We can’t eliminate COVID risk in schools. But can we solve the runny-nose riddle for screening symptomatic students?

Eleven people were infected with during a family gathering at a vacation home in the U.S. this summer.

The source of the outbreak, according to released Oct. 5 by the U.S. Centers for Disease Control and Prevention: a 13-year-old girl with the sniffles. “Nasal congestion” was her only symptom.

Earlier this month, as sniffly kids flooded Ontario’s COVID assessment centres, and the province’s testing backlog surpassed 80,000, the government for schools and daycares. The new rules allow kids with runny noses and several other short-lived symptoms to return to class without a test, following a similar move in British Columbia.

The revisions are controversial, especially in hot spots like Toronto.

Dr. Andrew Morris with Sinai Health and the University Health Network is among several infectious diseases experts who have raised concerns. He said the CDC case report reflects a hard truth about runny noses and COVID in kids: “It’s almost impossible to distinguish between colds due to rhinovirus and colds due to SARS-CoV-2 (the virus that causes COVID-19).”

But what would it take to build a system that keeps sniffly kids carrying coronavirus out of schools? How worried should parents be about their stuffed-up children? Can Ontario solve the runny-nose problem?

“Everything about this is hard,” said Amy Greer, Canada Research Chair in population disease modelling, and a specialist in infectious disease epidemiology at the University of Guelph. “The challenge with all this is that we don’t have better data.”

“I have never discussed runny nose so much in my life,” Dr. Barbara Yaffe, Ontario’s associate chief medical officer of health, said when announcing the change to the province’s school and daycare screening guidelines, a decision she said was rooted in evidence and based on medical advice.

“What we are trying to do is balance,” she said. “Obviously we want to minimize the transmission of COVID-19, but we also want to ensure that kids can go to school or child care if it’s safe.”

Dr. Janine McCready, an infectious diseases physician at Michael Garron Hospital, has spoken out against the new guidance around runny noses, warning that she is seeing positive cases among schoolkids with no known exposure, whose only symptom is a short-lived runny nose.

At the request of the Star, McCready reviewed a report by Public Health Ontario on COVID in kids, which the Health Ministry said helped inform the changes to school screening. She said the data “does not allay my concerns in our current situation.”

The report looked at the symptoms of 1,332 kids who tested positive in Ontario before July 13, and found that runny noses were reported in eight to 18 per cent of cases, depending on the age group. That’s less than some of the more serious symptoms — including fever and cough — which, according to the new screening guidelines, require students to stay home and consult a health-care provider about whether they need a test.

The report, which included a systemic review of the scientific literature, notes that the authors “did not identify published evidence that discussed which isolated or single symptoms are commonly, or uncommonly, seen in pediatric populations.”

However, as McCready points out, among some age groups captured in the Ontario data, such as four- to nine-year-olds, more than 10 per cent of sniffly kids with COVID reported only having a runny nose, roughly on par with the proportion of kids that age with coughs who reported a cough as their sole symptom, according to the report.

Dr. Ari Bitnun, a pediatric infectious diseases doctor at the Hospital for Sick Children, said, “he has no problem” with the province’s new guidance, because “if you get aggressive with every runny nose … you are going to have a lot of children that end up quarantined,” triggering other “bad outcomes,” including families pulling their kids out of in-person learning.

However, Bitnun said the guidance should be continually re-evaluated, based on the way the disease is spreading locally — “not provincewide, but very local, which is hard to do sometimes.”

In Toronto, local data on runny noses and COVID in kids is elusive. Toronto Public Health to reflect the new Ontario policy after reviewing its own data on 855 kids with COVID from January to September, but there was no separate category tracking nasal congestion.

“It was difficult to determine how many children only had a runny nose, and how many had a runny nose that improved in 24 hours,” associate medical officer of health Dr. Vinita Dubey said in an email. She said she will “continue reviewing our local data and recommendations as new scientific evidence emerges.”

Toronto Public Health’s revised guidelines are more stringent than the provincial guidance, recommending testing for any symptom that doesn’t improve, including a runny nose — a tweak Dubey said was made “because infections have recently dramatically risen” in Toronto.

There is still a lot we don’t know about runny noses and COVID in kids, because schools in many countries closed for much of the epidemic, and children were relatively sheltered from exposure. Many children with the virus are also asymptomatic or have very mild symptoms, making cases hard to catch.

A preprint of a Swiss study released in September underscores how difficult it is to use symptoms as an indicator of COVID in kids. For the study, which has not been peer-reviewed, researchers analyzed blood samples and symptoms of 2,500 children to gauge their exposure to SARS-CoV-2. They found that of all kids who reported having a runny nose, roughly half had been exposed to the virus, while the other half had not — suggesting the odds that the sniffles in these kids was due to COVID at 50-50.

This presented a vexing back-to-school test for policy-makers, particularly heading into fall, when kids typically experience other respiratory illnesses, which Greer said called for “a strong plan for how we would manage the number of children and families that would require testing.”

But the bottleneck that left many families waiting for hours for testing and multiple days for results suggests the province “did not anticipate” the problem, Greer said.

Dr. Andrea Chittle is a family physician who works at a COVID assessment centre in Guelph. She said the province needs to take “a broader, system-wide view.”

“I think the questions we need to be asking are around how can workers be supported so that they can be home with their children when their children are symptomatic? What more robust systems and plans can be put in place in schools so that we have less spread of (viruses) through schools?”

Making testing easier and more accessible for families is key to keeping schools open, Chittle said, suggesting pop-up sites near schools warrant consideration.

Before the school screening guidelines changed, Toronto mom Bekki Kam was stuck in COVID testing purgatory for six days with her two young kids, who were tested because they had runny noses. Both children tested negative.

At the time, Kam said the screening tool at her kids’ school — which directed all symptomatic kids to stay home for 14 days or test negative before returning — “seemed a bit like overkill.”

She isn’t sure what to make of the evidence around runny noses and COVID, but said she would support a more conservative approach if the government could “expedite” the testing process.

“If every kid on earth is going to have a runny nose in the next four, five months … isn’t there a way to make the process a bit better if that’s a big indicator?” she said. “I’m happy to have them tested but I don’t want them missing weeks and weeks at a time just because they have the sniffles.”

Even with the loosened school screening guidelines, Kam said she is dreading her kids’ next illness, and the possibility they may need a COVID test, citing reports that the recent switch to appointment-only testing has left some people waiting days for a slot.

In response to questions for this story, a spokesperson for the Health Ministry said the government is continuing to “review the evidence and will update the guidance, as required,” but “is not considering revising the COVID schools guidelines at this time.”

The statement did not specifically mention strategies for improving testing for children and schools and daycares, but the spokesperson said the province is taking steps to build an integrated lab and testing network and boost testing capacity, noting its plan to roll out rapid testing “in the coming weeks.”

On Friday, as the number of infections in the province surged, there were 56 new COVID cases reported in publicly funded schools in Ontario, bringing the two-week total to 628, according to the province’s online tracker.

With rising rates of community transmission of the coronavirus, the challenge of distinguishing between COVID-related sniffles and run-of-the-mill colds is becoming more pressing, Morris said.

While it might be “a reasonable strategy not to bother” testing sniffly kids when COVID rates are low, that has become more difficult to justify in some pockets of Toronto, where, according to recent data obtained by the Star, more than COVID tests are coming back positive.

“When the prevalence of disease is so high, we would expect many more colds to be due to COVID-19,” Morris said.

As hard as it is for families, McCready said based on the current situation in Toronto, “my advice would be that if anyone in the household has symptoms, then everyone should stay home, and those with symptoms should go get tested.”

With files from Jennifer Yang

Rachel Mendleson is a Toronto-based investigative reporter for the Star. Follow her on Twitter: