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17 May 2022

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Covid & Schools: A Post-Mortem &

Development of a Framework (Multi-Intervention Program)

To Prevent and Manage Infectious Disease Outbreaks

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• Covid & Schools: A Post-Mortem & Development of a Framework (Multi-Intervention Program) To Prevent/Manage Infectious Disease Outbreaks
• Joel Kettner, Associate Professor, University of Manitoba College of Medicine, former scientific director, Public Health Agency of Canada Collaborating Centre for Infectious Diseases, Former Chief Medical Officer of Health Manitoba on Infectious Dieaases in Educational Settings: Public Health Approaches
• Peggy Orbasli, & Heather Percy, Consultant & Manger of Public Health, Department of Health and Community Services, Newfoundland & Labrador on school vaccination campaigns and SH programs
• Daniel Morrish & Marc Neesam, Cambridge Assessment International Education, UK on the role of  health and science education in promoting literacy on infectious diseases

Infectious disease outbreaks have interrupted schooling and caused prolonged student absences many times in many countries. School health and emergency response programs have responded to such outbreaks, including HIV/AIDS, malaria, SARS, Lyme disease, measles, dengue fever and many more. The scale of the Covid 19 disruption is much larger but gaps revealed are typical of many outbreaks, large and small. However, governments, practitioners  and researchers  have not yet synthesized and learned from these typical patterns in the school setting.��The current responses to the Covid 19 pandemic have been focused on short-term problems & solutions, including in-school transmission, closing/opening schools, better communications with parents, building on the “success” of remote learning, measuring academic “learning losses” and providing mental health services. Evidence and experience suggest that longer-term investments in preventing/managing future outbreaks and child/student development are needed, including

• more focus on health & vaccine literacy, instilling a concern for the health of others and developing skills in basic hygiene and safety
• inter-sectoral investments in extended educational activities (school rules/routines/rituals, in-school/after school activities) to promote social & emotional development & healthy attachments to peers, teachers and trusted adults
• greater use of in-school vaccination campaigns & clinics
• investments in school nurses in schools to monitor student health, vaccines and coordinate interventions
• more investments in school, public health, social protection and emergency coordination & infrastructure to ensure continuation of school feeding programs, adequate washrooms & supplies, clean water, protective equipment, ventilation, emergency response procedures, student health monitoring, staff training and more.

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Infectious Diseases & Schools

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Focus: On in-school transmission & control, on direct school-based and school-linked prevention (policies, education, services, physical & social environment) & vaccinations and on indirect promotion of behaviours and conditions to reduce risk and promote health through context-relevant, capacity-building, education-friendly, systems-focused actions.

Defining a Multi-Intervention Program (MIP)

Multi-Intervention Programs (MIPs) address broad health & social issues (or topics) such as food/nutrition, substance abuse, sexual health/HIV, dropout prevention, bullying prevention, preventing violent extremism, positive behaviour support, gang prevention, child exploitation, physical activity and many others.

To be effective, the interventions within a MIP need to be coordinated as a multi-intervention program. These interventions can include policies and regulations on the issue, instruction and extended education on the topic, health, social or other services and modifications to the social and physical environment of the school or neighbourhood.

MIPs benefit from the infrastructure provided by the core components (macro-policy, health & life skills education, a coordinated set of student services and minimum conditions within the physical and social environment of schools & neighbourhoods) which established within Multi-Component Approaches (MCAs). MIPs often use the components as a planning framework in which specific interventions are delivered and coordinated. Consequently, MIPs should be implemented in a way that strengthens these core components (e.g., nutrition instruction within a core health & life skills education curriculum ) but often they are viewed or promoted as separate or even competing initiatives.

MIPs described by FRESH Partners

MCAs and MIPs – infectious diseases can be part of several MCAs

Infectious Diseases in Educational Settings: Public Health Approaches, Problems, Solutions��Covid & Schools: A Post-Mortem & Development of a Framework (Multi-Intervention Program) To Prevent/Manage Infectious Disease Outbreaks�Focusing Resources on Effective School Health (FRESH) Webinar, May 17, 2022

Joel Kettner MD MSc FRCPC

Public health physician;

Associate Professor, University of Manitoba College of Medicine, Winnipeg, Canada;

Former scientific director, Public Health Agency of Canada Collaborating Centre for Infectious Diseases;

Former Chief Medical Officer of Health, Province of Manitoba, Canada. 

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Caveats and Disclosures

• I am not an infectious diseases clinical specialist.
• I am not here to praise or bury government policies or public health officials.
• I am not here to claim that I would have been willing or able to do anything differently – or similarly – during the past two years.
• I am not a researcher; I prefer to criticize other people’s research.

