Covid-19 HSE Clinical Guidance and Evidence

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Interim NCCP advice in relation to return to school for those on cancer treatment or with a pre-existing cancer diagnosis (NCD19-031 / 14.09.20)

• Overview

• NPHET, HSE, Dept. of Health and Dept. of Education & Skills advice

• Information on COVID-19 and children

• Pupils with a current or previous diagnosis of cancer

• School workforce

• Family members

Overview

• Current events surrounding the COVID19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions.
• This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE, the DoH and the Dept of Education, and will be updated as necessary.
• This advice is available on the NCCP website here. ⁽¹⁾  We would advise that sites wishing to add this advice to their own websites should link directly to the NCCP webpage. This will ensure that the correct version is available. Information leaflets for patients and the public are available on the NCCP website here.⁽²⁾ This is also updated regularly. 

NPHET, HSE, Dept. of Health and Dept. of Education & Skills advice

This guidance is subject to the overarching advice of the National Public Health Emergency Team (NPHET), the HSE, the Dept. of Health and Dept. of Education and Skills. Information is available at:

• HSE HPSC - https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/
• HSE Coronavirus (COVID-19) – www.hse.ie/coronavirus
• DoH Coronavirus (COVID-19) - https://www.gov.ie/en/campaigns/c36c85-covid-19-coronavirus/
• Dept. of Education and Skills – https://www.gov.ie/en/campaigns/a128d-back-to-school/

Information on COVID-19 and children

In the months since the COVID-19 pandemic started, we have learned that: ⁽³⁾

• Children seem generally less likely to catch infection.
• Children seem more likely than adults to have no symptoms or to have mild disease. Symptoms in children include new onset cough, deterioration of existing respiratory condition, fever and changes in sense of smell. 
• Children have rarely been the person who brought COVID-19 into a household when household spread has happened.
• Children are not more likely than adults to spread infection to other people.
• There are some recent reports that the virus that causes COVID-19 may trigger a rare inflammatory disease called PIMS in some children. PIMS stands for Paediatric Inflammatory Multisystem Syndrome

Pupils with a current or previous diagnosis of cancer ⁽⁴⁾

• Given current knowledge about COVID-19 disease in children, it is now difficult to justify cocooning in most children with underlying conditions. Long-term cocooning of children with complex medical needs is likely to adversely affect them and may outweigh the potential risk of infection.
• For children with profound immunodeficiency/immunosuppression (e.g. due to ongoing or recent cancer treatment), their individual risk should be assessed by their treating team and consideration given to the possible necessity of avoiding school.
• For all other children, care should continue to be taken to reduce transmission through the measures promoted by the HPSC (https://www2.hse.ie/conditions/coronavirus/protect-yourself-and-others.html) including hand washing and social distancing by all household members etc.

School workforce

• It is acknowledged in Dept. of Education and Skills guidance that there are some school staff who may be unable to return to school.⁽⁵⁾ Anyone in an ‘extremely medically vulnerable’ category is generally advised to continue working remotely and should discuss this with their occupational health department. These are the same category who are advised to follow cocooning advice, as detailed on the HPSC ⁽⁶⁾  and HSE ⁽⁷⁾ websites.

From a cancer perspective, those in the ‘extremely medically vulnerable’ category (also referred to as ‘very high risk’ or ‘cocooning’ group) are as follows: ⁽⁸⁾

• people with cancer who are undergoing active chemotherapy
• people undergoing radical radiotherapy for lung cancer
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of active treatment ⁽⁹⁾
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
• Those patients who fall into the extremely medically vulnerable category should ideally start to cocoon (and work remotely) from two weeks before their treatment commences. They should be advised by their healthcare team at the end of treatment as to how long they should continue to follow these recommendations, according to the predicted duration of ongoing immunosuppression.  
• Patients who have had recent cancer surgery should follow the advice of their surgical specialist, as to how long to follow cocooning recommendations post-surgery and when it is reasonable to return to the workplace.
• Those who have a past history of cancer do not need to be excluded from the workforce, unless due to another significant comorbidity.⁽¹⁰⁾

Family members

• Children with immediate family members, including parents, in the ‘extremely medically vulnerable’ category can return to school and it is important for the child’s overall well-being.
• The priority is that the household continues to follow all current advice on how to minimise the risk of coronavirus, through regular hand washing, etc. (See the HSE website) More detailed advice on specific measures within a household are included in HPSC guidance (see p.9).
• In terms of reassurance, from what we know to date on children and coronavirus, children have rarely been the person who brought COVID-19 into a household when household spread has happened and children are not more likely than adults to spread infection to other people.
• Schools are putting measures in place to reduce the risk of coronavirus being transmitted to/within the school, such as hand hygiene regimes and cleaning measures within the school, reduced mixing between children and less objects going in and out of school.
• It is important for high-risk parents/family members to ensure that they continue to socially distance from other adults, e.g.  at school pick-up times, to minimise their likelihood of possible exposure.

References

1. https://www.hse.ie/cancerinfocovid-19hcp    
2. https://www.hse.ie/eng/services/list/5/cancer/patient/covid-19.html    
3. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/educationguidance/   
4. https://hli.ie/c.php?g=679077&p=4885072#Contributors%20(May%202020)  
5. https://www.gov.ie/en/publication/99b85-planning-and-preparing-for-return-to-school-covid-19-response-plan-for-safe-reopening-of-schools/#procedure-for-returning-to-work-rtw  
6. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/vulnerablegroupsguidance/COVID-19%20Guidance%20for%20extremely%20medically%20vulnerable%20groups.pdf  
7. https://www2.hse.ie/conditions/coronavirus/cocooning.html  
8. https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html#cocooning https://www.hse.ie/eng/services/list/5/cancer/news/covid-19.html   
9. Note that this has been amended from the previous definition in cocooning advice, refining the group to those undergoing active treatment
10. https://www2.hse.ie/conditions/coronavirus/cocooning.html