Technical Advisory Group on Schooling During the COVID-19
Pandemic
Copenhagen, Denmark
12 November 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 second TAG meeting, held in Copenhagen, Denmark, on 12 November 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
Introduction ... 2
Summary of second TAG meeting... 3
Key issue 1. Children and adolescents are not considered primary drivers of transmission of SARS-CoV-2 ... 4
Key issue 2. Pursuant to the above considerations, keeping schools open is a key objective ... 5
Key issue 3. Testing strategy in the school setting ... 7
Key issue 4. Changes in the school environment that are likely to be of overall benefit to infection control AND child health ... 8
Key issue 5. Effectiveness of applied control measures on infection control ... 9
Key issue 6. Educational outcomes, mental and social well-being ... 10
Key issue 7. Children in vulnerable situations ... 11
Key issue 8. Children’s and adolescents’ involvement in decision-making ... 12
Next steps and closing ... 14
References ... 15
Annex 1 ... 16
List of participants ... 16
Introduction
The first technical advisory group (TAG) meeting on safe schooling during COVID-19 identified eight key issues pertinent to mitigating the direct and indirect impacts of the pandemic on
children and adolescents. These were discussed further at the second TAG meeting on 12 November 2020, the purpose of which was to gain further expert input into the issues to support the development of advice statements. The intention is to present the outcomes of the TAG meetings at a high-level meeting with Member States of the WHO European Region scheduled for 8 December 2020.
The issues are:
• Key issue 1. Children and adolescents are not considered primary drivers of transmission of SARS-CoV-2
• Key issue 2. Keeping schools open is a key objective
• Key issue 3. Testing strategy in the school setting
• Key issue 4. Changes in the school environment that are likely to be of overall benefit to infection control AND child health
• Key issue 5. Effectiveness of applied control measures on infection control
• Key issue 6. Educational outcomes, mental and social well-being
• Key issue 7. Children in vulnerable situations
• Key issue 8. Children’s and adolescents’ involvement in decision-making.
Additional background can be found in the WHO document Considerations for implementing and adjusting public health and social measures in the contact of COVID-19. Interim guidance. 4 November 2020 (1).
Summary of second TAG meeting
Natasha Azzopardi-Muscat (Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe) opened the second TAG meeting and welcomed participants on behalf of WHO.
She thanked the TAG members for guiding WHO, partners and Member States on outstanding questions as the European Region faces rising numbers of COVID-19 cases and countries wish to keep open their schools. Some countries already are taking decisions to close schools again and are differentiating between primary, secondary and further education institutions in their decisions. We therefore need to be more granular in the advice we offer. Infection prevention and control measures in schools vary across countries and within regions of countries, as not all schools have the same potential to implement the prescribed measures.
The last high-level meeting with Member States in August created clear consensus to keep schools open as long as possible, but the question now that needs to be answered is, what is as long as possible? Any guidance that can be provided on when it is safe to keep schools open from an epidemiological perspective, what characteristics to look for when considering closure and how negative effects can be limited would be useful. She cited the Regional Director for Europe, who emphasizes that countries must keep in mind the needs of children who may not be able to adapt to distance learning when making decisions about school closures.
Martin Weber (Programme Manager, Child and Adolescent Health, WHO Regional Office for Europe) reminded participants of the role of the TAG, as outlined in their 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.
He thanked partners and colleagues from the United Nations Children’s Fund, United Nations Educational, Scientific and Cultural Organization and WHO headquarters for their contributions and support.
The overall objective of the two TAG meetings and the high-level meeting of ministers of health and education is to ensure that the lives and education of children 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.
Dr Weber reminded the TAG members of their privileges, noting that the TAG can be:
• outspoken when providing advice;
• outspoken in advising against specific interventions and actions; and
• enabled to request the generation of better evidence to be able to consider the direct and indirect impacts of infection prevention and control measures on SARS-CoV-2
transmission and on broader child health and well-being.
As a precursor to TAG 2 discussions, it was noted that the principles of equity would be applied to any advice agreed by members to ensure applicability to the dimensions of age, gender, socioeconomic status and ethnicity.
Dr Weber also noted that the secretariat may schedule another meeting prior to the high-level meeting with Member States on 8 December if, for example, new evidence becomes available that might impact substantively on agreed advice. He expressed the hope that the TAG members would be able give their time.
The following discussions of the main issues on schooling during COVID-19 was moderated by the TAG Chair, Antony Morgan (Glasgow Caledonian University, United Kingdom). The aim was to reach agreement or identify disagreement on the eight key statements derived from evidence presented and discussions in TAG 1 and summarized in the background document prepared for TAG 2.
The Chair requested TAG members to consider each statement in relation to the following three criteria:
• the accuracy of the statement, reflecting the available evidence and discussion during the first TAG meeting;
• whether new evidence had become available since TAG 1; and
• whether there were any omissions.
Given that the emerging evidence is complex, the Chair requested that TAG members, WHO and partners be pragmatic. While advice is needed now, it should be accompanied by explicit
reference to the process and considerations upon which it is based.
Key issue 1. Children and adolescents are not considered primary drivers of transmission of SARS-CoV-2
Studies show that SARS-CoV-2 susceptibility and infectivity rise with age. COVID-19 is reported less frequently in children than in adults in most countries of the European Region.
More outbreaks are reported in secondary and high schools than in primary schools across the Region. Within-school outbreaks that involve only staff members are also observed. Data suggest that children and adolescents are followers, not drivers, of the pandemic, with a slower dynamic in younger children.
Community transmission drives school transmission, and cases in school reflect transmission in the community. 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.
Key issue 2. Pursuant to the above considerations, keeping schools open is a key objective
Given the adverse effects of school closures, they are considered only as a measure of last resort.
To achieve the goal of keeping schools open, adequate public health and social measures should be implemented (new guidance on this has been produced (1)) so that in-school schooling can continue. High-income countries have been closing schools less frequently and reopening them earlier than lower-income countries, a practice that is likely to contribute to widening inequities across the Region in the long run. Under the new interim guidance on considerations for
implementing public health and social measures, the continuity of education for children for their overall well-being, health and safety should be at the forefront of all relevant considerations and decisions (1).
Does the TAG support the above statements? Can advice be issued on this basis?
The TAG requests changes/additions to the statement as follows.
• The two discussed statements should be more nuanced in relation to:
o defining age groups, as the primary and secondary school systems differ in countries across the Region: it should be stated that this advice does not include consideration of university settings;
o transmission in education settings seeming to be limited if effective mitigation measures are in place: these measures need to be differentiated for different age groups, as the comparative value of individual measures is still not known; and o separating community transmission from school transmission.
• A clear statement should be added that there should be no proactive school closures.
• Schools should be the last place to close, as it was learned from the first wave that school closures are detrimental to child mental health and well-being and educational outcomes.
• In primary schools (school settings with children up to 10–12 years of age), a more relaxed approach can be taken, while infection prevention and control measures need to be optimized in secondary school settings.
Discussion
The literature suggests that transmission is low within school settings (2), but no large population-based studies in this area are available currently. Information emerging from the United Kingdom, where two large population-based studies that are testing thousands of people randomly each week are being carried out, suggests that there may be a higher level of
transmission from older teenagers (15–19 years) into households than previously recognized.
This nevertheless does not seem to be linked to the school setting, but rather to activities outside of school. Adolescents’ behaviours outside of schools should be investigated more. Evidence from Germany suggests that while older adolescents may be contributing to community
transmission, those under 15 years are not driving, but following, transmission in the community, with clear time lags observed in incidence rates (3).
It was stated that children and adolescents tend to be less symptomatic cases if infected (it is estimated that up to 80% of cases in this age groups are asymptomatic), but this does not apply evenly across all age groups.
TAG members agreed that the evidence to date suggests that younger school-age children play a limited role in transmission, with adolescents aged between 15 and 19 years not seeming to be much different from young adults. The available data regarding the importance of school settings for transmission in older secondary-school students are contradictory.
Data to corroborate whether there is more transmission from adults to children remain
incomplete. When appropriate mitigation measures are in place, transmission is low in education settings.
