Navigating Patient Concerns and Requests in the COVID-19 Context
Last Updated: October 23, 2020
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Your one-stop shop for all of your COVID-19 related needs, including clinical guidance, maintaining regular primary care practice in the COVID-19 context, social care guidance, local services and more.
This resource helps providers answer patient inquiries and concerns about everyday life while considering changes due to COVID-19. It provides family physicians and primary care nurse practitioners information on topics such as children and schools’ reopening, masking in public spheres and more.
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Patient Frequently Asked Questions (FAQs) New
This section helps providers answer patient inquiries and concerns about everyday life while considering changes due to COVID-19. It provides family physicians and primary care nurse practitioners information on topics such as COVID-19 risk for children and schools’ reopening, masking in public spheres and more. Click on a question to view current evidence, recommendations and advice.
COVID-19 risk for children
- Evidence to date suggests that children are less likely to be infected with COVID-19, and once infected, tend to have milder infections, with a substantial portion being asymptomatic (PHO, May 15, 2020; AHS, August 7, 2020, ECDC, August 6, 2020). These broader patterns have been observed locally in Ontario via epidemiological data (PHO, July 13, 2020).
- Children with cardiac, lung, neuromuscular, and developmental disorders, as well as those in immunocompromised states, may be at an increased risk for more severe illness if infected with COVID-19. Limited evidence to date suggests that COVID-19 poses a similar risk as other respiratory infections (SickKids, July 29, 2020).
- High-quality data on infections among children, especially in those with underlying conditions, is limited (PHO, May 15, 2020; AHS, August 7, 2020; SickKids, July 29, 2020).
- A small percentage of children infected with COVID-19 may develop a multi-system inflammatory syndrome (MIS-C). See Multisystem Inflammatory Syndrome in Children (CEP) for more information.
- There has not been adequate time to study COVID-19’s long-term effects on either adults or children. All evidence so far is speculative, based on experiences with other respiratory viruses, or on the short-term pathophysiology of the infection (PHO, July 10, 2020).
- Currently, PHO has defined “long-term symptoms” as those developing after 6 weeks or persisting beyond 6 weeks of COVID-19 symptom onset. According to this definition:
- There is some evidence that olfactory dysfunction and gustatory dysfunction may be relatively common long-term effects.
- Based on other coronaviruses, additional long-term effects that may be anticipated include cardiovascular system abnormalities, depression, glucose metabolism disorders, hyperlipidemia, lipid metabolism dysregulation, post-traumatic stress disorder and reduced lung capacity.
- For more information, see Long-Term Sequelae and COVID-19 – What We Know So Far (PHO, July 10, 2020)
- Most reviews to date indicate that mask wearing is likely an effective method of source control, despite a lack of high-quality evidence (PHO, June 17, 2020; AHS, June 19, 2020; Travel Med Infect Di, May 28, 2020; IJNS, August 2020).
- The majority of research has been conducted on other respiratory illnesses using adult subjects. Evidence specific to mask use by children is lacking (SickKids, July 29, 2020).
- Mask effectiveness (the ability of the mask to prevent droplets from spreading) is different than cross-contamination (handling of a mask that may result in contamination of hands or mask). Touching or handling masks does not make them non-effective. Mask effectiveness is only compromised by damage or improper use.
- While touching or handling masks does not degrade the fabric, it may lead to contamination of hands, mask, or other surfaces if hand hygiene is not practiced before and after handling the mask (Sommerstein et al, July 6, 2020; Chughtai et al, June 2019; Zamora et al, 2006).
- There is concern that some children may have difficulty refraining from touching masks. It is likely that a child’s propensity to handle their mask is an entirely individual trait. Some observational studies have indicated that subjects wearing a mask touch their faces less often than subjects who did not wear a mask; however, these studies focus on adults and health care workers (Lucas et al, 2020; Shiraly et al, August 13, 2020).
- Education: Children may be at increased risk of touching their face or mask if they are unfamiliar with wearing a mask, or do not like to wear it. Parents can try to prevent this by explaining the importance of wearing a mask without touching it (Esposito & Principi, May 2020).
- Comfort: Choosing a mask that a child likes and is comfortable wearing properly (covering nose, mouth and chin with no gaps), parents may increase the chances of the child wearing their mask throughout the day (CPS, August, 2020).
