfaces and then touching mucous membranes (i.e., mouth, nose, eyes).¹⁵⁹ While fomite transmission is not the predominant mode of transmission,¹⁶⁰ it likely contributes to transmission given evidence demonstrating presence of SARS-CoV-2 in the vicinity of infected individuals and the fact that fomite transmission does occur with other respiratory viruses, including human coronaviruses.¹⁶¹ Therefore, environmental cleaning and disinfection should be implemented to reduce the risk of transmission of SARS-CoV-2 and other infections in schools, but should not be the main focus for reducing SARS-CoV-2 transmission.

Consensus Guidance Statement(s):

• A regular cleaning schedule, using Health Canada-approved disinfectants,¹⁶² should be used with emphasis on high-touch surfaces and washrooms at least twice daily.
• Efforts should be made to reduce the need to touch objects/doors (no-touch waste containers, prop doors open where possible).
• Policies to ensure there is “no sharing” of food, water bottles or cutlery should be enforced as a priority.
• The importance of hand hygiene to children after contact with any high-touch surface (such as door handles) should be reinforced.
• When possible, only toys and class equipment that can be cleaned and disinfected by staff and/or students (as appropriate) should be used.
• School closures during school hours for the purpose of more intensive cleaning may carry more harm (in the form of missed instruction time) than benefit. 

While SARS-CoV-2 is primarily transmitted via respiratory droplets during close unprotected contact, it is now recognized that aerosols play a role in transmission of SARS-CoV-2, especially in indoor and in poorly ventilated areas.^163-165 Several outbreaks and clusters have been reported in indoor spaces, including an often cited article by Lu et al, which documented transmission of SARS-CoV-2 between families at three tables in a restaurant.¹⁶⁶ Transmission was likely facilitated by a wall air conditioning unit that did not have fresh air intake and may have dispersed infectious particles.¹⁶⁷ Irrespective of the contributions of larger droplets versus smaller aerosols in transmission, it is expected that environmental conditions, exposure time and airflow influence the transmissibility of SARS-CoV-2.^{168, 169} As such, adequately ventilated classroom environments (e.g., open windows with air flow even during the winter, improved airflow through ventilation systems and reduction in recirculated air) are important measures to reduce the likelihood of transmission compared with poorly ventilated settings, and fewer infection clusters have been noted in outdoor settings.^{163, 170}

Consensus Guidance Statement(s):

• Keeping classroom windows open at all times or periodically as appropriate, if safe, and according to weather conditions. Opening windows for short times at intermittent intervals can be of benefit. 
• The use of outdoor learning environments when feasible according to weather conditions is encouraged.  
• Attention should be paid to improving classroom ventilation (e.g., optimizing ventilation system maintenance and increasing the proportion of outside air brought in through these systems) in consultation with experts in physical plant design and modification. 
  • Heating, ventilation and air conditioning (HVAC) system function should be optimized (e.g., ensuring filters sealed without bypass, filters cleaned and replaced as appropriate, use of filters with higher MERV ratings).^{170, 171}  
  • If fans or portable air conditioners are used, there should be procedures in place for routine cleaning and preventative maintenance. In addition, the equipment needs to be carefully placed so that air is not blowing person to person.
  • At this time, there is insufficient evidence to routinely recommend portable air cleaners with high efficiency particulate air (HEPA) filter units in all classrooms. However, they may be considered in spaces/classrooms with limited ability to improve ventilation (i.e., unable to open windows, no HVAC ventilation), taking into consideration the transmission risk (e.g., age, need for aerosol-generating medical procedures).^{172, 173} If used, there should be consultation with the manufacturer’s directions and service professionals to optimize placement. Generally, the placement should take into consideration the likelihood that aerosols/droplets are being captured by the intake and that the exhaust does not blow from person to person. Manufacturer’s instructions on maintenance should be followed.¹⁷¹  