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• I am a public health physician – practitioner, educator, thinker, writer, speaker.
• I am a privileged white male descendent of European settlers to Turtle Island (North America).
• I am in the bottom 1% of the top 1% income bracket in Canada;
• I make my living based on public concerns and fears regarding infectious and other diseases and injuries.

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Land acknowledgment

• The land in Canada was inhabited for tens of thousands of years by Indigenous peoples until white Europeans invaded and began a colonization process 500 years ago.
• The treaties, although imperfect, defined the sovereignty relationships between First Nations and the British monarchy.
• Manitoba is the homeland of the Métis nation.
• Colonization has caused profound harm – including health and education - to First Nation peoples, harm that continues to this day.
• Restoring justice includes educating people about the truth and to work under the guidance of Indigenous peoples towards reconciliation.

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Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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Summary of main points/opinions

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1. Microorganisms and infectious diseases come and go and come back.
2. Our ability to prevent exposure to them or eliminate them is limited.
3. Microorganisms have evolved to survive in home and school settings.
4. Public Health’s most important partners are parents and teachers.
5. Public Health’s parental authority is government.
6. How we decide to prevent, control or co-exist with microorganism should be a complex balancing of benefits and harms, involving many perspectives, and guided by values and priorities of equity and social justice.
7. Like Education, not all Public Health is good for all of us.
8. Achieving better Public Health is the shared responsibility of all and depends on learning how to play fair and to think critically.

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Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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The “p’s” of public health/Public Health

1. prevention
2. population
3. perspective
4. partnership
5. Power

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E’s of engagement

• Education
• Encouragement
• Enticement
• Enforcement
• Environment/empowerment

E’s of evaluation

• Epidemiology
• Efficacy
• Effectiveness
• Efficiency
• Equity

Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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The settings approach to Health Promotion

• A setting is any place where people spend time
• A setting:
• Has people – the social environment
• Is situated in a natural environment
• Contains things that have been produced by humans – the built environment
• A setting is a place that can promote health or cause disease or injury
• A setting is governed by laws and policies determined elsewhere and by local people with authority and responsibilities.

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Health promotion action means…

• Build healthy public policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services

Prerequisites for Health, (Supportive Environments) �Ottawa Charter for Health Promotion, 1986.

• peace, (s)
• shelter, (b)
• education, (s)
• food, (n,b)
• income, (s)
• a stable eco-system, (n)
• sustainable resources, (n)
• social justice, (s)
• equity. (s)

Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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FRESH: A Comprehensive School Health Approach to Achieve EFA.

Joerger, Hoffman, UNESCO, 2002

COVID-19 in children and youth (0-19 yrs) in Canada, �reported as of May 13, 2022

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• 700,000 cases
• 6000 hospitalizations
• 600 intensive care unit admissions
• 44 deaths

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COVID-19 in children and youth (0-19 yrs) in Canada, �reported as of May 13, 2022

Population 0-19 = 8 million

Cumulative data over two years

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• 700,000 cases = one per 25 children per year.
• 6000 hospitalizations = 1% of all cases, one per 2500 children per year.
• 600 intensive care unit admissions = one per 1000 cases, �one per 25,000 children per year
• 44 deaths = one per 15,000 cases, one per 350,000 children per year.

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Causes of death in children, 2020

Total deaths 616

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1. Unintentional injuries 127
2. Cancer 112
3. Congenital malformations 50
4. Suicide 39
5. Infections 26

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(COVID-19 ~ 22 per year)

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Settings framework for public health policies and action�for infections in education settings

Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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Challenges and Problems to be solved

• Keeping outbreaks in perspective; other diseases don’t stop;
• Reducing exposure and/or increasing resilience;
• Maintaining balance between benefits and harms of interventions; where to focus the resources on effective school health?
• Clarifying what it means to follow “the science”;
• Understanding the scope of expertise and role of Public Health;
• Understanding the accountability and responsibilities of governments;
• Engaging with various sectors and communities;
• Tolerating questions and other perspectives;
• Decentralizing operational decision-making in the settings.

Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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The educational solution – �learning to think critically and ask questions

• Clarify the question.
• Categorical – Yes/No?
• Quantity – estimates, size, proportions, rates, absolute risk, relative risk, ratios. (numeracy)
• Be aware of biases.
• Avoid polarization.
• Check assumptions.
• Question the evidence.
• Is it representative?
• Find the relevant information;
• Analyze the logic of the argument and conclusions;
• Look for confounders and distinguish associations from causal associations.
• Seek out counterfactuals and alternative perspectives.
• Reflect on the answers and the next questions.

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The educational solution – �learning to think critically and ask questions

• Clarify the question.
• Categorical – Yes/No?
• Quantity – estimates, size, proportions, rates, absolute risk, relative risk, ratios. (numeracy)
• Be aware of biases.
• Avoid polarization.
• Check assumptions.
• Question the evidence.
• Is it representative?
• Find the relevant information;
• Analyze the logic of the argument and conclusions;
• Look for confounders and distinguish associations from causal associations.
• Seek out counterfactuals and alternative perspectives.
• Reflect on the answers and the next questions.

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Outline of presentation

• Introduction, caveats and disclosures, and land acknowledgments
• Summary of main points/opinions
• What is public health?
• The settings approach to public health policy and action
• Education and infectious diseases
• Problems
• Solutions
• Summary of main points/opinions

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Summary of main points/opinions

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1. Microorganisms and infectious diseases come and go and come back.
2. Our ability to prevent exposure to them or eliminate them is limited.
3. Microorganisms have evolved to survive in home and school settings.
4. Public Health’s most important partners are parents and teachers.
5. Public Health’s parental authority is government.
6. How we decide to prevent, control or co-exist with microorganism should be a complex balancing of benefits and harms, involving many perspectives, and guided by values and priorities of equity and social justice.
7. Like Education, not all Public Health is good for all of us.
8. Achieving better Public Health is the shared responsibility of all and depends on learning how to play fair and to think critically.

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Jami Neufeld & Joel Kettner (2014) The Settings Approach in Public Health: Thinking about Schools in Infectious Disease Prevention and Control, Winnipeg, MB, National Collaborating Centre on Infectious Diseases

• “schools as sentinel settings to identify the beginning of an influenza season. When significant absenteeism is noted (e.g. more than 10% of any class),…. A policy requiring testing could be set at the regional health authority or provincial level
• …..including interruption of learning and hardship for working parents
• the natural environment (season, weather, circulating viruses) is associated with risk and burden of illness and needs to be accounted ….
• built environment considerations could include the cleanliness of surfaces, indoor air quality, access to clean water and soap – and other hand sanitation devices – for hand washing. Adequate space for the number of students (to avoid crowding) ….
• Behaviours that are promoted in the school such as hand-washing, cough etiquette, and avoidance of touching mouth and nose. The reinforcement of these behaviour norms could be linked to the health and/or biology curriculum….
• influenza vaccination could also be offered at the school if a province or regional health established a school-based program….
• creating a healthy and supportive school could contribute to building life skills to create healthy systems that include healthy lives, healthy relationships, healthy families, and healthy communities”

Newfoundland and Labrador �School Vaccination and �School Health Promotion Teams�

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May 17, 2022

Population�522,453 (as of January 2022)

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• Population of St. John’s and vicinity 199,394

Community Health Nursing in Schools

• Trusted relationships

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• Disease prevention

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• Education

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• Immunizations

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• Responsive to community needs

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Benefits of Public Health Led Immunization in Schools

• Equitable access

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• Relationships

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• No culture of vaccine hesitancy

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• Over 90% vaccination rates

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Routine immunization schedule for children as part of the school health program:

Men-C-ACYW135 : type A, C, Y and W135 meningococcal disease in a conjugated vaccine

HB: hepatitis B

HPV-9: 9 strains of human papillomavirus

Tdap: tetanus, diphtheria and acellular pertussis for adolescents

School Immunization Schedule

Health Promotion Support for Schools

• Topic area specialists

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• School Health Promotion Liaison Consultants

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• Team approach

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Hygiene and disease prevention�in national curriculum frameworks

• Marc Neesam and Daniel Morrish

17 May 2022

An exploratory study into the placement of public health-related content in five national curriculum frameworks.

Introductions

• Dr Daniel Morrish, Head of Curriculum Projects
• 15 years of school curriculum experience (5-18)
• Southern Europe, Central Asia, MENA, West Africa and East Africa
• General and vocational education

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Marc Neesam, Head of Professional Development Solutions

10 years of school curriculum experience (5-18)

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Led the development of the 2021 Cambridge Primary and Lower Secondary Curriculum

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Central Asia, MENA, West Africa and East Africa

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Method to identify approaches to the placement of health messages in competency-based national curriculum frameworks

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• English
• Online
• Competence
• Cross-curriculum themes

Findings (Kenya) Where is hygiene and health covered?

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Pertinent and contemporary issues

Grades 1-3 learning outcomes

• Environmental education curriculum design
• Hygiene and nutrition curriculum design

Grade 4 learning outcomes

• Home science curriculum design
• Physical education curriculum design

Findings (Estonia) Where is hygiene and health covered?

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“The theoretical basis for suitable health behaviours is primarily established in Biology and Chemistry lessons”

Thank You

For more information or to join in the development of a Multi-Intervention Program (MIP) on Infectious Diseases, contact:

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• dmccall@internationalschoolhealth.org ��

Here is the web page for the project

• http://www.schools-for-all.org/infectious-diseases.html