- Children should remove masks if they become soiled or wet. Wet masks may be more difficult to breathe through. If the soiled mask is washable, it should be stored in an airtight bag or container until it can be cleaned.
- Any mask with damaged fabric should be discarded.
- There is no single recommended design, choice of material, layering or shape among the non-medical masks that are available. Non-medical masks may be made of different combinations of fabrics, layering sequences and available in diverse shapes (WHO, June 5, 2020).
- The majority of studies to date have not tested the differences between mask types in real-world situations, but studied filtration efficiency of different materials in laboratory settings, while rarely employing industry-approved methods for such testing (PHO, June 17, 2020; AHS, June 19, 2020).
- The ideal combination of material for non-medical masks should include three layers (WHO, June 5, 2020):
- An innermost layer of a water-absorbing (hydrophilic) material (cotton or cotton blends), to readily absorb droplets.
- A middle hydrophobic layer of either synthetic non-woven material such as polypropylene, or a cotton layer which may enhance filtration or retain droplets.
- An outermost layer of hydrophobic material (polypropylene, polyester, or blends) which may limit external contamination from penetrating through to the wearer’s nose and mouth.
COVID-19 and school reopening New
Despite the risks due to the pandemic, school reopening is important for children’s overall health. Emerging evidence suggests children are at a lower risk of severe illness due to COVID-19, while school closures have been associated with decreased vaccination coverage, delayed diagnosis and care for non-COVID-19 related medical conditions, and significant adverse impacts on social development and mental health (Guidance for School Reopening, SickKids, July 29, 2020).
Impact of school openings on virus outbreaks
- A small number of studies on outbreaks in other jurisdictions suggest that transmission in the school setting is low (Public Health Ontario, August 4, 2020).
- Areas that have seen schools reopen and then close again usually find this corresponds to a general increase in community transmission, not specifically tied to the reopening of schools (Public Health Ontario, August 14, 2020).
- Although school outbreaks have been reported, in the majority of countries, risk mitigation strategies appear to have been largely successful when community transmission is low. (SickKids, July 29, 2020).
New Paediatric screening, testing, isolation and return to school
In consultation with the Chief Medical Officer of Health, the Ontario government has updated its COVID-19 school and child care screening guidance. This additional information will help to determine when it is most appropriate for students, children and families to seek a test for COVID-19.
The Ontario government has developed a COVID-19 Screening Tool for Children in School and Child Care screening tool for patients. The first set of questions asks about symptoms such as fever or cough. Students and children with any of these symptoms are advised to stay home until they are able to consult with a health care provider and receive an alternative diagnosis or a negative COVID-19 test. The second set of questions asks about other symptoms that are commonly associated with other illnesses, such as a runny nose or headache.
To support primary care providers across the province, the paediatric screening, testing and isolation algorithm (below) was developed to help navigate patients’ questions and provide direction regarding return to school. Along with this guidance, primary care providers should consider the local epidemiology of COVID and other circulating viruses.
Paediatric screening, testing, isolation and return to school algorithm
This pathway should only be used for children over age 1. Additionally, when parents express concern, the child requires an MD assessment.
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Julia Orkin (SickKids), Michelle Science (SickKids), Lennox Huang (SickKids), David Kaplan (Ontario Health), Jordana Sacks (Family Medicine), Allan Grill (Family Medicine), Daniel Warshafsky (CMOH), Mary Choi (CMOH), Dilnoor Panjwani (CMOH), Claire MacDonald (CMOH), Howard Shapiro (TPH) and Allison Chris (TPH).
Processes and practices for reopening schools
The following approaches to school reopening are common in other jurisdictions (Public Health Ontario, August 14, 2020):
- Reopening gradually, in a phased approach, with primary schools opening first and secondary schools opening later.
- Keeping ill students and staff away from school.
- Encouraging physical distancing, especially among older students and staff where possible (Government of British Columbia, August 21, 2020; Government of Quebec, August 24, 2020).
- Increased hand and respiratory hygiene.
- Reducing indoor exposure time.
- Limiting exposures between students by dividing them into learning groups or cohorts with limited exposure between these groups.