Some children may be at higher risk of adverse outcome from COVID-19 due to underlying medical conditions, such as immunocompromised states or chronic medical conditions, including cardiac and lung disorders and neuromuscular disorders.^{39, 174, 175} Children and youth who have medically complex conditions, particularly those with medical technological supports associated with developmental disabilities and/or genetic disorders, are also at higher risk.³⁹ At the present time, there is no convincing evidence to suggest the level of medical risk to these children and youth from SARS-CoV-2 is different from other respiratory viruses. Reassuring, though limited, data are emerging which indicate that clinical manifestations and disease severity in immune compromised children are similar to those in otherwise healthy children.^176-180 As a result, given the unintended consequences associated with not attending school, attending school is recommended for the majority of these children and youth (see Section 10 for more details pertaining specifically to medically and behaviourally complex children and youth). Nevertheless, we recognize that the data pertaining to this group of children and youth is limited as they have likely been following isolation rules even more stringently than healthy children and, therefore, it is essential that ongoing monitoring takes place so that adjustment of the school model and preventive interventions can be made according to emerging evidence. Additional details specific for children with cancer are provided by the Pediatric Oncology Group of Ontario (POGO).

Consensus Guidance Statement(s):

• The majority of children and youth with underlying medical conditions should be able to safely attend school provided that the appropriate enhanced safety measures are in place. However, it is recommended that parents/caregivers discuss this with the child’s health-care providers so that they can make an informed decision based on individual circumstances. This is particularly relevant for children with newly diagnosed illnesses requiring the first-time use of new or augmented immunosuppression.
• In the event that such children/youth have a documented exposure to SARS-CoV-2, in addition to involvement of the local public health unit, it is recommended that the child’s/youth’s parent/caregiver(s) contact the child’s/youth’s health-care provider for further management if they have concerns. 

In-person school attendance presents unique challenges to children and youth with medical, developmental and/or behavioural complexities and their families. This includes children requiring intensive supports for activities of daily living and/or medical conditions, such as feeding, positioning, toileting or breathing supports. Many of these families have had a prolonged period of time in home isolation compounded by a lack of respite and/or homecare supports. In particular, the challenges for families and children/youth with neurodevelopmental disorders, such as autism spectrum disorder, caused by cessation of school during the pandemic have been identified.¹⁸¹ Transitioning medically and behaviourally complex children and youth back to school requires specific focus and should be prioritized as many of these children/youth and families have been disproportionately impacted by the pandemic response and are already in crisis mode.¹⁸² For those who have returned to school, continued attendance during periods of increased SARS-CoV-2 prevalence may also be a significant concern to families. Consultation with their parents and families to better understand their individual circumstances and needs is recommended.

Children and youth with medical, physical, developmental and/or behavioural complexities often have educational assistants (EAs) and nursing support in the school environment who may assist children/youth with toileting, suctioning, respiratory support and enteral feeding. These individuals require additional consideration with regards to measures to help mitigate their personal infection risk and infection transmission to others.

Consensus Guidance Statement(s):

• For children and families considering return to in-person school:
  • Parents/caregivers may consider scheduling appointment(s) with their health-care provider(s) for a return to school consultation(s) if they think their child’s/youth’s complexities and medical status warrant as such.
  • Parents/caregivers and school staff should liaise to accommodate a more individualized return to school to ensure smoother transitions. Equitable access to school is essential.
  • Children and youth with neurodevelopmental disorders/behavioural challenges should be allowed modified transition back to school. Optimally, this would involve the option to visit the school prior to general school opening. Difficulties with transitioning back to school should not be used to exclude children and youth from school and any delayed transition plans need weekly reassessment.
  • Behaviour/ASD school board teams need to be involved in transition planning prior to school re-entry for children and youth who are likely to have significant challenges. More resources may need to be devoted to these teams due to increased demand.
  • In cases where therapists (both internal and external to the school board) are supporting a child/family, active communication between the school, parents and therapist are encouraged to develop transition plans.
• Ensure that those families who choose not to send their child/youth to school receive remote learning opportunities and do not lose access to in-home supports, including home care and respite supports.
• Ensure that children and youth with medical, physical, developmental and/or behavioural complexities can readily transition between in-person and remote learning models.
• Ensure that students continue to receive access to therapy and nursing services while in the school. Maximize continuity among those providing services and/or use virtual care for service provision, to decrease exposures. If in-school rehabilitation supports are delayed, accommodations should be made to ensure that their rehabilitation needs are being met either at home or in person at their local children’s treatment centre.
• Provide environmental (e.g., smaller class size) and classroom supports (e.g., teacher aides) for those children and youth who may need assistance with hygiene measures.
• Guidelines for children and youth with complex respiratory needs, including ventilation/tracheostomy, have been developed by teams at SickKids, Holland Bloorview Kids Rehabilitation Hospital and CHEO.
  • COVID-19: Guidelines for the Delivery of Home and Community Care Services for Children with Medical Complexity at School (PDF)
  • Return to School Recommendations for Children with Special Needs (Holland Bloorview)
  • Considerations for the return to school of children and youth with specialized care needs (CHEO)
• Policies and procedures should be in place for the cleaning of specialized equipment.
• EAs and nursing staff who support activities of daily living and cannot physically distance require appropriate PPE. Ideally, EAs should be assigned to a single classroom (if appropriate) and every effort should be made to minimize sharing of EAs between classrooms.
• The additional resource requirements to facilitate safe return to school should not be a barrier to return to in-person education for children and youth with medical, developmental and/or behavioural complexities. 

Although this document is focused on school-aged children and youth, we believe the safety of school staff is paramount, with the goal of having teachers and school staff, at a minimum, as safe in the classroom as they would be in other community or other work environments. We recognize the tremendous challenge that teachers and other front-line school staff face from a personal health perspective, as well as from an operational lens. Risk mitigation for teachers and other school staff should take into account situations where close contact and possible body fluid exposure (i.e., saliva, respiratory secretions) may occur.

Emerging data suggest that return to school has not led to high infection rates among school staff. Evidence collated during the first wave of the pandemic in Sweden showed that the relative risk among teachers was close to one, suggesting no increased risk compared to other professions overall.^{7, 186, 187} More recent evidence from Germany also show that staff employed in childcare/school/camp settings had a lower infection prevalence than those working in other settings, including hospitals, congregate living and the food sector.¹⁸⁸ Data from the Netherlands show that, since school reopening, few school employees have become infected with SARS-CoV-2 (0.7%) and no reports of employees being infected by children have been noted.⁶ Data from the U.S. found that among childcare providers, those who continued to provide direct in-person child care were not at increased risk of SARS-CoV-2 infection compared to those who did not.¹⁸⁹ In all settings, a variety of health and safety recommendations were in place to protect school staff. We have provided several considerations, but detailed recommendations are beyond the scope of this document.

Consensus Guidance Statement(s):

• Physical distancing of school staff from children/youth and other staff should be emphasized. Teachers should maintain a distance of two metres from students and other staff as much as possible, recognizing that distancing will not be feasible in classrooms with the youngest children.
• Staff lounges and common areas should be restructured (as needed) to ensure physical distancing, and staff should be reminded of the importance of distancing from other staff. Whenever physical distancing cannot be maintained, whether in the classroom or other parts of the school building, we recommend the wearing a NMM or medical mask.
• Facial expression is a critical part of communication, particularly for younger children, children for whom English/French is a second language, and children with certain underlying conditions such as hearing impairment or speech delay. Facial expression is also important for teacher-student connection, which impacts teacher effectiveness. This should be taken into consideration when developing and implementing NMM and PPE strategies for teachers.
• Depending on community infection rates, if close prolonged contact with others cannot be avoided, the use of PPE is recommended with input from experts in occupational health and safety and the Ministry of Labour. However, if used in the classroom, the teacher should explain the rationale to the children/youth in a developmentally appropriate manner.
• Staff may need to use enhanced PPE, including medical masks, face shields, gowns and gloves, in specific situations (e.g., the child who becomes ill at school and needs close physical attention). Such PPE should be readily available together with the training and policies/procedures to deal with this situation. Having designated staff trained in PPE use may facilitate preparedness and comfort among staff. This training should be done at frequent intervals.
• Policies and procedures need to be developed and updated in consultation with individuals with occupational health and safety expertise for all staff, in particular staff workers that have increased risk of severe outcomes/complications from COVID-19 (e.g., high-risk immunocompromised persons, such as those post-organ transplant, advanced age).
• To the extent possible, consideration should be given to assigning supply teachers to one school for as long a period of time as possible in order to minimize exposures both for their own safety and for the safety of other teachers and students. A minimum two-week interval between assignments would help reduce the risk of infection transmission from one school to another if there is a need for supply teachers to change schools.
• When community SARS-CoV-2 vaccination rollout commences, prioritizing vaccination of school staff should be considered in the ethical framework of vaccine rollout. Optimizing the potential vaccine coverage of the highest risk within the ”school ecology” is essential to keeping schools open and safe. 

With regards to children’s and youth’s home environment, it would be appropriate to consider the risk posed by potentially infected children/youth and school staff to household members (e.g., children, siblings, parents, grandparents, roommates). The risk posed by SARS-CoV-2 likely varies in relation to socioeconomic status, household overcrowding, and the presence of other children/youth and adults at increased risk of severe COVID-19 at home.

Consensus Guidance Statement(s):

• A separate document is being prepared by SickKids in collaboration with others to provide guidance to families on how to mitigate risks in the home environment, especially where there is a sibling, parent or older adult with underlying conditions that put them at increased risk for more severe disease reside in the same home. 

It is anticipated that we will continue to detect cases of symptomatic and asymptomatic SARS-CoV-2 infection in schools and it is important that public health authorities and schools be prepared to respond to cases involving both students and staff. This includes the need for readily available testing and contact tracing, which is critical for the timely detection and avoidance of outbreaks.¹⁰⁴ Parents and caregivers need to be empowered by their employers to be able to take paid sick days and/or work remotely if their children/youth are not able to attend school. We recognize that neither laypeople nor health-care providers will be able to reliably distinguish between COVID-19 and other respiratory viral illnesses on a clinical basis (i.e., without a diagnostic test). For specific recommendations related to SARS-CoV-2 testing for schools see Section 2.

Consensus Guidance Statement(s):

• Staff, families and children/youth should be aware of the symptoms and signs associated with COVID-19. Individuals with symptoms or signs consistent with COVID-19 must stay home.¹²⁶ Staff and students who develop symptoms or signs consistent with COVID-19 while at school must be sent home with exposures to others minimized during this process. 
• Special awareness is required for those with medical conditions, such as asthma, allergic rhinitis and conjunctivitis, as the symptoms associated with flares may overlap with SARS-CoV-2 infectious symptoms. Every effort should be made by parents/caregivers in conjunction with the health-care team to maximize the control of these underlying conditions. In the event of an acute flare, depending on extent, children/youth may need to have nasopharyngeal testing for SARS-CoV-2.
• A process should be in place for the management of symptomatic staff and students who are at school. This should include: 
  • separation from other students and staff
  • masking of the affected person if tolerated
  • use of PPE for other school staff if close interaction with the affected individual is required
  • cleaning surfaces the individual has been in contact with
  • in the case of symptomatic students, contacting caregivers for pick-up as soon as possible. 
• There should be clear protocols for management of staff and students who are exposed to a confirmed case of symptomatic or asymptomatic SARS-CoV-2 infection.  
• All staff and students who develop signs or symptoms consistent with COVID-19 should undergo testing for SARS-CoV-2 in accordance with public health recommendations. There should be clear testing recommendations by local public health units with information about where testing can be completed.  
• Schools should carefully document attendance of students, staff and visitors and ensure up-to-date contact information to facilitate public health management should a case be identified in the school. Schools should have a rapid method to contact students/families with information.
• Rapid involvement of public health for any confirmed symptomatic or asymptomatic SARS-CoV-2 infection cases in the school setting is essential in order to perform timely contact tracing and follow-up. There should be clear testing recommendations for contacts with information about where testing can be completed.  
• There needs to be clear guidance from public health for return to school for those who test negative, test positive, and for those who do not get tested.
• Educational materials targeted to school staff, children/youth and parents should be developed for those who are exposed, which are culturally sensitive and clearly delineate subsequent management.
• Consideration must be given as to how to maintain confidentiality of confirmed symptomatic or asymptomatic SARS-CoV-2 infection cases within the school. Strategies should be put in place to manage potential issues when students return (e.g., stigma, bullying).   

It is acknowledged that clear, age and developmental stage-appropriate communication about COVID-19 is important. Regular updates should be provided to children and their parents/caregivers throughout the school year.

Consensus Guidance Statement(s):

• Parents/caregivers, children/youth and the community at large should be educated that SARS-CoV-2 is likely to persist and circulate like other respiratory viruses in the future. It is unlikely that herd immunity will be achieved in Ontario (by vaccination or natural infection) in the near term, and so the operationalization of school in the context of the COVID-19 pandemic will likely be an issue for a prolonged period.
• Parents/caregivers should be made aware that SARS-CoV-2 causes mild disease in the majority of children, youth and young adults.  
• Parents/caregivers and children/youth and the community at large should be provided with up-to-date information on local SARS-CoV-2 epidemiology and other emerging evidence pertaining to SARS-CoV-2, such as vaccination. It is felt that provision of such information will aid in reducing anxiety in parents/caregivers and children/youth. 
• Ensuring up-to-date childhood immunizations, as well as annual influenza vaccination, should be promoted as a strategy to reduce the circulation of a common infectious agent circulating in fall/winter and thus limit, where possible, other preventable infections.
• The enhanced infection prevention and control measures being used at school should be reviewed with students and parents and the wellness room normalized. School staff should incorporate the wellness room into the dialogue by explaining what happens when someone has symptoms at school.  
• Ensure that messaging to school staff and students uses non-judgmental, normalizing strategies taking into account the stigma that students may feel (however unintended) when placed in the wellness room or when they return to school after being away because of illness or quarantine.   
• School Mental Health Ontario has created an information sheet regarding social stigma as it relates to COVID-19 and mental health that schools can also access on this topic. 

The continued operation of schools in the safest way possible for students, families, teachers and other school staff is of the utmost importance. In order to optimize success on an ongoing basis it is essential that research take place to assess SARS-CoV-2 transmission dynamics in schools and to determine effectiveness of the various mitigation strategies.

Priority areas of research include but are not limited to the following: 

• Understanding optimal surveillance strategies for schools in areas of low and higher community transmission. Considerations include evaluating the use of non-testing-based data (e.g., absenteeism, screening) and testing-based strategies for students and teachers (including serology and PCR testing) for surveillance. 
• Utility of innovative technologies for screening and contact tracing in the school setting (e.g., cellphone technologies). 
• Assessing the effectiveness and consequences of risk mitigation strategies, such as masking, face shields, physical distancing (one metre versus two metre distance) and cohorting, on learning, health and mental health outcomes for children of different ages in schools within the context of existing school infrastructures.  
• Investigation of school outbreaks to determine their causes and, specifically, to investigate the role of children and youth compared to staff/adults in order to better understand SARS-CoV-2 spread dynamics in general and to be able to improve mitigation strategies in the school setting.

In order to facilitate the development of testing-based surveillance and monitoring strategies for SARS-CoV-2, there are various areas of research that require attention:

• The evaluation of point-of-care testing strategies, and contact tracing strategies for surveillance, routine screening and management of potential outbreaks in schools. 
• Development of new testing methodologies that are more comfortable, feasible, with rapid return compared to nasopharyngeal swabs. Experience from our academic hospitals has shown that children who require frequent nasal swabbing develop anxiety for the testing, which in many cases has led to test refusal. Examples for alternative sampling could include anterior nares (front of the nose) testing, buccal swab testing, saliva sampling, as well as swabs of the throat/oral cavity. Additionally, testing is being evaluated by some groups in an attempt to detect the urinary excretion of SARS-CoV-2. 

It is recognized that there are other school support staff, in addition to teachers, who may have significant exposure to students and other staff. Guidance for their safety while at work should be developed and updated in collaboration with occupational health and safety and public health groups. In particular, bus drivers and transportation to school is an important consideration that requires detailed recommendations, including bus scheduling options, addressing bus capacity and other safe operational considerations.

Guidance for parents/caregivers and children/youth on alternative travel options should continue to be provided. One potential concern is that more parents/caregivers will drive their children/youth to school, either because of reduced school bus capacity (related to public health measures for buses) or because they feel it is safer, which could increase traffic congestion and risk of pedestrian injury. Strategies to accommodate such a scenario could include enhanced safety supervision and education and expanding drop-off and pick-up locations near the school. For children and youth who do not live far from school, walking or cycling/scootering should be encouraged, weather permitting. Expanded facilities for storage of bicycles and scooters may be needed. 

• Michelle Science MD, M.Sc., FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Assistant Professor, Department of Paediatrics, University of Toronto
• Sean (Ari) Bitnun MD, M.Sc., FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto

Listed alphabetically by institution and last name

The Hospital for Sick Children (SickKids) 

• Upton Allen OOnt., MBBS, M.Sc., FAAP, FRCPC, Hon FRCP (UK), FIDSA, Chief, Division of Infectious Diseases, The Hospital for Sick Children, Professor, Department of Paediatrics and The Institute of Health Policy, Management & Evaluation, University of Toronto 
• Catherine Birken MD, M.Sc., FRCPC, Senior Scientist, Child Health Evaluative Sciences, Staff Paediatrician, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto  
• Cindy Bruce-Barrett RN, BScN, MN, PMP, Director Corporate Strategic Projects
• Aaron Campigotto MD, M.Sc., FRCPC, Division of Microbiology, The Hospital for Sick Children, Assistant Professor, Department of Laboratory Medicine & Pathobiology, University of Toronto
• Eyal Cohen MD, M.Sc., FRCPC, Program Head, Child Health Evaluative Sciences, Staff Physician, Complex Care Program, The Hospital for Sick Children, Professor, Paediatrics and Health Policy, Management & Evaluation, University of Toronto, Co-Director, Edwin S.H. Leong Centre for Healthy Children
• Ronald Cohn MD, FACMG, President and CEO, The Hospital for Sick Children, Professor, Department of Paediatrics and Molecular Genetics, University of Toronto
• Jeremy Friedman MBChB, FRCPC, Associate Paediatrician-in-Chief, Staff Paediatrician, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto
• Ian Kitai MB, B.Ch., FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto 
• Daphne J Korczak MD, M.Sc., FRCPC (Paediatrics), FRCPC (Psychiatry), Associate Scientist, Neuroscience and Mental Health, Psychiatrist, The Hospital for Sick Children, Associate Professor of Psychiatry, Faculty of Medicine, University of Toronto
• Jeff Mainland MBA, EVP, The Hospital for Sick Children
• Shaun Morris MD, FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Associate Professor, Department of Paediatrics, University of Toronto
• John Nashid MBA, Project Manager, The Hospital for Sick Children
• Julia Orkin, MD, FRCPC, Staff Paediatrician, The Hospital for Sick Children, Assistant Professor, Department of Paediatrics, University of Toronto
• Stanley Read MD, PhD, FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto
• Rachel Solomon MPH, Chief Data Officer, The Hospital for Sick Children
• Laurie Streitenberger B.Sc., RN, CIC, Senior Manager, Infection Prevention and Control, The Hospital for Sick Children
• Anupma Wadhwa MD, M.Sc., FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Associate Professor, Department of Paediatrics, University of Toronto
• Valerie Waters MD, M.Sc., FRCPC, Division of Infectious Diseases, The Hospital for Sick Children, Professor, Department of Paediatrics, University of Toronto

Unity Health Toronto

• Justine Cohen-Silver MD, M.Sc. (Biostatistics), FRCPC (Paediatrics) MPH (Health Promotion), Paediatrician, Women’s and Children’s Health Program, St. Michael’s Hospital and St. Joseph Health Centre, Unity Health Toronto, Assistant Professor, Faculty of Medicine, University of Toronto, Investigator, Li Ka Shing Knowledge Institute, Physician Lead, Parkdale School Outreach Clinic, St. Joseph Health Centre, Unity Health Toronto
• Sloane Freeman MD, M.Sc., FRCPC, Paediatrician, Women’s and Children’s Health Program, St. Michael’s Hospital, Unity Health Toronto, Assistant Professor, Faculty of Medicine, University of Toronto, Associate Scientist, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Physician Lead, Model Schools Paediatric Health Initiative
• Kevin Schwartz MD, M.Sc., FRCPC,DTM&H, Division Head, Infectious Diseases, St. Joseph’s Health Centre, Unity Health Toronto, Assistant Professor, Dalla Lana School of Public Health, University of Toronto

CHEO (Children’s Hospital of Eastern Ontario)

• Charles Hui MD, FRCPC, Chief of Infectious Diseases, Immunology and Allergy, CHEO, Associate Professor of Paediatrics, Faculty of Medicine, University of Ottawa
• Lindy Samson MD, M.Sc., FRCPC, Infectious Diseases Physician and Chief of Staff, CHEO, Associate Professor, University of Ottawa
• Nisha Thampi MD, M.Sc., FRCPC, Division of Infectious Diseases, Medical Director, Infection Prevention and Control Program, CHEO, Assistant Professor, University of Ottawa

Holland Bloorview Kids Rehabilitation Hospital

• Evdokia Anagnostou MDCM, FRCPC, Senior Clinician Scientist and Paediatric Neurologist, Co-lead, Autism Research Centre, Canada Research Chair in Translational Therapeutics in Autism, Dr. Stuart D. Sims Chair in Autism
• Darcy Fehlings MD, M.Sc., FRCPC, Senior Clinician Scientist, Head, Division of Developmental Paediatrics, University of Toronto, Professor, Department of Paediatrics, University of Toronto
• Laura McAdam MD, M.Sc., FRCPC, Physician Director, Child Development Program, Clinician Investigator, Paediatrician
• Golda Milo-Manson MD, M.HSc., FRCPC, Vice-President, Medicine and Academic Affairs, Developmental Paediatrician, Associate Professor of Paediatrics, University of Toronto
• Melanie Penner MD, B.Hsc., M.Sc., FRCPC, Clinician Investigator, Autism Research Centre, Assistant Professor, Department of Paediatrics, University of Toronto
• Sharon Smile MBBS, DM, M.Sc., Developmental Paediatrician, Equity, Diversity and Inclusion Champion, Division of Developmental Paediatrics, University of Toronto
• Meenu Sikand, B.Sc., MA, Executive Lead, Equity, Diversity and Inclusion

Children’s Hospital at London Health Sciences Centre

• Michelle Barton-Forbes MD, M.Sc., Division Chief, Paediatric Infectious Diseases, Department of Paediatrics, Children’s Hospital at London Health Sciences Centre, Associate Professor, Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University 
• Michael Silverman MD, FRCP, Chair/Chief Division of Infectious Diseases, London Health Sciences Centre and St. Joseph’s Health Care, Associate Professor, Department of Medicine, Department of Epidemiology and Biostatistics, Department of Microbiology and Immunology, Western University

McMaster’s Children’s Hospital

• Martha Fulford, B.Sc., B.Ed., MA, MD, FRCPC, Division of Infectious Diseases, Department of Paediatrics, Associate Professor, McMaster University 
• Sarah Khan MD, M.Sc., FRCPC, Division of Infectious Diseases, McMaster Children’s Hospital, Associate Medical Director of Infection Prevention and Control, Hamilton Health Sciences, Assistant Professor, McMaster University 
• Dominik Mertz MD, M.Sc., Division of Infectious Diseases, Department of Medicine, Associate Professor, McMaster University, Medical Director, Infection Prevention and Control, Hamilton Health Sciences 
• Jeffrey Pernica MD, M.Sc., FRCPC DTMH, Head, Division of Infectious Diseases, McMaster Children’s Hospital, Department of Pediatrics, Associate Professor, McMaster University 
• Fiona Smaill MB, ChB, FRCPC, Department of Laboratory Medicine, Hamilton Health Sciences, Professor, Department of Pathology and Molecular Medicine, McMaster University 
• Jacqueline Wong M.Sc., MD, FRCPC, Division of Infectious Diseases, McMaster Children’s Hospital, Department of Pediatrics, Assistant Professor, McMaster University

Kingston Health Sciences Centre

• Kirk Leifso MD, M.Sc., FRCPC, FAAP, Staff Physician, Pediatric Infectious Diseases, Department of Pediatrics, Kingston Health Sciences Centre, Assistant Professor, Department of Pediatrics, Queen’s University

Physicians of Ontario Neurodevelopmental Advocacy (PONDA)

• Dr. Alvin Loh MD, Chair, PONDA Network, Developmental Paediatrician, Medical Chief of Staff, Surrey Place, Assistant Professor, Division of Developmental Paediatrics, University of Toronto

Adult infectious diseases experts

• Janine McCready MD, FRCPC, Division of Infectious Diseases, Michael Garron Hospital, Lecturer, Department of Medicine, University of Toronto 
• Andrew Morris, MD, SM, FRCPC, Medical Director, Sinai Health-University Health Network, Antimicrobial Stewardship Program, Professor, Division of Infectious Diseases, University of Toronto 
• Daniel Ricciuto, MD, FRCPC, Infectious Diseases Consultant, Chief and Medical Director, Quality and Patient Experience, Medical Director, Infection Prevention and Control, Lakeridge Health, Adjunct Faculty, Division of Infectious Diseases, University of Toronto 
• Abdu A Sharkawy MD, B.MSc., FRCPC, Division of Infectious Diseases, University Health Network, Toronto Western Hospital, Assistant Professor of Medicine, Department of Medicine, University of Toronto

We are very grateful for the reviews and contributions provided by the following key stakeholders:

• Teachers: Ryan Imgrund, Nigel Bariffe, Laura McCoy, Stacie Carroll, Giovanna Panzera, Jodi Greenwood
• Epidemiology: Amy Greer
• Holland Bloorview Kids Rehabilitation Hospital Family Leader volunteers with lived experience expertise: Adrienne Zarem, Cheryl Peters, Jean Hammond, Joanne Downing, Oksana Romanov, Meredith Sandles, Aline Chan, Gunjan Seth
• Holland Bloorview Kids Rehabilitation Hospital School Authority: Sarah Nauman (school principal)
• PONDA members: Olaf Kraus de Camargo, Mohammad Zubairi, Sarah Pot (parent), Jennifer McLean, Elizabeth Grier, Paige Church

We appreciate the lived expertise and detailed review of Family Advisors Joanne Witt, Sitara de Gagné, Cindy Desbiens, Laura Veloso, Ruth Liu and other members of the SickKids Family Advisory Network. 

This document has been endorsed by Children First Canada and the following Pediatric Chairs of Canada:

• Craig Campbell, Western University/Children's Hospital - London Health Sciences Centre
• Robert Connelly, Queen’s University
• Ciaran Duffy, University of Ottawa
• Allison Eddy, University of British Columbia
• Meredith Irwin, University of Toronto
• Andrew Lynk, Dalhousie University
• Angelo Mikrogianakis, McMaster University