First meeting of the Technical Advisory Group on Safe Schooling During the COVID-19 Pandemic

First meeting of the

Technical Advisory Group on Safe Schooling During the COVID-19

Pandemic

Copenhagen, Denmark

26 October 2020

implemented in schools is now emerging. The WHO Regional Office for Europe and the Government of Italy jointly convened a high-level meeting on 31 August 2020 to discuss the situation and share experiences. Member States agreed to establish a network of experts to collate and review the emerging evidence on best practices and the potential negative effects of school reopening. A technical advisory group (TAG) was convened to review the evidence and make recommendations for a second high-level meeting, to be held in late November 2020. Member States will reconvene at this meeting to review lessons learned and further emerging evidence, adjust interventions accordingly and recommend the way forward. This report is of the first TAG meeting, held in Copenhagen, Denmark, on 26 October 2020.

Keywords

CHILD SCHOOL COVID-19 SARS-COV-2 SCHOOL TEACHER INFECTION CONTROL

This meeting report presents a summary of the presentations and discussions. It is not a full transcript and involves only limited individual attribution of statements. The views expressed are those of presenters and participants at the meeting and are not necessarily those of the World Health Organization

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CONTENTS

Page

Acronyms ... iv

Introduction ... 1

Aims and objectives ... 1

Synopsis/summary of the meeting ... 3

Opening and introduction ... 3

Expert presentations, Round 1 ... 4

Expert presentations, Round 2 ... 6

Conclusions of the first TAG meeting ... 8

Annex 1 ... 9

Programme ... 9

Annex 2 ... 10

List of Participants ... 10

Acronyms

ECDC European Centre for Disease Prevention and Control EPHSM Emergency Public Health and Social Measures Pillar Team IHR International Health Regulations (2005)

IPC infection prevention and control TAG technical advisory group

TESSy The European Surveillance System

UNESCO United Nations Educational, Scientific and Cultural Organization

Introduction

Around 180 countries across the world closed their schools early in the pandemic to control the transmission of the SARS-CoV-2 virus, affecting 1.5 billion students. Most of the 53 Member States of the WHO European Region closed their schools in mid-March in an attempt to control the transmission of SARS-CoV-2.

Evidence on the impact of school closures on children and the effectiveness of infection prevention and control (IPC) measures being implemented in schools is now emerging. The WHO Regional Office for Europe and the Government of Italy jointly convened a high-level meeting on 31 August 2020 to discuss the situation and share experiences. A roadmap towards a consensus on safe schooling in the European Region during the COVID-19 pandemic was developed, aiming to ensure the safety and well-being of children, their families and communities.

Member States agreed to establish a network of experts to collate and review the emerging evidence on best practices and the potential negative effects of school reopening. A decision was reached to develop a so-called living platform that will be populated by Member States with relevant national data that will enable them to learn from each other’s experiences. Accordingly, a technical advisory group (TAG) was convened to review the evidence and make

recommendations for a second high-level meeting, to be held in late November 2020. Member States will reconvene at this meeting to review lessons learned and further emerging evidence, adjust interventions accordingly and recommend the way forward. This report is of the first TAG meeting, held in Copenhagen, Denmark, on 26 October 2020; a second TAG meeting has been organized for 12 November.

Aims and objectives

The overall objective of the two TAG meetings and the high-level meeting of ministers of health and education is to ensure that children’s lives and educational processes in the European Region are as unaffected and uninterrupted as possible, while simultaneously ensuring the safety of children, educators, other school staff and communities by keeping COVID-19 transmission under control.

As terms of reference, the TAG will advise the Regional Office on:

• the epidemiology of school transmission and its modelling, developing scenarios based on available data to guide when school closure (complete or partial) is useful or not useful in relation to community transmission and highlighting data gaps that need to be addressed;

• the interpretation of regional research findings from the emerging evidence on education institutions and COVID-19 to inform policy decisions on education, social development and health outcomes for children and staff;

• the lessons learned and key issues emerging from countries’ early experiences of school reopening to contribute to WHO’s advice to Member States on national strategies and policies on school-based interventions for safe schooling and monitoring of processes;

and

• the evidence from global efforts and reviews, advising on their applicability to the European Region.

The first TAG meeting set the stage for the process and reviewed the current situation and evidence. It is expected that the information presented at the first meeting will lead to recommendations from the second TAG meeting for Member States to inform policies for schooling during the COVID-19 pandemic.

Synopsis/summary of the meeting

The meeting was opened by Natasha Azzopardi-Muscat (Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe). She highlighted the importance of the meeting, emphasizing that the European Region has reached a point of concern in terms of recent increases in COVID-19 incidence in most Member States. The meeting was very timely, supporting the Member States of the WHO European Region by offering guidance and

recommendations and reviewing best practices on how to keep schools open during the pandemic and, in the worst-case scenario, how to use different education methods. Given this development, Member States needed advice soon, and the process would need to be accelerated.

Antony Morgan (Glasgow Caledonian University, United Kingdom) was proposed as chair of the TAG and was confirmed by acclamation.

Martin Weber (Programme Manager, Child and Adolescent Health, WHO Regional Office for Europe) provided an overview of the purpose of the meeting, including the expected outcomes of the two TAG meetings and the subsequent high-level meeting of ministers of health and

education to be held in November 2020. He summarized the meeting agenda, comprising two rounds of expert presentations followed by discussions involving all participating TAG members.

Vivian Barnekow, WHO consultant, then described processes undertaken to date, including the outcomes of the high-level meeting of 31 August 2020. The high-level meeting made some recommendations, including:

• identifying the overall goal of the TAG, which is to identify the best possible measures moving forward;

• incorporating equity as a core principle to avoid vulnerable groups of children experiencing further disadvantage;

• establishing a network of focal points from Member States to provide necessary information regarding schooling throughout the European Region;

• ensuring the involvement of children and young people in decision processes on safe schooling; and

• collaborating with United Nations partners and the European Centre for Disease Prevention and Control (ECDC).

Natasha Azzopardi-Muscat stressed the significance not only of incorporating modelling research, but also of facilitating collaboration with stakeholders, including schools, universities and nurseries. She introduced three representatives of Young People’s Voices from Kazakhstan, Denmark and Germany: Malika Nakisbekova, Frida B. Rasmussen and Emilia Carai. The students showed a video they had produced featuring perspectives from students around Europe during home-schooling and shared their own personal impressions. They reported different experiences of home-schooling among students, ranging from feelings of increased autonomy and time-saving to a sense of heavy loss related to motivation, educational attainment, and maintenance of a healthy daily routine and social life. The representatives suggested that pupils from disadvantaged backgrounds and young people from different age groups should be asked to provide a more comprehensive perspective. They aim to carry out a survey to identify students’

educational attainment, mental and social well-being, and nutrition and physical activity behaviours during the time of the pandemic.

Expert presentations, Round 1

Piers Mook (Infectious Hazards Management, WHO Regional Office for Europe) presented current epidemiological data on transmission of SARS-CoV-2 in schools and disease related to COVID-19 in children. COVID-19 is reported much less frequently in children than in adults in most countries of the European Region, and all countries report that children tend to have much milder symptoms than adults. Studies show that SARS-CoV-2 susceptibility and SARS-CoV-2 infectivity rise with age. More outbreaks are reported in secondary and high schools than in primary schools across the European Region. Staff-to-staff transmission is more common than student-to-staff or student-to-student transmission. Children with underlying conditions are at higher risk of serious illness.

Florian Götzinger (Department of Paediatric and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Wilhelminenspital, Vienna, Austria) gave a presentation on severe disease in children. Severe COVID-19 infections are rare in children and infants but occur across all age groups. The study of COVID-19 in children and adolescents in Europe he

conducted with colleagues¹ showed that among 582 children recruited to the study, 8.2%

required intensive care and the fatality rate was 0.69%. All fatal cases were over 10 years of age, and two of the four children who died had pre-existing conditions. The study mainly captured hospital-based data, so the real case-fatality rate is likely to be substantially lower. The most common presenting symptoms were fever and upper respiratory symptoms. Risk factors for admission to an intensive care unit were underlying malignancy, cardiac, respiratory and neurological disease, and viral coinfections. Children with comorbidities and with coinfections therefore seem more prone to severe infection that requires further specialized care.

Walter Haas (Head of Respiratory Infections, Robert Koch Institute, Germany) addressed the impact of school closures on the wider population. He demonstrated a heat map showing that after calendar weeks 33 (when schools reopened) and 42, COVID-19 incidence among school- aged children and adolescents tripled compared to the situation during the summer holidays. He pointed out that these data suggest children and adolescents are followers, not drivers, of the pandemic, with a slower dynamic in younger children. This is supported by data on school outbreaks in different age groups that identify the potential of large outbreaks in school settings, which seems to increase with age. Adult personnel are involved in most of these events. For that reason, precautions must be taken primarily to control the spread of COVID-19 in the

community, but measures to prevent spread in school settings, rapidly identify cases and contain outbreaks are central to keeping schools open. He argued in favour of establishing a testing strategy that focuses on vulnerable groups, children with severe disease, outbreak/cluster prevention and prevention of capacity shortages, as testing of all children with respiratory symptoms will not be feasible. He recommended that in the autumn/winter season, children with respiratory symptoms who are not prioritized for testing should stay at home to recover for five days.

Jonathan Suk (ECDC) elaborated on SARS-CoV-2 transmission in household and school settings. COVID-19 incidence in children under 15 years of age is increasing (7%) compared to the situation before schools were reopened (5%). ECDC Member State surveys and data up to 31 August 2020 from The European Surveillance System (TESSy), however, show that children are

1Götzinger F, Santiago-García B, Noguera-Julián A, Lanaspa M, Lancella L, Calò Carducci FI et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health 2020;4(9):653–61. doi:https://doi.org/10.1016/S2352-4642(20)30177-2 (accessed 1 November 2020).

less likely to be the index case in households. Onward transmission is observed more in older children and young adults than in younger children, but also primarily in household rather than other settings. School closure therefore is not assumed to be an effective measure for controlling spread of COVID-19. Differences between preschool, primary and secondary schools should be taken into consideration.

Discussion of Round 1

The first round of presentations was followed by questions and reflections from participants.

The following questions (in italics) were asked and answered.

What is the definition of “outbreak” in schools in Germany?

“Outbreaks” in Germany are identified/notified by a surveillance data system, through which they are investigated by local health authorities and cases are further combined into clusters.

Have any studies been conducted to investigate the risk factors for transmission or protective behaviours to avoid transmission?

An upcoming study will conduct detailed testing investigations on children and their families to generate better data on specific behaviours around transmission, especially in children from 0–5 years.

Considering that most transmission comes from outside of school settings, are we aware of any evidence around social mixing?

Transmission depends mostly on the setting. Germany’s experience is not necessarily true for every country. The study published in Eurosurveillance presented in Round 1 shows data on household outbreaks linked with school outbreaks.

The epidemiology of COVID-19 in children has been presented, including the risk of severe infection/complications, but for a balanced perspective, what process will be used for quantifying and qualifying the direct and indirect impact on children of the consequences of school closures?

This question will be discussed in more detail at the next TAG meeting on 12 November. It will represent a main outcome of the meeting and will be reflected in its recommendations to the high-level meeting.

Acknowledging the importance of occupational studies, are we aware of any ongoing studies on the impact on staff in schools?

Studies of occupational health risks among staff would be of great interest, but currently there appears to be no studies underway. A decision was made to share additional information at the upcoming meetings.

Do asthma or other chronic conditions among children increase the risk of severe disease, and what approaches on going to school are countries adopting for these children?

Asthma, and also mild cystic fibrosis, do not per se seem to increase the risk of severe disease in children, but severe bronchopulmonary dysplasia and severe cardiac or neuromuscular diseases do appear to increase the risk. More data are needed. The Ministry of Health in Austria and the Society of Paediatrics recommend that parents of chronically ill children should seek

personalized risk assessments with their treating paediatrician.

Overall reflection after Round 1 The following reflections were made:

• The presentations from student participants showed major differences among

populations. It is very important to reach a wider spectrum of students, including those from migrant populations and socially disadvantaged communities.

• The group of young people had difficulties in distributing their survey and reaching a wider population. Other networks acknowledge the challenges they face and are willing to support them to reach a wider audience.

• Participation of young people is strongly encouraged and needed.

• Eileen Scott (NHS Health Scotland, United Kingdom) reported that United Kingdom (Scotland) has not seen many large-scale outbreaks during school reopening and there is little evidence of people-to-people transmission. Increasing cases in the population are suspected to be a result of adults having more opportunities to interact as a consequence of schools being open. Understanding the level of household transmission and school transmission alongside broader measures is important.

Expert presentations, Round 2

Kayla King (consultant, WHO Regional Office for Europe) and Ihor Perehinets (Acting Programme Area Manager, Country Health Emergency Preparedness and International Health Regulations (IHR) (2005), WHO Regional Office for Europe) introduced the measures being collected in the European Region by the Emergency Public Health and Social Measures Pillar Team (EPHSM), housed within the WHO World Health Emergencies COVID-19 Incident Management Support Team. EPHSM collects and monitors a comprehensive database of public health and social measures based on situation reports from WHO representatives, real-time government sources, national IHR focal point reports and media sources from all 53 Member States and two States Parties. This has been compiled into a Severity Index that shows aggregate change across the European Region in relation to school openings and closures from 27 January to the present. As of 26 October, more than 12 000 measures had been collected across various categories, 709 of which were related to school interventions.

Eva Rehfuess (Ludwig-Maximilians University, Munich, Germany) presented the preliminary results of a Cochrane scoping review of measures implemented in school settings to safely reopen and/or keep schools open during the COVID-19 pandemic. The study identifies and maps the evidence assessing the various impacts of these measures on students, teachers, other school staff and the wider community. The scoping review is the first step in developing a Cochrane review on the effectiveness (as well as adverse effects) of measures to safely reopen and/or keep schools open during the COVID-19 pandemic.

Martin Weber (Programme Manager, Child and Adolescent Health and Development, WHO Regional Office for Europe) presented a matrix table that considers the impact of COVID-19 control measures in school settings on children. The matrix is based on an ongoing rapid literature review and will be updated as new evidence arises. It will be useful in assessing the impact of IPC interventions on the virus and on overall child health and well-being, with a special focus on equity.

Antony Morgan (Chair of the TAG) introduced the work of the COVID-19 Maternal, Newborn, Child and Adolescent Health Research Network initiated by WHO headquarters. There were two subgroups within the working group, one focusing on transmission and the other on health, well-

being and social impacts. The groups have now been merged. The working group brings people conducting research on COVID-19 and education institutions together to share information, set priorities for future research, and feed knowledge into WHO and United Nations Educational, Scientific and Cultural Organization (UNESCO) guidance processes.

Olivier Le Polain (Epidemiologist, Health Emergency Information and Risk Assessment, WHO headquarters) described WHO documents on school guidance and criteria for adjusting public health and social measures published in September. The guidance documents will be updated again this month with new transmission-level categories. The continuity of education for all children and their overall well-being, health and safety were emphasized as being at the forefront of all considerations and decisions.

Discussion of Round 2

The second round of presentations were followed by questions and reflections from participants.

Shamez Ladhani (Public Health England, United Kingdom) shared information on a large outbreak survey analysis conducted in England that has documented the risk of transmission between children/staff/students and within staff. Serosurveillance studies are also underway in primary and secondary schools. A survey that will recruit a large number of staff and students in 150 schools across the United Kingdom is planned for 2021. Staff and students will be tested throughout the year to look at the transmission of COVID-19, and all information will be made accessible online.

Tigran Yepoyan (UNESCO) informed participants about a global education meeting hosted by UNESCO. He emphasized that recommendations and guidelines should consider the level of stress and anxiety that children (especially those in vulnerable situations), their families, teachers and school staff are undergoing. Much research is being conducted on medical epidemiology elements, but data on the psychosocial impacts of school closures are lacking. These impacts need to feed into the recommendations and guidelines soon.

Conclusions of the first TAG meeting

Natasha Azzopardi-Muscat summarized the emerging messages from the first TAG meeting. The work of the TAG was timely, as the window to inform measures being implemented with sound evidence is closing rapidly due to an exponential increase in cases across the European Region.

The following summary points were made:

• children and adolescents are not considered primary drivers of transmission of SARS- CoV-2;

• school closures are not considered to be an effective single measure for the control of COVID-19;

• evidence suggests that community transmission drives school transmission, and cases in school reflect transmission in the community;

• testing strategies in schools need to focus on vulnerable groups and follow up of identified clusters of infection;

• widespread testing of school-aged children with respiratory symptoms is not feasible;

• severe cases in children are very rare;

• it will be particularly important to look at and consider the adverse effects of school closures and other control measures on children’s education outcomes and mental and social well-being, and to minimize these effects where possible in the future;

• children in vulnerable situations are affected disproportionately by control measures; and

• children and adolescents need to be involved in decisions on any measures concerning them and school.

The second TAG meeting will discuss further the reflections that surfaced during this first meeting. In addition, any information left out of the first TAG meeting will be shared.

Natasha Azzopardi-Muscat requested that useful and pragmatic recommendations be agreed at the second TAG meeting in light of the recent rise of cases in the European Region. Dorit Nitzan (Regional Emergency Director, WHO Regional Office for Europe) added that the TAG meetings offer an opportunity to look beyond the health system to improve education systems and schools.

She proposed to use this opportunity to build education systems, infrastructures and conditions for a better future for children’s well-being.

Annex 1

P

26 October 2020 Opening Session

14:00 – 14:05 Opening and welcome by WHO Natasha Muscat

Dorit Nitzan, 14:05– 14:10 Aim and purpose of the meeting including expected outcomes of

the two expert group meetings

Martin Weber

14:10 – 14:15 Presentation on outcomes of the High-level meeting 31 August 2010

Vivian Barnekow,

14:15 – 14:20 Young peoples’ voices Malika, Frida, Emilia

Presentations Round 1

14:20 –15:00 The epidemiology of COVID-19 in children and schools (5 minutes)

Piers Mook Severe disease in children – what do we know and how common

is it (5 minutes)

Florian Gotzinger COVID-19 in schools – experiences from Germany (5 minutes) Walter Haas COVID-19 in children and the wider population – what might be

the role of school closures? (5 minutes)

Jonathan Suk Discussion 20 minutes

Presentations Round 2

15:00 – 15:50 Overview of school measures implemented in the European

Region in response to COVID-19   (7 minutes) Ihor Perehinets School measures during COVID-19: a scoping review

(5 minutes)

Eva Rehfuess

The Matrix revisited (5 minutes) Martin Weber

Research actions. Social and mental effects of Covid in schools (5 minutes)

Antony Morgan Classifying level of community transmission and linkage to public

health action – what might it mean for schools?

Olivier Le Polain Discussion 20 minutes

15:50 – 16:00 Way Forward Natasha Muscat

Martin Weber

Annex 2

L

Temporary Advisers (Members of the TAG) Bruce Adamson

Children and Young People’s Commissioner Scotland Edinburgh

Scotland Freia de Bock

German Federal Agency of Health Promotion

Head of Department Effectiveness and Efficiency of Health Education Cologne

Germany Chris Bonell*

Public Health Sociology University College London London School of Hygiene and Tropical Medicine London

United Kingdom David Edwards General Secretary Education International Brussels

Belgium

Florian Gotzinger

Consultant for Paediatric Infectious Diseases and Immunology Programme director for Paediatric Infectious Diseases

Vienna Healthcare Group Klinik Ottakring

Austria Walter Haas

Head of respiratory infections Robert Koch Institute

Berlin Germany

Adamos Hadjipanayis President

European Academy of Paediatrics European University Cyprus Nicosia

Cyprus

Mark Jit*

London School of Hygiene and tropical medicine Department of Infectious Disease Epidemiology Colette Kelly

Director Health Promotion Research Centre (HPRC) NUI Galway Galway

Ireland

Olga Komarova

Scientific Centre of Children Health Moscow

Russian Federation Shamez Ladhani

Immunisation, Hepatitis, and Blood Safety department Public Health England

London

United Kingdom Pierre-Andre Michaud Adolescent Health Lausanne University Lausanne

Switzerland Antony Morgan

Glasgow Caledonian University

GCU School of Health and Life Sciences London

United Kingdom

Leyla Namazova-Baranova*

European paediatric association, EPA/UNEPSA Moscow

Russian Federation Ivana Pavic

Deputy Director

Croatian Institute of Public Health Zagreb

Croatia Eva Rehfuess

Chair for Public Health and Health Services Research

Institute for Medical Information Processing, Biometry and Epidemiology Ludwig-Maximilians University

Munich Germany

Sergey Sargsyan Chief Paediatrician Yerevan

Armenia Ettore Severi

Expert outbreak response

European Centre for Disease Control (ECDC) Stockholm

Sweden Anette Schulz

Coordinator Schools for Health in Europe (SHE) Network University College South Denmark

Research Centre for Health Promotion Haderslev

Denmark Eileen Scott

Health Intelligence Principal Public Health Scotland Edinburgh

Scotland

United Kingdom Jonathan Suk

Senior Expert Public Health Emergency Preparedness European Centre for Disease Control (ECDC)

Stockholm Sweden

Anders Tegnell Chief Epidemiologist

Public Health Agency of Sweden Stockholm

Russell Viner*

President

Royal College of Paediatrics and Child Health (RCPCH) London

United Kingdom

Youth Representatives Emilia Carai

Copenhagen International School Denmark

Malika Nakisbekova International School Miras Almaty

Kazakhstan

Frida B. Rasmussen Birkerød Gymnasium Denmark

Un Agencies UNESCO

Tigran Yepoyan

Regional advisor for health and Education, Eastern Europe & Central UNICEF

Basil Rodriques

Regional advisor Child health UNICEF EECA Geneva

Switzerland

Parmosivea Soobrayan*

Regional Advisor Education

UNICEF EECA Geneva

Switzerland Malin Elisson

Senior Advisor of Education

UNICEF Regional Office for Europe and Central Asia

World Health Organization

Headquarters Anshu Banerjee*

Director

Maternal, Newborn, Child & Adolescent Health & Ageing Abdi Mahamud

Incident Manager

Acute Events Management Olivier Le Polain

Epidemiologist

Health Emergency Information and Risk Assessment Valentina Baltag*

Scientist

Adolescent and Young Adult Health Faten Benabdelaziz*

Coordinator

Enhanced Wellbeing

Regional Office for Europe Natasha Azzopardi Muscat Director

Division of Country Health Policies and Systems Dorit Nitzan

Regional Emergency Director Richard Pebody*

Team Leader

Infectious Hazard Management Piers Mook

Technical Adviser

Infectious Hazard Management Ihor Perehinets

Technical Adviser

Health Systems and Public Health Martin Weber

Programme manager

Child and Adolescent Health and Development Vivian Barnekow

Consultant

Child and Adolescent Health and Development Tammy Boyce

Consultant

Policy and Governance for Health and Well-being João Breda

Head WHO European Office for Prevention and Control of Noncommunicable Diseases & a.i.

Programme Manager Nutrition, Physical Activity and Obesity Susanne Carai

Consultant

Child and Adolescent Health and Development Dan Chisholm*

Programme Manager for Mental Health Valentina Grossi

Consultant

Water and Climate

Policy and Governance for Health and Well-being Dorota Jarosinska

Programme Manager

WHO European Centre for Environment and Health Kayla King

Consultant

Country Health Emergency Preparedness & IHR Aigul Kuttumuratova

Technical officer

Child and Adolescent Health

Division of Noncommunicable Diseases and Life-Course Satish Mishra

Technical officer Healthy Ageing

Disability and Long-term Care Min Hye Park

Consultant

Child and Adolescent Health and Development

Jonathon Passmore Programme Manager

Violence and Injury Prevention Francesca Racioppi*

Head

WHO European Centre for Environment and Health Nino Sharashidze

Technical Officer

WHO European Centre for Environment and Health Tanja Schmidt

Technical officer

Country Health Emergency Preparedness & IHR Julianne Williams

Technical Officer

European Office for Prevention and Control of Noncommunicable Diseases Kremlin Wickramasinghe

Technical Officer

European Office for Prevention and Control of Noncommunicable Diseases Lucia Dell-Amura

Administrative Assistant

Director Programme Management Nathalie Julskov

Assistant to Director

WHO Health Emergencies Programme Olga Pettersson

Programme assistant

Child and Adolescent Health and Development

* unable to attend the first meeting

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