This week, 250 Toronto families received a package of swabs in the mail. Parents will swab their kids and themselves and send the samples back to be tested for COVID-19, and repeat this weekly — a faucet of data to help answer urgent questions about the role children play in driving transmission of the coronavirus.

The TARGet Kids study, which aims to enrol 1,000 families, is one of two major ongoing research projects in Canada that have rapidly pivoted in recent weeks to help answer the many unknowns about COVID-19 and children. Both will help inform policies to determine when it’s safe to reopen schools and daycares, which have been shuttered here since March — a necessary intervention, but also a brutal drag on children’s learning, parents’ mental health, and the economy, since most working parents rely on child care.

Illustrating the uncertainty, Ontario and Quebec, neighbouring provinces with the two worst outbreaks in the country, have taken divergent tacks. Quebec will begin reopening elementary schools and daycares in less than two weeks, while Ontario has offered no firm timeline and even deflected questions about the next school year.

“There are many questions right now that I think parents and policymakers are really struggling with,” says Dr. Jonathon Maguire, co-lead of TARGet Kids and a pediatrician and researcher at St. Michael’s Hospital.

Parents “don’t want to put their children at risk. On the other hand, they’re finding it increasingly difficult to be so physically isolated, and trying to manage so many things that are on people’s plates now: trying to keep their careers going, trying to keep their kids nourished and educated all at the same time. It’s very difficult. A balance is going to need to be struck.

“There are lots of passionate debates about this issue right now, and I think it stems from the very little information currently known.”

Evidence from multiple countries has shown that kids, thankfully, are mostly mildly affected by COVID-19. Nearly 22 per cent of Canada’s population are children under 19, but only 5 per cent of known cases are in this age group, according to the Public Health Agency of Canada. Of nearly 17,000 Canadian cases with detailed information including hospitalization status, 18 children under age 19 were hospitalized, with two in intensive care.

This overall picture doesn’t offer the kind of granular evidence necessary to inform policy, however. Researchers have two main questions: Which kids are at risk of severe illness if infected? And for the safety of the people around them — parents, teachers, daycare providers — what role do kids play in driving outbreaks?

The weekly swabbing component of the TARGet Kids study will help answer the second question.

For the past decade, the research team behind TARGet Kids, a collaboration between St. Michael’s Hospital and the Hospital for Sick Children, has followed a cohort of more than 11,000 children through their primary care providers, an effort to help understand childhood health concerns like micronutrient deficiencies and obesity.

When the COVID-19 crisis struck, the research team received a rapid grant to enlist 1,000 families and probe key characteristics about the disease in parents and children.

The decision to shut down schools and daycares was supported by evidence showing kids are powerful conveyors of respiratory illness. Canadian studies in Hutterite colonies have demonstrated that giving flu vaccines to children alone drives flu rates down across the entire community. Most parents don’t need peer-reviewed research to confirm that kids are slobbering, close-talking germ pumps.

But COVID-19 isn’t the flu. By swabbing every member of 1,000 families weekly and collecting symptom questionnaires, the TARGet Kids study is hoping to learn how the virus moves through households: do parents primarily give it to kids, or kids to parents? How likely are infected kids to make their parents sick, and vice versa? It will also act as a baseline to measure the impact of easing social distancing restrictions.

“These questions about infectivity are really, really important to be able to answer questions about whether children should be together back at school,” says Maguire.

It may also help determine the true scope of children as “silent spreaders”: those who are infected but asymptomatic, or have such mild symptoms that they go undetected.

“We know kids can get infected, but because they’re likely having more mild illness, it’s very likely that a lot of illness in children is being missed,” says Dr. Isaac Bogoch, an infectious disease specialist with the University of Toronto and Toronto General Hospital.

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Mild also doesn’t mean non-infectious. A pre-print study released Wednesday, led by German virologist Christian Drosten, found no difference in viral loads between age groups, and warned that children may be as infectious as adults: “Based on these results, we have to caution against an unlimited reopening of schools and kindergartens in the present situation,” the authors wrote.

The question on disease severity in children is equally as important, since policymakers and parents alike need to know if children, especially those with underlying health conditions, will be at risk if sent back to the classroom. Evidence from other countries has been informative, researchers say, but it’s no substitute for studying the impact on COVID-19 here, since pediatric populations differ among countries.

“We have to look at the Canadian data to see how our kids are responding to this virus,” says Dr. Charlotte Moore Hepburn, medical affairs director for the Canadian Paediatric Surveillance Program (CPSP), a joint initiative of the Canadian Paediatric Society and the Public Health Agency of Canada.

The Canadian Paediatric Surveillance Program also responded rapidly to the pandemic. The program, which has been running for over 20 years, asks 2,800 participating pediatricians and specialists across Canada to report monthly on a handful of uncommon but extremely serious childhood health conditions. It was initially built to scan the country for signs of polio, a requirement to certify that Canada is free of the viral scourge.

Because the surveillance program was already humming, researchers were able to quickly deploy it in the service of battling COVID-19: since April 1, participating doctors across the country have been reporting information weekly rather than monthly, a signal of urgency.

“It is, in my opinion, the poster child example of why it’s essential to invest in public health infrastructure outside of pandemic times,” said Moore Hepburn.

The surveillance program is using two avenues to examine severe pediatric COVID-19 cases. First, it is collecting detailed information on children who are hospitalized with the disease across Canada, hoping to better understand these rare but serious cases. Secondly, it is asking doctors to report back on cases of COVID-19 in children who also have an underlying condition, including asthma, chronic lung disease, obesity and diabetes.

These conditions have not been linked to severe COVID-19 illness in children, Moore Hepburn emphasizes, but researchers want to explore any risks. An absence of poor outcomes will be just as helpful — including for reassuring parents that returning to school is safe.

And looking ahead to any new therapies or vaccines that emerge, “it’s difficult to detail who would derive the greatest benefit unless you’re able to understand who is at greatest risk,” says Moore Hepburn.

Demonstrating how much there is to learn, doctors in Canada and the U.K. issued bulletins in recent days about unusual presentations of COVID-19 in kids.

CPSP distributed an alert about potential skin changes, including reddish-purple lesions on the feet and hands. Because children may be asymptomatic or only mildly affected, kids with what the media has dubbed “COVID foot” should be swabbed, the alert said. The British health system also warned doctors about a serious but extremely rare inflammatory condition potentially linked to COVID-19, though the link, if any, is still obscure.

Moore Hepburn says CPSP hopes to report some interim findings in early May, while Maguire says TARGet Kids is already getting swabs back and once testing is completed can provide results in real time to interested parties in government.

In deciding on school and daycares reopening, Ontario Education Minister Stephen Lecce said Wednesday that the province is balancing the priority of ensuring safety with the recognition that access to child care is a “prerequisite” for parents to participate in the workforce, especially women.

“We appreciate the relationship between the two and we’ll be making those announcements in the coming weeks,” Lecce said.