On October 28, 2021, Dr. Kieran Moore, the Chief Medical Officer of Health stated that the province will not require students to be vaccinated against COVID-19 to attend school and will not add the vaccine to its list of mandatory immunizations, which includes illnesses such as polio and measles.
Dr. Moore indicated that the vaccine will not be integrated into the Immunization of School Pupils Act “at present”.
“We have to look at the trends and the ongoing threat of this virus. If it persists season after season and is an ongoing threat, at that point we would review with government the integration of COVID vaccination status into the (law). At present our goal was to improve outbreak management within the school settings and to enable local public health agencies to have the data they need at their fingertips to be able to respond to outbreaks.”
Also on October 28, Education Minister Stephen Lecce announced what he called an additional layer of protection, saying that starting in mid-November, take-home COVID-19 tests will be available at all public schools across Ontario.
The PCR tests have been available in schools in Toronto and Ottawa and some other communities in a pilot project. Mr. Lecce said that now all students in public schools will have access to the tests.
If a student develops a COVID-19 symptom or is identified as a close contact of a positive case, they can pick up a test at their school, take the test at home and drop it off at a community location for processing, eliminating the need to book an appointment at an assessment centre.
The province also unveiled an expanded rapid testing program that would see students take regular tests over 10 days if public health and school officials are otherwise contemplating a whole-school dismissal due to high cases.
In addition, Minister Lecce announced that as of November 10, unvaccinated education workers will have to undergo rapid antigen testing three times a week instead of two as an added measure to protect schools from the risk of COVID-19.
Background
On September 13, 2021, Dr. Eileen de Villa, Medical Officer of Health for Toronto, wrote to the Toronto Board of Health, asking it to request the province require COVID-19 vaccination for eligible students based on their age. On September 27, the Board of Health adopted her recommendation.
Dr. de Villa’s recommendation came after the chair of the Toronto District School Board, Alexander Brown, requested the Ontario government to add COVID-19 to the list of required vaccinations in a letter addressed to Dr. de Villa, Education Minister Stephen Lecce and Ontario’s Chief Medical Officer of Health Dr. Kieran Moore.
Under the Act, adding COVID-19 to the list of “designated diseases” does not need to be legislated, but can be done by Ontario’s Minister of Health.
While some health experts are concerned that adding COVID-19 to the mandatory list could antagonize vaccine-hesitant parents and make them less open to persuasion, Dr. Anna Banerji, an infectious disease expert at the Dalla Lana School of Public Health, said that the COVID-19 vaccines should be compulsory for eligible children and youth.
“We have vaccines for diphtheria, diseases that are very rare, so why not ensure vaccination against COVID-19 in the middle of the pandemic’s fourth wave when we’re trying to keep kids in school?”
“Having these kids vaccinated could save some of their lives, or prevent a lot of kids from suffering and prevent (COVID-19) from being spread to other people in the community. I support it – I think it’s the right thing to do.”
Unexpected good news
Several weeks into the academic year, the Delta variant was driving higher COVID-19 infections in public school classrooms compared to last fall. In Ontario, one in five new COVID-19 cases in the province are school-related, compared with just seven per cent last fall. For example, schools accounted for 902 cases the week of September 20, or roughly 20 per cent of the total cases in the province. In the same period during the fall of 2020, schools accounted for 189 cases or seven per cent of all cases in the province.
However, outbreaks of COVID-19 in Ontario elementary and secondary schools are down considerably from where they were at the end of September. Public health experts credit vaccinations, masks ventilation upgrades, cohorting and other protective strategies as helping to keep the virus under control in classrooms.
Research indicates that outbreaks in both elementary and secondary schools started to grow in mid-September, about a week after most classes began following the summer holidays. However, the rate at which elementary outbreaks grew was far higher than that of secondary schools, where most students are fully vaccinated against COVID-19. By September 20, ongoing outbreaks in elementary schools sat at 35, more than triple the 11 recorded cases in secondary schools on the same day.
Public health experts caution that with children between the ages of 5 and 11 still unable to receive the vaccines, a reduction of public health measures along with the coming flu season and colder weather will likely lead to an increase in the number of infections in schools.
Colin Furness, an infection control epidemiologist at the University of Toronto said that the “only really big biome for COVID now is primary schools. To me, they’re the canary in the coal mine. The canary is fine but it’s not necessarily going to stay that way.”
Dr. Furness indicated that in the event of future outbreaks, they are likely “to show up and wreak havoc” in elementary schools.
Pediatric specialists report that most COVID-19 infections in children seem to be mild, and this appears to be true with the Delta variant. However, as the virus circulates more easily, the number of severe cases could increase in proportion to the wider community.
A small number of children are developing a life threatening condition called multi-system inflammatory syndrome or MIS-C. This is an inflammatory reaction in the body about four weeks after the infection with COVID-19. The inflammation can affect the heart, blood vessels and other organs, which can make some children very ill and in need of urgent care. Other children who contract the virus have lingering symptoms for months.
On October 1, 2021, Pfizer Canada submitted its initial trial data for the use of its COVID-19 vaccine in children aged five to 11 to Health Canada. On October 18, Pfizer asked Health Canada to approve its COVID-19 vaccine for children. The Pfizer vaccine for children ages five to 11 could receive approval from Health Canada by the end of November.
In initial trials, Pfizer tested a much lower dose, a third of the amount that is in each adult dose, in a study involving 2,268 kindergarten and elementary school-aged children. After their second dose, the company said that these children developed antibody levels just as high a teenagers and young adults getting the regular strength shots.
Public health units are preparing for vaccination rollout across the province
Public health units across the province are preparing to vaccinate children ages five to 11 once the COVID-19 vaccination is approved for them. Toronto Public Health (TPH) confirmed that it had formed a planning group that includes health partners, school boards, community representatives and the province. The medical officers of health for Peel Region, Middlesex-London, Hamilton and Ottawa indicated that they were making arrangements for the rollout of this new vaccination program. For example, the medical officer of health for Peel Region said that his public health unit is “ready to deploy a vaccine strategy” for that cohort, pending approval from Health Canada and guidance from the province and would keep residents informed on a timeline.
Dr. Vinita Dubey, as associate medical officer of health at Toronto Public Health recently said that “vaccinations have been proven very effective at lowering risks of severe illness, hospitalization and death.”
“This is why TPH supports and recommends provincial policies that encourage and increase COVID-19 vaccination among eligible school students.”
Dr. Dubey stated: “Vaccinations in the school setting will protect our school community and help build on our progress towards ending this pandemic.”
The question arises as to whether the Ontario Health Minister will accept the recommendations of Toronto Public Health, the Toronto District School Board and many other organizations and public health units and add COVID-19 to the list of designated diseases under the Immunization of School Pupils Act. In the event that the Minister of Health accepts the recommendations, the questions arise as to how the legislation will operate, will parents be permitted to apply for an exemption and what types of exemptions will be permitted.
The Immunization of School Pupils Act
Ontario’s only express enforcement of vaccination is set out in the Immunization of School Pupils Act, which governs which immunizations are required for students to attend school. The Immunization of School Pupils Act requires students to complete a program of immunization against all designated diseases listed under the Act, and requires students to provide proof of such vaccination – or to object through a specific exemption process – in order to continue to access the school.
Under section 3(1) of the Act, the parent of a student must cause the student to complete the prescribed program of immunization in relation to each of the following designated diseases:
- Diphtheria;
- Tetanus;
- Polio;
- Pertussis (whooping cough);
- Measles;
- Mumps;
- Rubella;
- Meningococcal disease; and
- Varicella (chicken pox).
However, a student can be exempt from these immunization requirements for (1) medical reasons; or (2) conscience or religious belief, if his or her parent completes the exemption process set out section 3(3) of the Act.
Exemption process
Where the exemption is sought for medical reasons, the parent must complete a “Statement of Medical Exemption” that has been signed by a physician or nurse practitioner, and submit this form to their local public health unit.
Where the exemption is sought for conscience or religious belief, the parent must attend an immunization education session (which discusses basic information about immunization, vaccine safety immunization and community health, and immunization law in Ontario), in order to obtain a Vaccine Education Certificate signed by a public health unit. The parent must also complete a “Statement of Conscience or Religious Belief,” and have it sworn by a commissioner for taking affidavits in Ontario. Finally, the parent must make copies of their Vaccine Education Certificate and the sworn “Statement of Conscience or Religious Belief” and submit the originals to their public health unit.
Exclusion or suspension of students pursuant to ISPA
Should a student fail to complete the program of immunization, or the exemption process, required by the Act, the student may be excluded and/or suspended from school in certain circumstances. Under section 12 of the Act, a student may be excluded from a school where:
(a) of the medical officer of health is of the reasonable opinion that there is an outbreak (or immediate risk of an outbreak) of a designated disease at the school; and
(b) the medical officer of health has not received:
i. a statement from a physician, nurse, or prescribed person confirming completion of prescribed program of immunization; or
ii. a statement of medical exemption signed by a physician or nurse.
Similarly, under section 6 of the Act, a student may be suspended from school where:
(a) the medical officer of health has not received:
i. a statement from a physician, nurse or prescribed person confirming completion of a prescribed program of immunization;
ii. an unexpired statement of medical exemption; or
iii. a statement of conscience or religious belief/parental completion of education session.
(b) the medical officer of health is not satisfied that the pupil has completed or will complete a prescribed program of immunization.
Decisions from the Ontario Health and Services Appeal and Review Board consistently uphold the validity of such exclusions and suspensions where a student fails to complete the immunization program or exemption process required by the Act.1
Given the relative novelty of the COVID-19 virus, COVID-19 is not listed as a designated disease under the Act, and therefore vaccination against COVID-19 is not currently mandatory for eligible students to attend school in Ontario.
Dr. Moore has confirmed that the province will continue to review trends and the ongoing threat of the virus. In the event that the virus persists season after season and presents an ongoing threat, the decision to make COVID-19 vaccination mandatory for eligible students may be revisited.
If you have further questions regarding COVID-19 vaccination requirements for Ontario students, please reach out to the author or one of the key contacts below.
1 See LRH v Noseworthy, 2019 CanLII 88572; JB v Eastern Ontario Health Unit, 2018 CanLII 31877; IB v Kyle, 2018 CanLII 30998.