Natasha Muscat reiterated the importance of answering the concrete question, how should countries plan for the second semester of the current school year? At what time during
community transmission would the TAG recommend going to blended or full online learning?
She pointed out that decisions need to be taken even if data are incomplete and evidence imperfect.
The TAG agreed that there is no specific rate at which school closures (meaning the switch to blended or full online learning) should be recommended. Rather, the risks and benefits need to be balanced. Risk of transmission should not be the only consideration: the value of keeping schools open should be judged vis-à-vis the health system’s capacity. Proactive and reactive school closures need to be differentiated, with countries advised that there should be no proactive school closures.
At the same time, there is an obligation to implement effective preventive measures to avoid the situation in schools getting worse than that in the community. In-school mitigation measures, especially for secondary schools, should be established as a preventive measure in situations in which levels of community transmission are quite high, as currently is the case in Europe.
Measures should not, however, be applied to the same extent for all ages. Some principles, such as smaller groups and bubbling, can be applied to all age groups, while others, like mask-
wearing and physical distancing, are age-specific.
If the transmission is very high and outbreaks occur in schools, reactive school closures may be considered.
It was stated that observations in many countries of the Region show that morbidity related to influenza and other common paediatric respiratory viruses currently is lower than usual, presumably due to preventive measures employed for COVID-19. The possibility that
respiratory morbidity will rise in the coming winter and spring seasons and cause some overlap with coronavirus morbidity nevertheless cannot be excluded.
Primary and secondary schools in Croatia were open at the time of the meeting. When there is one child with a positive SARS-CoV-2 test, usually the whole class has to self-isolate at home for 10 days, although in some situations, the school doctor or epidemiologist can decide that only part of the class should be isolated.
The TAG should advise on what else needs to be closed in society before schools are closed, as in many instances, politicians would like to close schools first and keep shops, restaurants, cafes and cinemas open.
The TAG agreed that schools should be the last place to close, as it was clear from the first wave that school closures are detrimental to child mental health and well-being and education
outcomes. A more relaxed approach can be taken in primary schools (school settings with children up to 10–12 years of age), while infection prevention and control measures need to be optimized in secondary school settings.
It was noted that an opportunity exists to harness data from natural experiments currently taking place in countries that went into second lockdown but kept schools open. Data should be
gathered rapidly from these countries; Ireland was mentioned as an example.
The results of the school prevalence study in the United Kingdom will be available in early December.
Key issue 3. Testing strategy in the school setting
Testing of all children with possible symptoms is unlikely to be feasible during the coming winter, even in wealthier countries. In certain situations, rapid diagnostic antigen tests might offer some additional possibilities that need to be explored further. It is preferable to establish a testing strategy that focuses on vulnerable groups, children with severe disease, outbreak/cluster prevention and prevention of capacity shortages. In the autumn/winter season, children with respiratory symptoms who are not prioritized for testing should stay at home to recover for five days, the final two days of which should be symptom-free (meaning that if symptoms are apparent on the fourth day but not the fifth, they must stay at home for six days – so they must be symptom- free for at least two days). If they continue to have symptoms on the fifth day, they must get a test.
Routine checks for symptoms and temperature checks of all children and school staff appears not to be useful in controlling the spread of infection in schools and the community (4).
What testing strategies should be recommended in schools? What role could rapid tests play?
The TAG requests changes/additions to the statement as follows.
• Asymptomatic children and adolescents should not routinely be tested with currently available tests.
• There is no evidence available that supports routine temperature or symptom checking in schools. It therefore should be avoided.
• Testing should be prioritized for symptomatic children with acute respiratory infection of any severity if they belong to a vulnerable or risk group or are in special situations with a high risk of further spread.
Discussion
The statement on testing strategy was found to be worded well.
The question of what happens when a child or teacher is tested positive was raised. Who needs to go into quarantine, when (is it when the test is undertaken because SARS-CoV-2 infection is suspected, or when a positive test result becomes available?) and for how long needs to be established. This aspect might be addressed within the context of testing in the school setting or as a separate issue.
The demand or desire for repeated testing of asymptomatic cases will have to be pushed back on the basis that it does not add much information to the epidemiologic picture and cannot be justified on ethical and cost grounds.
The role of rapid tests in school settings remains unclear. It may be useful for symptomatic secondary children and close contacts, but there are concerns about large numbers of false positive cases.
There is no evidence to support routine temperature checking or screening for symptoms in schools. It therefore should be avoided.
The TAG agreed that an explicit statement must be made that the testing strategy needs to reflect realities and testing capacities. It will be important that test results are made available quickly to support contact tracing, as long delays make effective contract tracing impossible and therefore render the test meaningless. Children are being asked repeatedly to self-isolate for having had contact with a suspected case. This has proven to have a detrimental impact on continuity of education and their ability to learn.
The European Centre for Disease Prevention and Control (ECDC) has developed recommendations on the objectives for testing in schools (5).
Key issue 4. Changes in the school environment that are likely to be of overall benefit to infection control AND child health
As investments are being made to improve the overall school environment to enhance infection control, measures that will have an overall beneficial effect should be prioritized. Improvement of health literacy of children through scheduled lessons will help their understanding of the basis of the infection control measures and promote adherence by children, adolescents and school staff. Improvement in school environments in relation to water and sanitation, hygiene facilities, indoor air and smaller class sizes will reduce transmission. The availability of a well trained school nurse helps to ensure interventions are applied and responses to illness and provision of mental health support are available, and can enable young people to be directed to support
services. Investing in active transport to school through walking and cycling reduces exposure on crowded public transport and contributes to physical well-being (5).
The TAG requests changes/additions to the statement as follows.
• The principles of health promoting schools are even more important in a pandemic. The health promoting school network, Schools for Health in Europe (SHE), should be encouraged to take the opportunity to promote sustained improvement in health through schools beyond the COVID-19 crisis, building back better.
• Active promotion of hand hygiene practices in schools, including ensuring the
availability of hand hygiene stations with running water and reliable supplies of soap and towels, should be viewed as long-term educational and health investments.
• Teachers and other adult school staff should be mentioned explicitly in the statement, as it is important to reflect their views, ensure that measures are feasible within their daily context, and empower them to implement infection prevention and control measures while being able to deliver their core functions.
Discussion
The TAG agreed that this statement is well worded and the content is not controversial, as the changes required in the school environment are well established through the health promoting school network.
All measures implemented in schools should support schools to provide education by employing a salutogenic approach1 towards life with the virus and not disturb schooling.
Mental health aspects need to be taken into account. Antonovsky’s approach to mental health was cited as being useful to managing the relationship between stress, health and well-being.
People should be empowered to understand risks and required behaviours and manage what is going on in school, and the measures implemented should make sense to them. Health literacy education should be provided for children, teachers and other staff. Work needs to be carried out across the education and health sectors to support them jointly to support children.
Some transmission prevention measures, such as active promotion/teaching of effective hand hygiene practices in schools and ensuring appropriate supplies and availability of functional hand hygiene stations, can also be viewed as long-term educational and health opportunities.
Some schools consider hygiene as an outdated education topic, meaning attention to it remains low. Investments in this area during the pandemic can help to bring improvements in long-term health behaviours.
Key issue 5. Effectiveness of applied control measures on infection control
There are few studies on potential adverse effects on child health and well-being of infection- control interventions in school, such as limiting contact between children, wearing masks (outside or in classes), closing areas and activities (play, sports, canteens and toilets), increasing ventilation and screening for illness. The interventions need to be evaluated properly and those with little or no effect should not be promoted.
Some interventions currently being adopted have low or no value for infection control – spraying environments with disinfectant, excessive disinfection (rather than cleaning) of surfaces, and excessive handwashing leading to sore hands are examples.
Based on emerging evidence, which interventions would the TAG recommend be stopped?
The TAG requests changes/additions to the statement as follows. The statement should:
• request countries to balance carefully the likely benefits and harms of interventions
• make a clearer distinction between no evidence and evidence of no effect
• list interventions for which there is evidence of no effect, such as temperature screening.
Discussion
Mapping for a Cochrane review is compiling evidence in relation to infection prevention and control measures. Forty-two studies have been identified: most are modelling studies, with only a few observational studies included. The outcomes look mainly at infectious disease control rather than child well-being and the socioeconomic impact of the measures. A draft of the Cochrane review will be available in a few weeks and hopefully will provide more evidence and advice.
1 Salutogenesis is a health-sciences approach focusing on factors that support human health and well-being, rather than on factors that cause disease and related problems (pathogenesis).
The ECDC has just launched a survey about schools and COVID-19 among its Member States, seeking evidence and/or country perspectives on the most effective in-school mitigation
measures. Results are expected in a few weeks.
The TAG believes the statement needs to be nuanced better. A clearer distinction needs to be made to differentiate between no evidence and evidence of no effect. The harms of closing school canteens are evident, but evidence on the adverse effects of mask-wearing is less clear. While there is no evidence that wearing masks is harmful to children, young children should not be asked to wear masks, as the evidence suggests it is ineffective in this group. This is reflected in WHO guidelines on masks in children.
Countries have implemented a number of measures that signal their intention to actively combat transmission, but they do not have an evidence base for their effectiveness. These include measures such as spraying of environments with disinfectants, and closing down toilets, sports facilities and canteens. There are great concerns that these measures are ineffective in the fight against the virus, while at the same time having negative effects on child health and well-being.
All infection control measures have unintended consequences. Some potentially have effects that are more harmful than beneficial. A judgement on benefits versus harms therefore needs to be applied for all measures implemented in schools. The statement needs to state more clearly the need for countries to balance potential benefits and harms.
Evidence for the effectiveness and harms of all measures is not (and will not be) fully available before decisions need to be made, so risk–benefit adjustments need to be considered. The
statement should define those interventions for which there is evidence of no effect or of harmful unintended effects.
Key issue 6. Educational outcomes, mental and social well-being
Control measures frequently have adverse effects on educational outcomes, mental health, social well-being and health-related behaviours. The positive and negative effects should be considered carefully. Studies currently are sparse, and all measures should be re-evaluated as evidence arises, with a special focus on equity. Present evidence suggests that learning loss due to lockdown, school closures and even distance learning is several times higher in the most deprived schools than in less deprived schools.
How can the differential impact of school closures be avoided? What additional measures could be taken in areas of higher deprivation?
The TAG requests changes/additions to the statement as follows.
• The Chair and secretariat should consider whether the statement should be merged with the previous statement or be better linked.
• When closing schools, countries must guarantee access to devices required for online learning, including functioning Internet connections.
• Countries should establish hotlines for children and adolescents seeking psychological support.
• The statement should include reference to evidence suggesting that staying at home leads to higher levels of violence against children
Discussion
Evidence that staying at home means increased levels of violence against children should be added to the statement.
There is ample evidence, particularly from the United Kingdom and United States of America, that more children are experiencing food insecurity due to lack of school meals.
Key issue 7. Children in vulnerable situations
Children in vulnerable situations are disproportionately affected by control measures. In addition to education, schools provide critical services for children, such as childcare and nutrition
through school meals. Absence of access to these services can put additional financial burdens on households, especially for the most vulnerable. Parents and caregivers take on additional responsibilities as children learn from home and those who need to earn an income are less able to do so.
What additional measures should be considered to further protect children in vulnerable situations?
The TAG requests changes/additions to the statement as follows.
• An equity lens needs to be adapted and applied across all statements.
• A clear distinction has to be made between children defined as living in vulnerable situations because of their socioeconomic situations and children with an individual risk factor for severe disease, such as those who are immunosuppressed (due to for example, treatment for cancer) or have severe chronic respiratory illnesses. Children per se do not comprise a vulnerable group in relation to COVID-19.
• A clear statement on additional support for schools in deprived areas and children living in vulnerable situations should be added.
• An additional statement around implementation considerations should be drafted, or implementation considerations should be added to each of the key issues.
Discussion
A triple burden of the COVID-19 epidemic on children and adolescents in vulnerable situations was described:
• SARS-CoV-2 transmission is higher and outbreaks are more likely to occur in areas of deprivation, and schools in these areas are less likely to be well resourced to reopen and stay open;
• children in these areas are more likely to suffer from the negative effects of school closures; and
• members of households in deprived areas are more likely to be infected and experience worse outcomes when infected.
Due to this triple burden, schools in these areas need more support to open and stay open safely.
Increased rates of child maltreatment and violence have been reported during lockdowns.
Schools play an important role in identifying children who have been exposed to maltreatment and violence, so school closures mean that support staff and social workers are unable to access and support children in need. According to surveys in Finland, 8% of teachers have been unable to make any contact with some of their learners during the school closures.
When it is necessary to switch to hybrid schooling or full online learning, children’s situations should be taken into account. An on-site option providing not just supervision, but also learning, should be provided for children living in vulnerable situations, similar to options offered to the children of essential workers (children of staff working in hospitals, for example, were provided with schooling or daycare during the first lockdown to allow parents to keep working). Living in a vulnerable situation (and lack of equipment at home) should be among the criteria used to determine which children should be allowed to be physically present in schools when hybrid schooling or full online learning have been activated.
From the medical point of view, all children, with the exception of those with
immunosuppression, severe chronic respiratory illnesses or other major risk factors, should be in schools, as they are not at increased risk of contracting COVID-19 disease. It is important to secure intensified or special support for children with learning difficulties.
Implementation of recommended interventions is often not working well even when the
guidance is clear and based on sound evidence, so a statement on implementation considerations should be added.
Key issue 8. Children’s and adolescents’ involvement in decision- making
Children have different experiences of home-schooling, 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. Pupils from less advantaged
backgrounds have reported that online learning is not being delivered effectively. Young people from different age groups and all backgrounds should be asked to provide their perspective on the measures affecting them.
How can young people be better involved in decision-making?
The TAG requests changes/additions to the statement as follows.
• The statement should urge Member States to recognize children’s and adolescents’
perspectives and give weight to their voices in relation to this topic and beyond.
• The Chair/secretariat should consider moving this key issue to the beginning to emphasize its central importance.
Discussion
The three youth representatives of the TAG (aged 15, 16 and 17 years), who currently are enrolled in high school, provided a short update on a youth-led survey they are running in a number of Member States to learn about children’s and adolescents’ experiences of online schooling and the different infection prevention and control measures implemented in school.
So far, 300 responses to their survey have been received. The other TAG members and WHO are requested to promote the survey through their channels and networks (links to the survey are shown in Table 1). A Word version is available in case networks include children without access to the Internet.
Table 1. Youth survey links
Language Link
Danish https://forms.gle/6CEv96gSheg6F7289 English https://forms.gle/fPh4bQjHBb5P65rM8 German https://forms.gle/xUm25DnaiHK4JMCW6 Greek https://forms.gle/hjoR74nmmjF4dbhb9 Russian https://forms.gle/N7sCw8QrVtq7yehHA
The youth representatives reiterated that the main way of involving children their age in decision-making is to provide them with a platform from which to be heard and giving them a louder voice. They reflected on the discussion and outcome of the meeting and stated that as long as any pub or shop – except for grocery stores or pharmacies – is open, schools must be open.
While sound evidence, ideally based on randomized controlled trials and case-control studies, is needed to support recommendations, children and adolescents can describe how they feel now and what would make them feel better – for instance, would they rather go to school with masks on or stay at home? The survey aims to provide some answers on these issues.
The youth representatives also put together video messages from school students across the European Region. They noted that while there were some positive voices about more
independence, autonomy and maybe a sense of adventure during the first lockdown, the situation now is that some, particularly older students who are working towards their final high-school exams, are getting more and more worried about not being able to catch up; they fear another lockdown and feel insecure about the future.
Next steps and closing
Antony Morgan concluded that the TAG agreed with the directions and did not reject any of the statements. It requested better nuancing of some of the statements (in relation to, for instance, different age groups and the difference between no evidence and evidence of no effect), additions to other statements (such as implementation considerations) and stronger wording in some places (around vulnerable groups/children in vulnerable situations and those in different age groups, for example). The secretariat and the Chair will work on revising the statements according to the outcome of the meeting, also taking into account information provided by participants through the ZOOM online chat facility and assessing the statements within an equality framework. It will be necessary to learn from practice in real time as the situation is evolving rapidly.
Natasha Azzopardi-Muscat thanked the TAG members and the Chair for having shared their views in a constructive, open and frank manner. The secretariat will make sure that all inputs from the TAG are reflected in the statements and will revert with a meeting report and a revised draft of the key statements.
The high-level meeting with Member States on 8 December will advocate for schools remaining open as long as possible and for a balance to be struck between the risks and benefits of
implemented infection prevention and control measures based on available evidence. It will be important to stress that this is work in progress and the advice will need to be updated
continuously as more evidence becomes available, but in the meantime, we need to steer the response and proceed on the basis of what we know. In preparation for the high-level meeting, the secretariat may schedule another meeting if new evidence becomes available, and expresses the hope that the TAG member can make available their time.
Natasha Azzopardi-Muscat thanked the TAG again for their time and closed the meeting.
References
21. Considerations for implementing and adjusting public health and social measures in the context of COVID-19. Interim guidance. 4 November 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/considerations-in-adjusting- public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance).
2. Suk JE, Vardavas C, Nikitara K, Phalkey R, Leonardi-Bee J, Pharris A et al. The role of children in the transmission chain of SARS-CoV-2: a systematic review and update of current evidence. medRxiv 2020. doi:https://doi.org/10.1101/2020.11.06.20227264 (https://www.medrxiv.org/content/10.1101/2020.11.06.20227264v1.full.pdf).
3. Otte Im Kampe E, Lehfeld AS, Buda S, Buchholz U, Haas W. Surveillance of COVID-19 school outbreaks, Germany, March to August 2020. Euro Surveill. 2020;25(38):2001645.
doi:10.2807/1560-7917.ES.2020.25.38.2001645.
4. Screening K-12 students for symptoms of COVID-19: limitations and considerations. In:
Centers for Disease Control and Prevention [website]. Atlanta (GA): Centers for Disease Control and Prevention; updated 16 November 2020
(https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/symptom- screening.html).
5. Objectives for COVID-19 testing in school settings – first update. 21 August 2020.
Solna: European Centre for Disease Prevention and Control
(https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-objectives-school- testing.pdf).
6. Considerations for school-related public health measures in the context of COVID-19.
Annex to considerations in adjusting public health and social measures in the context of COVID-19. 14 September 2020. Geneva: World Health Organization; 2020
(https://www.who.int/publications/i/item/considerations-for-school-related-public-health- measures-in-the-context-of-covid-19).
2 All weblinks accessed 18 November 2020.
Annex 1
List of participants
Temporary Advisers (Members of the TAG) Bruce Adamson*
Children and Young People’s Commissioner Scotland Edinburgh
Scotland Efrat Aflalo Ministry of Health Israel
Freia de Bock*
Head of Department Effectiveness and Efficiency of Health Education German Federal Agency of Health Promotion
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, UK
Colette Kelly
School of Health Sciences, College of Medicine Health Promotion Research Centre (HPRC) NUI Galway, Ireland, UK
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
Leena Paakkari
Research Center for Health Promotion University of Jyväskylä
Finland Peter Paulus
Leuphana University Luneburg
Germany 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 Livia Stoica
Secretary
Steering Committee for the Rights of the Child (CDENF)
World Health Organization
Headquarters Anshu Banerjee Director
Maternal, Newborn, Child & Adolescent Health & Ageing 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
Josip Figueras*
Head
European Health Systems Observatory 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 Oliver Schmoll
Programme Manager Water and Climate
Policy and Governance for Health and Well-being 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 Sampreethi Aipanjiguly
Communication Officer 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
First meeting of the
Technical Advisory Group on Safe Schooling During the COVID-19
Pandemic
Copenhagen, Denmark
26 October 2020
Evidence on the impact of school closures on children and the effectiveness of infection prevention and control 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. 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
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CONTENTS
Page
Disclaimer ... iv Acronyms ... v 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
Disclaimer
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.
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
Opening and introductionThe 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.
