About the document

This document has been prepared by the COVID-19 response coordination group of AddressHealth, India’s leading provider of health services to schools. The members of AddressHealth’s COVID-19 response coordination group are:

• 1. Dr Anand Lakshman, Public Health Expert
• 2. Dr Swati Hawaldar, Health Education & Communication Expert
• 3. Dr Deepa Paduvary, Consultant Pediatrician
• 4. Dr Harikah P.P. Consultant Pediatrician
• 5. Dr Anoop Radhakrishnan, Management Expert
• 6. Ms Sunitha Chander, School Nursing & Nursing Management Expert

Acknowledgement:

AddressHealth would like to acknowledge COVID-19-PHC Action Group, a voluntary group of public health researchers, practitioners and experts1. They have released a preparedness checklist for Community Health settings in India in the COVID 19 context which formed the basis of a similar document - COVID-19 PREPAREDNESS CHECKLIST FOR SCHOOL SETTINGS IN INDIA which was circulated to schools earlier. The current document is a follow up of the same based on the the most recent evidence and available guidelines.

Purpose of this document:

This document outlines the general principles that schools will need to follow as they begin the process of reopening depending on the Government guidelines for the same. It is based on the current available evidence and guidelines. The typical reader of this document is managing a school, especially a school run by a private trust/ society. We have kept in mind the typical private school setting in urban India. Please feel free to reach out to AddressHealth by email (info@addresshealth.com) or by phone (9901700088) for any clarifications or suggestions. 

It is intended to address periods, where schools have been allowed to be kept open by public health authorities, but are at risk of short to medium closures. It doesn’t address issues such as learning deficits and outcomes and strategies to overcome them. Also it is meant to supplement not replace any latest Government of India guidelines related to COVID 19 which are likely to be announced in the coming days, with which the schools must comply.

AddressHealth intends to update this document, as and when new guidelines are issued at the national or international level, or scientific evidence emerges, which has an impact on these guidelines. Please email us (info@addresshealth.com) or call +91-9901700088 for any inputs or clarifications.

Background

Our understanding of COVID 19 has increased compared to when the virus was first detected in Dec 2019. We now know that COVID 19 can spread through air especially in poorly ventilated closed spaces in addition to droplets expelled by an infected person and through contaminated surfaces. Also, the risk of infection by touching a contaminated surface is low.2 New variants of the virus have emerged as the virus keeps changing constantly.

COVID 19 vaccines are now available, and the Government of India aims to vaccinate the entire adult population above 18 years of age by the end of the year 2021. Vaccine trials for children are also in the final phases and COVID 19 vaccines for children are likely to be available very soon.

The fourth ICMR nation- wide serosurvey results showed that two third of Indians above the age of 6 had antibodies to COVID 19.Its findings are significant because this is for the first time children aged 6-17 years were included in the national serosurvey. Also this is an increase from the previous similar serosurveys results - 0.7 percent during May-June (2020); 7.1 percent during August-September (2020); and 24.1 percent during December-January (2020-2021)3

The current evidence suggests that children and adolescents can be infected with COVID 19, but they are less likely to be symptomatic and less likely to have severe disease. Further opening schools c, particularly when guidance outlined by the World Health Organization (WHO),United Nations Children’s Fund (UNICEF), and Centers for Disease Control and Prevention (CDC) is followed.4 

Despite all the above, schools will have the enormous responsibility of ensuring the safety of students and staff and mitigating the spread of COVID 19 to the maximum extent possible once they reopen.

Further we must acknowledge that we can reduce the risk of COVID 19 in schools but cannot completely eliminate it.

General Principles for Safe Reopening of Schools

• Practise the following key prevention strategies5 to the maximum extent possible
  • 1. COVID 19 Vaccination (for all teachers and staff and all vaccine-eligible family members living with the students)
  • 2. Universal, correct, and consistent use of masks
  • 3. Improve ventilation
  • 4. Physical distancing
  • 5. Testing for COVID 19
  • 6. Handwashing and use of alcohol-base sanitizers when hand washing is not feasible along with respiratory etiquette
  • 7. Stay home when sick and get tested policy for all teachers, staff and students
  • 8. Facilitate contact tracing to the extent possible in combination with isolation and quarantine in collaboration with local health authorities as per Government guidelines.
  • 9. Cleaning and disinfection with focus on high touch surfaces and closed poorly ventilated spaces.
• Implement ‘layered prevention strategies’ (use multiple prevention strategies together consistently) because all prevention strategies offer some protection individually but they offer better protection together.
• Work with the local public health authorities to monitor to the extent possible the following in their local communities and adopt prevention strategies accordingly.
  • ◦ Community transmission
  • ◦ Vaccine coverage
  • ◦ Testing
  • ◦ Outbreaks
• Form a School Emergency Response Team to take COVID 19 preventive and protective actions in the school
• Have ‘flexible’ and ‘nimble’ policies to respond to any new information about COVID 19.

Key Prevention strategies

1. COVID 19 Vaccination

Vaccination is crucial in curbing the spread of the pandemic. Vaccinated people are less likely to be infected and develop symptoms. They also have a ‘substantially reduced’ risk from severe illness and death.

Schools must ensure that all teachers and support staff in school are fully vaccinated against COVID. In case full vaccination is not possible, schools need to ensure that they have received at least one dose of the vaccine and are assigned duties not involving direct contact with students till they are fully vaccinated. Schools must promote vaccination for all eligible teachers and staff by providing information about COVID-19 vaccination, encouraging vaccine trust and confidence, and establishing supportive policies and practices that make getting vaccinated as easy and convenient as possible.

Also, it is advisable for the school to keep a record of the vaccination status of the immediate family members living with all students and promote vaccination for all those who are eligible.

2. Universal, correct, and consistent use of masks

• All students and staff must arrive at school wearing a face mask which fit snugly and cover the nose mouth and chin.
• They must continue wearing it all through, especially when in class, or doing any activity in groups, working in the laboratories, or reading in the libraries.
• When they remove their masks for eating, they must ensure 6 feet distance from others.
• Ensure and educate children not to exchange masks with others.

3. Improve Ventilation

Improving ventilation to the maximum extent possible will help outdoor air to flow in and dilute any possible contaminated air.

• Keep doors and windows open as far as possible keeping in mind safety of students
• Use exhaust fans in restrooms and kitchens
• Consider having classes and activities outdoors if possible
• Open windows in buses as far as possible without causing safety hazards
• Follow the recent CPWD General Guiding Principles for AC and ventilation.6 They are as follows:
  • Temperature setting of all AC devices should be in the range of 24-300 C
  • Relative humidity should be in the range of 40-70%
  • Bring in fresh air as much as possible
  • Avoid re-circulation of air as much as possible
  • Have adequate cross ventilation
  • Replace air using exhaust fans
  • Clean and sanitize filters of indoor units

  Keep physical distance, wear masks avoiding direct contact of air flow along with frequent surface decontamination

4. Physical Distancing

• Stagger the beginning and end of the school day. This should include strict social distancing measures for parent drop and pick up, such that no overcrowding happens in or near school premises.
• Stagger lunch breaks.
• Consider alternate day schedule
• Use cohorting. (Cohorts are sets of people who stay together and do not mingle with the others)
• Cancel functions, festival celebrations, sports games and other events that create crowded conditions. However school assembly may be conducted in the respective classroom or outdoor space/hall under the guidance of a teacher.
• For single-seater desks ensure at least 3 feet distance and if possible 6 feet distance between the students. If benches are used consider having ‘one child one bench’ norm. All desks must be face the same direction. Remove non -essential furniture to create more space.
• Teach and model creating space and avoiding unnecessary touching
• Limit non- essential visitors. Ensure temperature screening of all visitors at the entrance. Also ask all visitors to fill in a self-declaration form on symptoms, any tests done for COVID-19 (and its result) or contact history with recent COVID-19 positive persons
• Allow students to eat meals in classrooms while maintaining a distance of a minimum of six feet.
• Have one-way passage marked with tapes or signs across the hallways wherever feasible.
• Have specific markings 6 feet apart on the floors inside and outside the premises for queue management.
• Ensure an area of at least 4 m2 is available as a work station or for working on exercise equipment/ laboratory
• Use Public Announcement system to guide students and parents to maintain physical/social distancing.
• Ensure distance between children on school buses as far as possible

5. Testing for COVID 19

We recommend the following testing strategies to curb the spread of infection and detect new cases.

Any student, teacher or staff member who develops COVID 19 symptoms at school should preferably be tested using the Rapid Antigen Test administered by a trained school nurse. The school can collaborate with an accredited lab or administer a self-test kit approved by the ICMR.7 If the school decides to use a self-test kit, it must follow the ICMR advisory for the same.8 If the person tests negative on RAT, the collected sample should be sent to an ICMR accredited lab in Viral Transport Medium for RT PCR testing.

Screening of a sample of school and support staff on a regular basis will help detect asymptomatic cases. One of the methods that can be followed is Periodic COVID -19 Surveillance Testing of School Staff (& students, if feasible) using Lot Quality Assurance Sampling Methodology as described below.

6. Handwashing and use of alcohol-base sanitizers Washing hands frequently and thoroughly with soap and water will help prevent spread of infection. A minimum of 40 seconds must be spent in washing hands. Hands must be washed even if they are not visibly soiled. In the absence of soap and water an alcohol-based sanitizer can be used. Portable hand wash stations are recommended by AddressHealth, to be placed near the classrooms and open public areas.

7. Stay home when sick and get tested

Schools should communicate to all school staff and students to stay home when sick and get tested if they have symptoms of COVID 19. To support this, they should ‘have flexible, non-punitive and supportive paid sick leave policies and practices that encourage sick workers to stay home without fear of retaliation, loss of pay, or loss of employment level and provide excused absences for students who are sick. Employers should ensure that workers are aware of and understand these policies’.

Schools must have a plan in place to handle a situation if a student becomes sick at school.

They can also consider rapid testing on site as described earlier to facilitate early COVID 19 diagnosis and subsequent isolation or quarantine of lose contacts.

8. Contact tracing

Schools must follow the protocol of contact tracing in combination with isolation and quarantine as per the guidelines.

The policy related to this must be clearly communicated to all staff, students and parents beforehand. Schools have to intimate all close contacts of a COVID positive case as soon as they are notified keeping in mind the applicable privacy laws.

The current contact tracing guidelines for community settings are available at https://www.ncdc.gov.in/showfile.php?lid=570

Schools will have to co-operate with the health authorities as per the guidelines at that point of time.

9. Cleaning and disinfection School must keep in mind that the risk of infection by touching a contaminated surface is low. Spraying or fumigation of both indoor or outdoor spaces is not recommended by WHO.9 Similarly there is no evidence that sanitizing tunnels reduce the spread of COVID 19.10 The focus of cleaning and disinfection must be on high touch surfaces such as door knobs, railings, shared desktops as well as on poorly ventilated closed spaces using 1% sodium hypochlorite. Use 70% alcohol for metallic surfaces like door handles, security locks, keys etc.

End Note:

This document has been compiled to help schools, especially those run by private trusts/ not for profits to prepare to tackle the challenge of COVID-19, once schools reopen and are in session. It is focussed on mitigating the risk of children, staff and school authorities, contracting COVID-19 and containing the spread of the same within the school environment. It doesn’t attempt to address issues arising out of the challenge to the learning environment due to school closures, physical distancing etc. It has extensively borrowed references and guidance from the following:

• 1. COVID-19 PREPAREDNESS CHECKLIST FOR RURAL & URBAN PRIMARY HEALTH CARE & COMMUNITY HEALTH SETTINGS IN INDIA, COVID-19-PHC Action Group, April 2020
• 2. Guidance for COVID 19 prevention in K-12 schools updated on Aug 5, 2021. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html
• 3. Guidelines for Management of COVID 19 in Children https://www.mohfw.gov.in/pdf/GuidelinesforManagementofCOVID19inCHILDREN18June2021final.pdf accessed on 01 Jul 2021
• 4. Key Messages and Actions for COVID-19 Prevention and Control in Schools. UNICEF/WHO/IFRC. March 2020.
• 5. Ministry of Health & Family Welfare Website (www.mohfw.gov.in)
• 6. MOHFW SOP for Partial Reopening of Schools for Class 9 to Class 12 dated 08 Sep 2020 12
• 7. Ministry of Education’s COVID 19 SOP/Guidelines for Health & Safety Protocols for Reopening of Schools and Learning with Physical/Social distancing13
• 8. CBSE letter dated 08.10.20 to all Principals/ Heads of Institutions which asks schools to follow the MHRD/ Ministry of Education’s SOP/ guidelines5
• 9. Indian Academy of Pediatrics Guidelines on School Reopening, Remote Learning and Curriculum in and After the COVID-19 Pandemic

AddressHealth is a leading provider of school health services to schools in urban India. We currently serve private and government schools in Bangalore, Pune, Delhi – NCR and Hyderabad. Our services include School Infirmary Services, Annual Health Check-Up, Systematic Health Education and School Mental Wellbeing Programs. Please visit www.addresshealth.com for more details.