Victoria and NSW schools are reopening amid Covid outbreaks – what can be learned from overseas?

Experts say there are important lessons for Australia in order to reduce the rate of transmission and hospitalisation

As Victoria and New South Wales prepare to reopen schools for face-to-face learning, experts who have studied the experiences of other countries are warning that not all lessons have been learned, particularly on mask-wearing and ventilation.

NSW, which has about 5,500 active cases of the virus, and where 75% of the eligible population over the age of 16 are fully vaccinated, is preparing for students in kindergarten, years 1 and 12 to return to school on Monday.

The remaining grades will return the week beginning 25 October. Only fully vaccinated teachers will be allowed back. Only high school students will be required to wear masks.

In Victoria, once the lockdown is lifted, all children in year 3 and above will be required to wear masks indoors. This is already in place for regional schools that have returned to face-to-face learning. Masks indoors at school are strongly recommended but not compulsory for children in prep to year 2.

Victoria’s more stringent rules for children prompted the NSW deputy premier, Paul Toole, to tell Sky News on 9 October that the decision was “crazy”.

“I don’t really see the point of that – it’s really going to be constricting those children in that state,” he said.

But a paper published this week in the Proceedings of the National Academy of Sciences, which studied the impact of US school reopenings on Covid cases, found widespread mask-use mitigated risk of community spread.

The case for masks

The study analysed a year of data in nearly 15,000 school districts before the Delta variant emerged and found that, even then, reopening schools with in-person learning was associated with increased cases and death rates, particularly in counties that did not require staff or children to wear masks.

It is difficult to compare countries due to differences in vaccination rates, public health measures, virus case numbers and populations, but a co-author of the study, Prof Hiroyuki Kasahara from the Vancouver School of Economics, says there are important lessons for Australia.

Workers conduct a deep clean at a public school in Sydney.
Workers conduct a deep clean at a public school in Sydney. Photograph: Joel Carrett/AAP

“With the Delta variant, mitigation measures are even more important for safe school openings, not only for stopping community transmission but also for stopping children from being hospitalised,” Kasahara says.

“With the Delta variant, more and more children are hospitalised in the US and elsewhere after school opening.

“Many adults think that putting masks on five-year-olds is difficult but, in many countries, five-year-olds put their masks on without any problems. Some argue that putting masks on such a young child may have a negative psychological impact or prevent them from learning languages, but think about the fact that 140,000 US children lost their parents or caregivers because of Covid.

“The cost of implementing mask mandates on young children is low relative to its benefits, or the alternative cost of risking parents or children themselves getting hospitalised.”

In the Canadian province of British Columbia, the government put mask mandates in place for grades 4-12 when schools reopened, but not for kindergarten to grade 3.

“Now, because the cases among schoolchildren are rapidly rising, the British Columbia government decided to implement mask mandates on K to grade 3,” Kasahara said. “Many governments use this ‘wait and see’ approach before implementing mask mandates on young children, but fewer people would have been hospitalised or died if they had implemented it from the start.”

Ventilation and vaccinations

Vaccinating all staff is also critical to mitigating spread, Kasahara says. In Victoria, vaccinations are required for education workers, while in NSW, school-based education staff have been given priority access to vaccinations.

There is also accumulating evidence that good ventilation with high efficiency Hepa-filters helps prevent Covid-19 spread. A UK study found airborne spread of the virus was detected in a hospital ward on all five days before activation of air filtration, but on none of the five days when the air filter was in operation.

From the start of term four, 51,000 air purification devices are due to be rolled out to all government and low-fee non-government schools in Victoria. In NSW, a petition has been launched calling on the state government “to take immediate action to ensure adequate ventilation is installed and maintained in primary schools”.

OzSAGE, a multi-disciplinary network of health and scientific experts, has urged the NSW education department to follow Victoria’s lead and “learn from the successes and failures” overseas.

Students wait to receive the Pfizer vaccine for Covid-19 at Qudos Arena in August.
Students wait to receive the Pfizer vaccine for Covid-19 at Qudos Arena in August. Photograph: Getty Images

In a statement, OzSAGE said: “In San Francisco, through near universal mask use in schools and by providing safe indoor air, there have been very few instances of in-school transmission this year. On the other hand, in England, where neither masks nor safe air are routine in schools, and where vaccination was not recommended for 12-15 year olds until September and then limited to only one dose, 8% of school children were infected with Covid-19 within two weeks of the start of term.”

Kasahara says schools must also maintain good hygiene and physical distancing, and health departments should not abandon contact tracing efforts when a case emerges in a school.

“The risk of getting Covid differs across individuals,” he says. “Some are living with the elderly and others are immune compromised. Prompt exposure notice allows each parent to make their own decisions on sending their kids to school. Related to this is to make it easy for children to miss their classes, so no penalty [should be] associated with missing classes and [they should be offered] possible online options.”

Making testing easier would reduce risk further, Kasahara says.

“If parents have easy access to rapid antigen tests, then they can test their children when they have symptoms and may prevent them from transmitting to others when they are positive.”

In Victoria, rapid antigen testing will be rolled out across the healthcare system first, before other high risk settings, such as schools, childcare and corrections, are added to the program. The tests will be trialled in some Sydney schools.

Rapid antigen testing will be available for home use from November, though experts warn they are sometimes not as accurate as the traditional PCR nasal and throat swab tests.

The rise in cases

Dr Nusrat Homaira, a senior lecturer and paediatric respiratory epidemiologist at the University of NSW, says Australian schools and health systems have adopted many of the strategies found to be most useful overseas. She points out that NSW is reopening schools with a much higher background vaccination rate and lower overall number of cases than most other countries.

Israel, for example, reopened schools while still reporting more than 10,000 cases a day, but did not open high schools where fewer than 70% of students were vaccinated. About 250,000 children were kept home on the first day of reopening in September due to being infected with the virus.

In the US, the number of paediatric cases in hospital has hit new highs. But public health measures differ greatly between states, and there is a higher background rate of cases than in Australia. In the US 57% of those age 12 and above are fully vaccinated, but this varies widely between states. Even with rising cases in the US, hospitalisation rates among children with Covid have remained steady at about 2%.

Most children diagnosed with Delta in New South Wales experienced mild or no symptoms, with similar numbers – about 2% – requiring hospital treatment, the latest report from the National Centre for Immunisation Research and Surveillance says.

But not all of those in hospital had a serious illness, Homaira says.

“At Liverpool Hospital, we converted hospital wards into home units for children with Covid to stay in if their parents were in hospital with Covid, because there was no one else to take care of the child,” she says. “That happened a lot, it wasn’t necessarily that the child was severely unwell.”

Homaira says it is important for vulnerable and high-risk caregivers of children to get vaccinated, but that “children are more likely to pick up the infection from adults than the other way around”.

“I think we do anticipate as the vaccinated population come in contact with the unvaccinated population as we open up our schools, there’s going to be a rise in cases.

“But we are opening up at a much better stage than most other countries, with 76% of the eligible population fully vaccinated in New South Wales [78% as of Friday]. That’s a very impressive number. So I wouldn’t say that any rise in cases from schools opening is going to be as alarming as elsewhere.”

Contributor

Melissa Davey Medical editor

The GuardianTramp

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