Does Ontario’s updated school screening guide — which removed runny noses — strike the right balance?

As another pandemic school year looms — and parents’ anxieties grow, along with Delta’s infection rates — the province has quietly updated a screening tool with major implications, not just for Ontario’s ability to detect COVID in schools and daycares but for the daily lives of kids and parents. The update, made Friday afternoon, contained a small but significant change: runny noses no longer require a COVID test or exclusion from class or daycare.Tiny, leaky noses have played an outsized role in Ontario’s pandemic story. Runny noses have now been added or subtracted to the province’s list of school screening symptoms that require COVID testing three times since September 2020, when a surge in demand for testing overwhelmed Ontario’s laboratory capacity and triggered consequential changes to the province’s pandemic response. Much of that testing surge was driven by kids with minor symptoms like runny noses, which can be a symptom of COVID but also many other common viruses. As a result, “rhinorrhea” has been the focus of considerable debate among experts and policymakers — and a source of grief for families with tiny kids prone to chronically leaky noses.So while the change may come as a relief to parents, it arrives at a time of heightened fear and uncertainty around the Delta variant, which is more transmissible and potentially more dangerous for kids, many of whom remain ineligible for vaccination.The province’s chief medical officer of health has pointed to new data showing low positivity rates for kids with just a runny nose, including a pre-print study from Ottawa that analyzed more than 10,600 COVID tests in children with only a single symptom.But some experts say the province should exercise caution in the face of a surging Delta wave, especially in hot spot areas or when contact tracing is strained. Even this summer — when Toronto’s case counts were low — many COVID-positive patients were still being missed by contact tracing, said Dr. Janine McCready, an infectious disease physician with Michael Garron Hospital.“Heading into the fall, when we know cases are going to rise, do we want to be a bit more conservative?” she asked. “I do worry.”But experts interviewed by the Star all agree: In an ever-shifting pandemic, screening guidance must adapt to the changing landscape. “It’s trying to strike a balance in not excluding children from school with mild symptoms that are more likely now to be caused by other viruses, and trying to keep them in school and cause the least disruption possible,” said Dr. Jane Healey, a pediatrician at Mississauga’s Trillium Health Partners. “No management guidelines will be perfect in this pandemic. They all have risks and benefits, it’s all just trying to find the balance as they evolve.”Health units have previously adapted the province’s school guidelines to reflect their local infection rates. In an email, the health ministry said local health units could choose to implement a “more restrictive screening tool” for local use. On Monday, Toronto Public Health said it will “follow” the province’s screening tool but was still in the process of updating its own screening guidelines on its website.When runny noses first made headlines last September, Dr. Kieran Moore — then the medical officer of health for Kingston, Frontenac and Lennox and Addington — urged parents to continue testing kids with runny noses, citing data from Ottawa that 17 per cent of positive pediatric cases had “rhinorrhea” as an only symptom.Nearly a year later, Moore, now Ontario’s medical officer of health, says the data is showing something different.“We did a lot of testing for very mild symptoms like runny nose, and we found that we didn’t get a lot of positives at a population level,” he told reporters during an Aug. 3 press conference.Moore said Ontario’s school screening rules this year will have “less impact on families.” This is a relief to parents like Lindsay Page, an east Toronto mom whose two daughters, 1 and 3, have been tested for COVID eight times between them, mostly due to runny noses. “Parents are just so beyond burnt out and kids are struggling,” she said. “I think (the guidelines should be) also about protecting everybody’s quality of life and mental health at this point.”But Page added that she only welcomes the changes to the screening tool if they’re evidence-based. “I think the endgame isn’t a matter of loosening the rules,” she said, “but rather taking what we know and applying it with logic.”The Star asked the Ministry of Health to share the data that informed Moore’s recent remarks about low positivity rates in kids with runny noses. In an email, the ministry pointed to a new pre-print study from Ottawa, meaning it has not yet been published or peer-reviewed.Of the more than 10,600 COVID tests done on kids with only one symptom, the study found that while a runny nose had “positive predictive value” for elementary-aged kids, there was “no evidence that the single symptom of e

Does Ontario’s updated school screening guide — which removed runny noses — strike the right balance?

As another pandemic school year looms — and parents’ anxieties grow, along with Delta’s infection rates — the province has quietly updated a screening tool with major implications, not just for Ontario’s ability to detect COVID in schools and daycares but for the daily lives of kids and parents.

The update, made Friday afternoon, contained a small but significant change: runny noses no longer require a COVID test or exclusion from class or daycare.

Tiny, leaky noses have played an outsized role in Ontario’s pandemic story. Runny noses have now been added or subtracted to the province’s list of school screening symptoms that require COVID testing three times since September 2020, when a surge in demand for testing overwhelmed Ontario’s laboratory capacity and triggered consequential changes to the province’s pandemic response.

Much of that testing surge was driven by kids with minor symptoms like runny noses, which can be a symptom of COVID but also many other common viruses. As a result, “rhinorrhea” has been the focus of considerable debate among experts and policymakers — and a source of grief for families with tiny kids prone to chronically leaky noses.

So while the change may come as a relief to parents, it arrives at a time of heightened fear and uncertainty around the Delta variant, which is more transmissible and potentially more dangerous for kids, many of whom remain ineligible for vaccination.

The province’s chief medical officer of health has pointed to new data showing low positivity rates for kids with just a runny nose, including a pre-print study from Ottawa that analyzed more than 10,600 COVID tests in children with only a single symptom.

But some experts say the province should exercise caution in the face of a surging Delta wave, especially in hot spot areas or when contact tracing is strained. Even this summer — when Toronto’s case counts were low — many COVID-positive patients were still being missed by contact tracing, said Dr. Janine McCready, an infectious disease physician with Michael Garron Hospital.

“Heading into the fall, when we know cases are going to rise, do we want to be a bit more conservative?” she asked. “I do worry.”

But experts interviewed by the Star all agree: In an ever-shifting pandemic, screening guidance must adapt to the changing landscape.

“It’s trying to strike a balance in not excluding children from school with mild symptoms that are more likely now to be caused by other viruses, and trying to keep them in school and cause the least disruption possible,” said Dr. Jane Healey, a pediatrician at Mississauga’s Trillium Health Partners.

“No management guidelines will be perfect in this pandemic. They all have risks and benefits, it’s all just trying to find the balance as they evolve.”

Health units have previously adapted the province’s school guidelines to reflect their local infection rates. In an email, the health ministry said local health units could choose to implement a “more restrictive screening tool” for local use. On Monday, Toronto Public Health said it will “follow” the province’s screening tool but was still in the process of updating its own screening guidelines on its website.

When runny noses first made headlines last September, Dr. Kieran Moore — then the medical officer of health for Kingston, Frontenac and Lennox and Addington — urged parents to continue testing kids with runny noses, citing data from Ottawa that 17 per cent of positive pediatric cases had “rhinorrhea” as an only symptom.

Nearly a year later, Moore, now Ontario’s medical officer of health, says the data is showing something different.

“We did a lot of testing for very mild symptoms like runny nose, and we found that we didn’t get a lot of positives at a population level,” he told reporters during an Aug. 3 press conference.

Moore said Ontario’s school screening rules this year will have “less impact on families.” This is a relief to parents like Lindsay Page, an east Toronto mom whose two daughters, 1 and 3, have been tested for COVID eight times between them, mostly due to runny noses.

“Parents are just so beyond burnt out and kids are struggling,” she said. “I think (the guidelines should be) also about protecting everybody’s quality of life and mental health at this point.”

But Page added that she only welcomes the changes to the screening tool if they’re evidence-based. “I think the endgame isn’t a matter of loosening the rules,” she said, “but rather taking what we know and applying it with logic.”

The Star asked the Ministry of Health to share the data that informed Moore’s recent remarks about low positivity rates in kids with runny noses. In an email, the ministry pointed to a new pre-print study from Ottawa, meaning it has not yet been published or peer-reviewed.

Of the more than 10,600 COVID tests done on kids with only one symptom, the study found that while a runny nose had “positive predictive value” for elementary-aged kids, there was “no evidence that the single symptom of either rhinorrhea (runny nose) or cough predicted SARS-CoV-2 infections among 0-4 year olds.”

Meanwhile, a single symptom of either runny nose or cough accounted for 61 per cent of COVID tests done on under-5 kids without known exposures to a positive case, the study found.

“It varies slightly by age but the vast majority of runny noses (99+ per cent) are not COVID,” the ministry said in an email.

But the study also found that all symptoms, runny noses included, had higher predictive value when kids were high-risk exposures. This means including more symptoms on screening guidelines might make sense in places where people aren’t aware they’re high-risk exposures, perhaps when contact tracing has fallen down, said study author Dr. Nisha Thampi, an infectious disease pediatrician with the Children’s Hospital of Eastern Ontario.

She said this is perhaps even more important with Delta, which is not captured in her latest study.

“Schools, in my mind, have been a reflection of community risk. This year, I think they’ll become sentinel for risk in the community,” Thampi said. “I think in the beginning (of the school year) it would do us well to be cautious and over-inclusive.”

But policy makers also need to consider the rise of other respiratory viruses now circulating in the community, which will further strain families and laboratory testing capacity, said Healey, also the physician lead for COVID-19 test results notification at THP, which includes Credit Valley Hospital and Mississauga Hospital.

“This is a very different pandemic landscape than at the outset of the third wave.”

In February, very few respiratory illnesses were circulating. At that time, Healey and other pediatricians were warning that an isolated runny nose could be a symptom of COVID after hospitals saw a dramatic drop in children being admitted for influenza, respiratory syncytial virus (RSV) and other common seasonal illnesses

Now, with mobility across the province at its highest since the start of the pandemic, hospitals are reporting an increase in kids coming to the ER with viral symptoms.

According to Public Health Ontario data, the number of children testing positive for non-COVID respiratory illnesses is higher than this time last year, though the province isn’t yet recording an uptick in RSV cases.

At Trillium Health Partners, the COVID assessment centre is now seeing fewer pediatric cases, but Healey says kids appear to have more noticeable symptoms than in prior waves, with more fevers or coughs. There also appear to be fewer asymptomatic kids.

However, Healey cautioned other factors could be influencing these observations and the overall sample size of pediatric cases is too small for definitive conclusions.

And while there are concerns that Delta could be more virulent in children, fuelled by alarming headlines in the U.S., where pediatric hospitals in hot spots are being overwhelmed, experts say there isn’t enough data.

In the revised screening guidelines, the following symptoms trigger a COVID test and exclude a student from daycare or school: fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell and nausea, vomiting and/or diarrhea. Symptoms that have been removed — in addition to a runny nose — are sore throat, nasal congestion and headache.

Experts who spoke with the Star said that while cough and breathlessness are most associated with COVID, gastrointestinal symptoms for children — on their own, or with a fever — have been showing up in positive cases. Many have seen children arrive at emergency departments with nausea, vomiting and diarrhea as the only COVID symptoms.

In the new study from Ottawa, Thampi and her co-authors found that fevers, as an isolated symptom, were predictive of COVID for children of all ages. But certain single symptoms were more predictive in specific age groups: nausea and vomiting for kids under five; headache, runny nose/congestion and cough for “school aged children and youth”; and sore throat for high school-aged kids.

Ontario’s new screening guidelines apply to kids of all ages.

“Screening guidance continues to evolve as we learn more about COVID-19, how it spreads, and how it affects people in different ways,” a health ministry spokesperson said. “The specific symptoms to screen for take into consideration their positive predictive value as well as community rates of SARS-CoV-2 and other respiratory viruses.”

Since it’s not yet known how the highly transmissible Delta variant will affect schools, there is an argument for including a greater number of symptoms in the screening tool, said Dr. Allan Grill, chief of family medicine at Markham Stouffville Hospital, part of Oak Valley Health. However, at this point, it’s critical to take into account the impact of accumulated learning losses, he said.

“You might have a kid with a runny nose that ends up not having COVID and misses a week of school,” he said. “Public health colleagues look at the data and look at the situation and try to make the best and most informed decision they can.”

Grill notes the screening guidance is just one mitigation strategy in place to help keep COVID out of schools. Indoor masking, cohorting, an emphasis on hand hygiene and vaccine rates among staff and older students are also key, he said.

Toronto Public Health’s associate medical officer of health, Dr. Vinita Dubey, also said the screening tool will never be perfect because a proportion of kids have no symptoms.

A student’s vaccination status is considered in the revised screening guidance; children and teens who are fully vaccinated no longer have to isolate while a sibling awaits COVID results, while those who are unvaccinated must stay home until cleared to go back to school.

For families not yet sure whether to get their child vaccinated, the “convenience factor” of getting back to school faster is a key consideration,” said Healey.

“If vaccinated, children will potentially have a lot less disruption, after experiencing so much disruption already. That is a very important benefit to vaccinating the older children.”

Jennifer Yang is a Toronto-based health reporter for the Star. Follow her on Twitter: @jyangstar

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie