TORONTO - When Karen Shein sends her two children off to elementary school in a few weeks, they will be packing more than just the usual back-to-class gear.
Tucked into their school bags will be alcohol-based hand sanitizer, little bottles of insurance against the onslaught of germs they are sure to encounter as kids once again gather en masse for the annual September rite of passage.
And this fall, with a surge of swine flu cases possibly in the offing, keeping little hands clean could be more critical than ever to prevent children getting sick or spreading the virus to others.
"With the pandemic," says Dr. Bonnie Henry of the B.C. Centre for Disease Control, "we've been saying it's really important this year more than others, even, for you to have the ability for children to wash their hands, because we know that influenza is what we call 'amplified' in schools."
But while public health officials press home the message that good hand hygiene is one of the best ways to beat this usually mild but potentially deadly bug, not all schools are equipped to provide the basics needed to accomplish that goal.
"I've taught the kids how to wash their hands properly and also how to use a paper towel to shut off the tap and exit the washroom after their hands have been cleaned," Shein says of her eight-year-old daughter and five-year-old son.
But there's a problem: while washrooms in their Toronto school are equipped with soap dispensers, there are no paper towels, she says.
"It's frustrating because you send them to school and the school's teaching certain things but not necessarily doing them."
Years of budget restraints have forced many Canadian schools to trim expenses - and often that has meant stripping items like costly paper towels that were once seen as basics.
Henry, director of Public Health Emergency Management at the BCCD, says finding enough resources is an issue for schools all across the country.
"I mean dollars and people, so the janitor that always used to go around and clean things," she says. "Many schools now share a cleaning service between a number of schools and they don't have somebody that's dedicated to their own facility."
"There's a lot of issues in schools around keeping soap and paper towels. And, of course, there's the balancing of concerns between having hot water and cold water and warm water."
Added to that is the reality that some children abuse supplies, playing with soap, scattering paper towels around the washrooms and turning the hot water tap on too high, putting a child in danger of getting scalded.
"So it's not a simple issue."
Chris Broadbent, manager of health and safety for the Toronto District School Board, agrees that both cost and vandalism are concerns when it comes to stocking washrooms in its 560 elementary and secondary schools.
In rare cases, high school students have even set fire to rolls of paper towel in washrooms, he says.
"Kids being kids, I guess, there are some that are mischievous enough that they will empty the toilet roll or whatever. We put a lot of mechanisms and locks in place that try to defeat that, but they can be creative at times."
Over the years, expensive and environmentally wasteful paper towels have given way in many schools to hand dryers, he says.
"But all of our washrooms are equipped with liquid soap and-or hand dryers of one description, whether it's paper towels or an electric hand blower."
While students aren't encouraged to bring their own hand sanitizer, schools can order it from the board's distribution warehouse, Broadbent says.
"With H1N1, a lot of schools took the precaution of providing one for every classroom, but it's under the control of the teacher, obviously. And it's there to support handwashing, not as an alternative."
"We clearly support and promote proper handwashing as the best way to go," says Broadbent, noting that the board has worked with Toronto Public Health to provide handwashing reminder signs for schools, a hand-hygiene DVD as part of the curriculum and a streaming video on its website.
Like many school boards across the country gearing up for a possible resurgence of H1N1, the Toronto board plans to keep the issue front and centre when students return to class.
Schools will "reissue previous awareness pieces - 'Now that you're back, don't forget you've got to wash your hands,' and get kids back thinking the way they need to think," he says.
"Just like they forget some math, they sometimes forget about handwashing protocol. So we'll remind them."
This week, the government of Manitoba sent out updated information about H1N1 to school principals and superintendents, including measures for preventing infection.
Schools across the province have been advised to encourage students to sneeze or cough into elbows or sleeves, to wash their hands often with soap and water, and to avoid touching their eyes, nose or mouth.
"When soap and water are not available, hand sanitizers may be an acceptable alternative if hands are not visibly soiled," the influenza advisory says.
Henry says she has no problem with kids bringing their own hand sanitizer to school as a backup.
"We do know that even young children, if the teacher is involved, can use alcohol-based hand rubs."
But for making sure hands are clean and aren't a conduit for bacteria and viruses, nothing can beat plain soap and water, she says.
"There's been a lot of work around the world on the importance of handwashing or hand hygiene in children and how that prevents transmission of disease between kids," says Henry.
In her new book coming out in September - "Soap and Water & Common Sense: The Definitive Guide to Viruses, Bacteria, Parasites and Disease" - she details how researchers provided plain soap to children in the slums of Karachi, Pakistan.
Even though the water they were using was contaminated, introducing soap led to a big drop in gastrointestinal and respiratory illnesses among the children and cut the death rate dramatically.
"Washing your hands is one of those things that's old-fashioned, but it still makes a lot of sense - and it's as true today as it was hundreds of years ago," she says.
"There are things that we can do that will protect us and they're not high-tech. They're very simple and they do work."