Schools Pathway for Covid-19, the Public Health approach
Paper prepared by the Office of the Clinical Director, Health Protection, HSE.
24 Aug 2020
There are almost 1 million students attending educational facilities in the primary and post primary sectors, across approximately 4,000 schools, in which close to 100,000 staff are employed1.
The importance and significance of ensuring educational facilities safely open to pupils, and remain safely open for pupils and staff, is acknowledged across society and supported within the Public Health Medical community and the health services at large. Educational facilities are communities providing for not only the educational needs of pupils, but also many of their holistic, health and pastoral needs. It is a setting whereby social interaction and physical activity can be learned and occur in a place of safety, support and warmth.
It is important to note that in the months since the Covid-19 pandemic has occurred, we have learned that2:
- Children seem more likely than adults to have no symptoms or to have mild disease. Symptoms in children include cough, fever, shortness of breath, sore throat, anosmia, ageusia or dysgeusia
- Investigation of cases identified in school settings suggest that child to child transmission in schools is uncommon and not the primary cause of Sars-CoV-2 infection in children, particularly in preschool and primary schools
- Children are rarely identified as the route of transmission of infection in to the household setting
- Children are not more likely than adults to spread infection to other
- There are some recent reports that the virus that causes Covid-19 infection may trigger a rare inflammatory disease, Paediatric Inflammatory Multisystem Syndrome, in some children. International research in to this rare disease and its association with Covid-19 is
Both ECDC2 and PHE3 have recently reported that investigations of cases identified in school settings suggest that child to child transmission in schools is uncommon and not the primary cause of SARS- CoV-2 infection in children whose onset of infection coincides with the period during which they are attending school, particularly in preschools and primary schools. PHE recent research identified that most secondary cases identified within school settings were through staff to staff transmission. This highlights the absolute importance of staff being symptom aware, exposure aware, complying with all distancing and hygiene measures amongst adults, in both the class room and transit / break times. Onwards transmission between students was responsible for the least number of cases in their outbreaks.
Schools are a core part of local communities, therefore it is a community endeavour to keep schools open and pupils, staff and communities safe. It is crucial that all staff, pupils and their families follow
- 1 The Department of Education ‘Roadmap for the full return to school’ https://www.gov.ie/en/publication/b264b-roadmap-for-the-full-return-to-school/
- 2Covid-19 in children and the role of school settings in Covid-19 transmission, ECDC 2020
- 3SARS-CoV-2 infection and transmission in educational settings: cross-sectional analysis of clusters and outbreaks in England PHE
national public health advice, within and outside the school setting, and consider carefully their activities and risk exposures, to ensure the opportunity for infection with Covid-19 and spread within our own communities is minimised. The lower the rates of community infection, the less likely we are to experience significant cases, concerns or outbreaks in the school setting.
Prevention and Protection within school settings
Guidance for the re-opening of educational facilities has been provided across a range of forums including:
- The Department of Education ‘Roadmap for the full return to school’
- The HSE / HPSC Covid-19 ‘Interim Recommendations for the re-opening of schools and educational facilities’
- The HSE / HPSC Covid-19 ‘Infection Prevention and Control guidance for Early learning and care and School Age childcare settings during the Covid-19 pandemic’
The above guidance provides robust advice to educational facilities on prevention and awareness measures necessary and recommended for the safety of staff and pupils in relation to Covid-19.
Implementation of these measures will minimise the risks for all pupils and staff with respect of Sars- CoV-2 infection. Schools should adapt and customise these recommendations for their own particular settings, adhering at all times to the principles involved.
Potential case of Covid-19 in an educational facility
It is inevitable that with confirmed cases of Covid-19 circulating within the community, there will be suspect or confirmed cases amongst pupils and staff attending, or working within, educational facilities.
However, children will also continue to display symptoms of many other circulating respiratory viruses. It is known that young children often have a persistent cold.
Children with a blocked or runny nose, but no fever can attend school or childcare, but if they require paracetamol or ibuprofen for their symptoms, they must not attend school for 48 hours and GP assessment for testing is indicated.
If a child develops a fever and symptoms such as outlined in HPSC guidance whilst in school:
- They should be immediately isolated in a pre-identified place within school, with good ventilation and preferable an outside window
- The school should contact their parent or guardian and ask them to collect their child as soon as
- The child should be cared for appropriately by a staff member whilst they are waiting to go home.
- The staff member should wear a mask. Use of gloves is not essential, but staff members may wish to use them. If a staff member has helped someone with symptoms, it is essential they
avoid touching their nose, mouth or eyes whilst caring for them, and undertake hand hygiene.
- If any child presents extremely unwell, from whatever potential cause, 112 and an ambulance should be called. NB we do not expect this to happen in relation to Covid-19.
- After the isolation space in vacated, it should be cleaned and contact surfaces disinfected. The staff member assisting with the child does not need to go home unless they develop symptoms themselves, or are later advised to by public
Schools do not need to inform parents that a pupil or teacher has been removed due to their symptoms. Other pupils or staff do not need to be removed from class. HSE Departments of Public Health will take action if the person has confirmed Covid-19 infection on testing, which will include HSE advice and guidance on communication to school pupils and staff where needed.
The parents / legal guardian of the sick child should contact their GP as usual, to discuss clinical concerns. If it is determined by the GP that the child/pupil requires to be tested for Covid-19, any other household contacts should be removed from the school setting.
It is vital that schools have current lists of staff and pupils, by classes with contact telephone numbers for parents and guardians. These should be in excel and ready to share with Department of Public Health, if required and requested under Infectious Diseases legislation, 1981, as amended.
Covid-19 Assessment and testing pathway for younger children (≥3 months – 13 years) and older children (≥ 13 years old)
Once the child has been collected from school, the parents should contact their GP by phone if the child has symptoms of concern, and/or symptoms consistent with Covid-19 infection e.g. fever OR a new cough, shortness of breath, deterioration of existing respiratory condition OR symptoms of ageusia or dysgeusia.
Their GP will assess and advise as per normal clinical practice and refer for testing as required and outlined in here. Testing is advised for any child who meets the testing criteria unless there is a strong clinical reason to do otherwise. For children aged greater than or equal to 13 years of age or who attend secondary school, please refer to the adult testing guidance here.
The Covid-19 Assessment and decision making pathway for all children greater than or equal to 3 months until completion of primary school should be used to guide next steps here.
Covid-19 test results remain confidential as per doctor – patient relationship. No other child, parent, family or teacher will be informed of their results. However, parents should be advised at the point of testing that their child’s swab test result if Covid-19 detected will likely need to be shared with the educational facility, if this is deemed necessary by the Medical Officer of Health, for the safe management of any potential outbreak. Only details as necessary for safe onward management are shared with an agreed senior person in the school, such that appropriate public health actions can be undertaken.
Covid-19 Test Results
Covid-19 not detected result
If a symptomatic child has a Covid-19 ‘not detected’ result, the child should remain at home until he/she is clinically well enough to return to school, unless parents are specifically asked by HSE Public Health for their child to remain excluded because of other investigations e.g. if the child is a known close contact of a now confirmed case.
All diarrhoea symptoms need to have been resolved for 48 hours prior to return to school.
Confirmed cases of Covid-19
Confirmed cases will be contacted directly by the contact tracing centres and case information and contact identification will be initiated. The case will be referred to the Medical Officer of Health within the regional Public Health Department, for onward Public Health Risk Assessment (PHRA) and management in this setting.
The Medical Officer of Health (Consultant in Public Health Medicine, MOH), and teams will liaise directly with the school and inform them of the confirmed case as necessary; will undertake a Public Health Risk Assessment to inform any further actions and recommendations by the Medical Officer of Health.
The MOH has statutory responsibility (Appendix 1) under the Infectious Diseases regulations, 1981, as amended to investigate and manage infectious disease sources2
1 “On becoming aware, whether from a notification or intimation under these Regulations or otherwise, of a case or a suspected case of an infectious disease or of a probable source of infection with such disease, a medical officer of health, or a health officer on the advice of a medical officer of health, shall make such enquiries and take such steps as are necessary or desirable for investigating the nature and source of such infection, for preventing the spread of such infection and for removing conditions favourable to such infection.”
Public Health principles for management of outbreaks, or potential outbreaks, and aligned testing strategy within the educational facility
- Public health will urgently discuss with the school to establish any appropriate exclusions,
i.e. advice to isolate for identified staff or students and to remove from school setting based on an informed Public Health Risk Assessment.
- Core to the PHRA will be assessing the likelihood of onward transmission from the case identified. This will inform their further
- Every facility will be unique in how the schools are organised and therefore the risks associated within them will be unique too e.g. special educational needs settings, primary, secondary and boarding schools will all have very different environments, and will need to be assessed separately.
- HSE Public Health will assess whether the index case is also likely to be the primary case within the school setting or a secondary case. They will assess the likelihood of onward transmission from the case identified. This will inform their further.
- The definition of close contacts within the school setting will be variable. It will not be automatically assumed that a whole class will be deemed as close contacts. This is because the school settings are so varied e.g. in young primary school children, ‘pods’ will likely be deemed close contacts and all removed. In secondary settings where there is social distancing rather than a ‘pod’ per se, close contacts will be determined by proximity and interaction with the index case; class placement; classroom structure; common travel; social networks and friendship groups.
- Close contacts will be identified following PHRA and engagement with the school and removed from the school setting. They will be tested as per national contact guidelines (Day 0 and 7) and they should be advised to restrict their movements and remain alert for symptoms, as per national
- Onward testing strategy will be determined by information from the initial risk assessment. There is no blanket policy to test entire classes or years. The strategy will be determined after risk assessment of the confirmed case, considering the likely source of infection and the likely potential for onward transmission of infection within the school
- The risk assessment may be dynamic and change as new information becomes
- The testing strategy may evolve as information
- There may be other community close contacts who will also be excluded from the school but because of their community exposure NOT their school exposure e.g. siblings / cousins etc
- Depending on results from testing, or following initial PHRA, the MOH may recommend wide spread swabbing within a class or a facility under HSE mass testing
- Whether all students from a class / year are removed whilst undergoing testing, or whether remain in school, will be determined by the risk assessment. Drivers of removal are as per attached drivers for partial school
- An Outbreak Control Team may be called as appropriate, and to assist the Medical Officer of Health in the investigation and control of Covid-19 cases and
- A general outbreak plan for Covid-19 outbreaks can be found here
- ACTION FOR SCHOOLS
To inform the public health risk assessment and to manage cases and outbreaks and identify relevant contacts, schools should have prepared a summary outlining the below ready to give to the Medical Officer of Health as part of the statutory investigation and management of Covid-19.
- a brief description of the school (type, numbers of staff and students and special features) pertaining to the schools
- A list of staff and students with appropriate contact telephone numbers
- Prepare a broad description of classrooms
- An outline of the staff and students movements around the school, between lessons and breaks
- A list of ‘pods’ and ‘bubbles’ should be kept up to date
Consideration of the need for full, or partial, educational facility closure
If there are concerns regarding the need for closure, or partial closure, of an educational facility, these will be discussed by the MOH in conjunction with the educational facility, and as part of local outbreak control teams within the Departments of Public Health. Any decision to close, or partially close, an educational facility will be based on the best approach to control the spread of Covid-19 and allow opportunity to remove the conditions favourable to such infection, as deemed necessary and appropriate by the MOH. In the evaluation of the need for closure of any educational facility affected by any outbreak of infectious disease, the standard Public Health approach is to utilise a Risk Assessment model. This enables the most accurate and effective determination of the likely health impacts of a range of possible interventions, ranging from exclusion and testing of a small
group or ‘pod’ of pupils, up to and including closure of an affected facility. The actual criteria used by an MOH, may be modified in the light of local conditions or specific local information, which informs the Public Health Risk Assessment (PHRA) required to provide for sensible and safe decisions regarding closure and, by extension, reopening of an educational facility.
There are marked differences in educational facilities spanning age (from 5-18 years), and the behavioural and medical needs of pupils attending the educational facilities. Establishing these facts will focus the PHRA undertaken by the MOH and their teams. It is unlikely that a single issue (or
single case of Covid19) would automatically lead to a decision to close an educational facility, although multiple cases across the facility setting will increase the likelihood of school closure.
Public Health Risk Assessment (PHRA)
Regional Departments of Public Health will undertake a PHRA to explore the following:
- unique information and factors relevant to that particular educational facility and its infrastructure, with regard to infection transmission
- interactions of the community of pupils and teachers both within the school and how they interlink within the wider community
- patterns of infection within the wider local community and
- consider general community infection rates in the regions serviced by the educational facility
This information will inform the decisions regarding the need for full, or partial, closure of any educational establishment, or any control measures to be immediately implemented short of actual closure. A range of issues (e.g. multiple cases in different classes) may lead the Medical Officer of Health, in conjunction with any relevant Outbreak Control Team (OCT), to decide that maintaining an open facility will present ongoing risk to staff, pupils and the wider community above which that is acceptable. Also keeping a school open may not allow for the adequate control of the spread of infection or adequate removal of the conditions favourable to infection.
Criteria for closure (Full or partial)
Criteria to be ordinarily considered with regard to any potential outbreak and educational facility closure, or partial facility closure, include but are not limited to:
- Evidence or clear concern that spread within the school is the primary driver of cases, or suspect cases, notified. This is as opposed to spread of infection externally within the community setting (e.g. within households where children / teachers live etc)
- The numbers of, or rate of increase of, Covid-19 detected cases amongst staff / pupils is concerning
- The number and complexity of staff and pupil family units and structures within the educational facility setting amongst those as either cases, contacts or suspected cases e.g. teacher with several children / close cousins in the educational facility all across different years
- The severity of cases (e.g. hospitalised) amongst children / staff is atypical and giving rise to concern e.g. several hospitalisations amongst children who would be pre-morbidly well
- Physical structure or layout of school which limits the range or adequacy for any increased recommended prevention measures e.g. further social distancing implementation within pods or groups, more specific recommendations relating to hygiene or cleaning measures
- Age group or ability of students e.g. if it is an educational facility or unit caring and educating pupils with specific medical or behavioural needs. This may compromise the ability for staff and pupils to realistically comply effectively with requirements for symptom awareness, and disease transmission prevention recommendations during an outbreak
- Inability to undertake enhanced infection, prevention and control measures as might be recommended from identification of transmission risks within the setting of concern e.g. due to nature of toys or equipment required, particularly for educational facilities or units for children with behavioural or physical needs and limitations
- Concerns regarding engagement with public health medical teams of senior personnel within the educational facility or system, with regard to their understanding of, or commitment to, implement sufficient risk mitigation and infection prevention and control measures as identified as necessary for the particular educational setting, in light of confirmed or suspect cases of Covid-19
- Evidence that the pupils (and families) / teachers are not adequately participating in recommended control measures e.g. not reporting and excluding children with mild symptoms; re-enforcing training and implementation of social distancing and hygiene measures across the continuum of school and home etc
- Any evidence that significant spread in wider local community can be shown, or be highly suspected of being linked or intertwined with the educational facility setting
- Results from any swabbing recommendations identified a large number/high proportion of asymptomatic cases, particularly amongst groupings or pods not previously considered to be at high risk of infection transmission
- Inability of the educational facility to safely operate as per e.g. legal requirements for staff : pupil ratios if partial closure was being considered
In all Public Health investigations, in which closure of an educational facility affected by any infectious disease outbreak is being considered, the criteria guiding closure will broadly provide the criteria for reopening. However, outbreaks are dynamic, and in the course of the investigation new risks may be identified and therefore new parameters required to be included for criteria to re-open or allow for full staff / pupil return. A list of the agreed criteria for closure (involving for example, high levels of disease, the requirement of decontamination to a level that meets with the approval of the MOH, (OCT), the compliance of management and staff etc), will form the basis for the criteria to guide reopening. It would only be when all these criteria, and any additional identified in the process of investigation have been satisfied, that a decision on reopening, or full return of staff / pupils would be made by the MOH.
As a result, each educational facility Covid-19 outbreak will be assessed on an individual basis and a unique decision made as to whether it is safe for the facility to remain fully or partially open, or whether closure is necessary.
It should be noted that Medical Officers of Health and their teams do not have powers of inspection.
There is significant interest across the public and political domain with regard to Covid-19 and educational facilities. Decisions on the need to exclude any pupils, test pupils, close, or partially close any educational facility are undertaken by Medical Officer of Health, informed by a robust Public Health Risk Assessment.
Clearly there is much evidence evolving about education facilities – it will, therefore, be a dynamic process and this is appropriate