- Using masks to reduce exposure, especially where physical distancing is harder to maintain. Older students are more likely to be asked to wear masks, with some requirements in high traffic areas like hallways or buses (Government of British Columbia, August 21, 2020; Government of Quebec, August 24, 2020).
School mask requirements
In Ontario, students in grades 4-12 will be required to wear non-medical or cloth masks indoors but may remove them when outside with their own cohorts or during mealtimes.
If students do not supply their own masks, masks will be supplied for them.
The requirement for students in grades K-3 to wear masks will be determined by individual school boards. See Masks and students under 10 for details.
All school staff will be required to wear masks, and may also wear eye protection or face shields.
Masks and students under 10
- Children under 10 appear to be less likely to transmit COVID-19 to others.
- Young children’s masks may become damaged, wet or soiled more quickly, and frequent replacement may be impractical from a resource perspective.
- Masks can become a potential hazard for physical injury if caught on objects, especially if worn improperly.
- More than older children, young children rely more on social interactions, facial expressions and body language for proper learning.
Mask exemptions in schools
- Mask exemptions for students and staff will be determined by individual school boards for relevant medical conditions.
- A recent Rapid Evidence Report by the AHS COVID-19 Scientific Advisory Group found no evidence that clearly identifies specific populations at risk of adverse outcomes or harms related to the use of medical or cloth masks (AHS, August 21, 2020). The Canadian Thoracic Society recommends that those with chronic respiratory conditions should not be exempted as a population from wearing masks, as there is no evidence that mask-wearing leads to exacerbations of underlying lung conditions (CTS, June 2, 2020).
- However, recommendations for mask exemptions should be determined on a case-by-case basis. For example, for those with seizure disorders, masks may obscure facial cues of the onset of an episode; or patients with trauma or PTSD may find masking triggers acute symptoms.
- All staff and students must self-screen every day before attending school.
- If a student or staff member is experiencing any symptoms of COVID-19, they must stay home from school and should seek testing and appropriate medical attention.
- Students and staff must remain at home while waiting for test results.
- Any student or staff member who develops COVID-19 symptoms while in school should be immediately separated from others until they are able to go home. They should not take student or public transportation.
- Staff with symptoms and parents/guardians of children with symptoms should be directed to use the online self-assessment tool and follow instructions. Those who test positive may not return to school until they are cleared according to public health guidance.
- If a symptomatic individual tests positive for COVID-19, they should continue to self-isolate at home and follow the directions of their local public health unit.
- An outbreak in a school will be defined as two or more lab-confirmed COVID-19 cases in students and/or staff in a school with an epidemiological link, within a 14-day period, where at least one case could have reasonably acquired their infection in the school.
- The local public health unit will work with the school to determine epidemiological links (e.g., cases in the same class).
- The local public health unit will assist in determining which cohort(s) may be sent home or if a partial or full school closure is required based on the scope of the outbreak.
- Guide to reopening Ontario’s schools (August 13, 2020)
- Operational guidance: COVID-19 management in schools (MOE, August 26, 2020)
- Guidance for School Reopening (SickKids, July 29, 2020)
- Rapid Review: COVID-19 Pandemic School Closure and Reopening Impacts (PHO, Aug 4, 2020)
- COVID-19 – What We Know So Far About…Wearing Masks in Public (PHO, June 17, 2020)
- COVID-19 Scientific Advisory Group Rapid Response Report: Effectiveness of masks to reduce community spread (AHS, June 19, 2020)
- Canadian Thoracic Society recommendations regarding the use of face masks by the public during the SARS-CoV-2 (COVID-19) pandemic (Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, June 2, 2020)
- Advice on the use of masks in the context of COVID-19 (WHO, June 5, 2020)
- Long-Term Sequelae and COVID-19 – What We Know So Far (PHO, July 10, 2020)
- Evidence synthesis briefing note: Re-opening, operation, and monitoring of schools (RAEB, Aug 31, 2020)
There is little evidence available to assist primary care providers in evaluating individual patient requests for mask exemptions. Health authority guidance on exemptions is broad and sometimes contradictory, as little research exists on the impacts of mask use on specific populations, either in general or in the context of COVID-19.
Current guidance is based on hypothesizing how challenges relevant to specific conditions might be triggered or exacerbated by masks. A recent Rapid Evidence Report by the AHS COVID-19 Scientific Advisory Group found no evidence that clearly identifies specific populations at risk of adverse outcomes or harms related to the use of medical or cloth masks. (AHS, August 21, 2020), though specific adverse experiences of mask use include:
- Perceived increased work of breathing
- Possible (clinically insignificant) increases in C02
- Possible increase in risk of headaches (in those with history of headache)
For primary care providers receiving requests for mask exemptions, the guiding principle should be: Preserving public health vs Reducing individual risk
Primary care providers do not have an obligation to provide mask exemptions to patients when they are not medically warranted. However, providers do have an obligation to:
- Address an individual’s concerns
- Discuss appropriate alternatives
- Offer clear risk-reduction recommendations for when patients go out in public (JAMA Health Forum, July 10, 2020)
Considerations for preserving public health
The primary benefit of facemasks is source control – protecting others from one’s own respiratory droplets. As such, mask use by every individual is a public health concern, and exemptions must take the health of others into account.
Example: There is concern that mask use will exacerbate lung conditions.
There is no evidence of this, however, and the Canadian Thoracic Society’s recommendation is that those with chronic respiratory conditions should not be exempted as a population from wearing masks. (CTS, June 2, 2020). A recent perspective in JAMA argued that mask-wearing is particularly important for patients with chronic cough, as they may have a higher probability of spreading the virus (JAMA Health Forum, July 10, 2020).
Considerations for reducing individual risk
Individuals medical conditions or disabilities have the right to use and enjoy public spaces equally. While there is no evidence-based list of exemptions, the following populations have been identified by authoritative sources (CDC, AHS, CTS) as possible candidates for exemption:
- Children, particularly 2 years or younger
- Those with difficulty breathing
- Those unable to place or remove the mask on their own
- Developmentally challenged individuals
- Those with neurodevelopmental or psychiatric conditions
- Those living with mental illness
- Elderly individuals with cognitive impairment
- Those with facial trauma or recent oral maxillofacial surgery
- People who are hearing impaired or who are communicating with a person who is hearing impaired, and where the ability to see the mouth is essential for communication
- Those with sensory-processing disorders
- Those with facial deformities incompatible with masking
- Those with epilepsy or seizure disorders where facial expression is critical to recognition of seizure
Putting it into practice
- Individuals unable to wear a mask for any reason should avoid circumstances where they will be unable to physically distance from others.
- If they must go out in public, individuals unable to wear a mask should strictly follow physical distancing guidelines and use hand hygiene.
Education and alternatives
- Assess mask use on an individual basis and develop strategies to mitigate discomfort. For instance, develop a plan where a patient with chronic pulmonary illness removes their mask during an acute exacerbation and replaces it when symptoms are under control.
- Choice of mask is important to the patient’s comfort and ability to wear it regularly. Discuss different options to identify which face covering the patient would be comfortable wearing.
- Have the patient practice with the mask for short durations of time, and in low-stress or quiet environments.
- Where appropriate, consider transparent facemasks to improve communication and ability to observe facial cues.
For Primary Care Providers
- Considerations for Wearing Masks (CDC, Aug 7, 2020)
- COVID-19 Scientific Advisory Group Topic: Evidence of Harm from Mask Use for Specific Populations (AHS, August 21, 2020)
- Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians (JAMA Health Forum, July 10, 2020)
- COVID-19: Face Masks and People With Disabilities (Disability Rights Education & Defense Fund, July 23, 2020)
- Helping people with autism spectrum disorder manage masks and COVID-19 tests (Harvard Health Blog, June 10, 2020)
- COVID-19 and Ontario’s Human Rights Code – Questions and Answers (OHRC, Aug 11, 2020)
Acknowledgement and legal New
The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach.
They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.
Clinical Working Group
A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:
• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CHE
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP
In addition to our clinical working group the CEP also obtained feedback from others, including:
• Arun Radhakrishnan, MSC, MD, CM, CCFP
• Central Region Primary Care Leadership
• David Daien, MD, CCFP
• David Makary, MD, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH
Thank you to everyone who supported the development of this resource.
In collaboration with:
With support from: