Commentary October 23, 2020

The Missing Piece — COVID-19 Testing and School Reopening

Stanford Health Policy's Michelle Mello and Stanford medical student Yasmin Rafiei write in this New England Journal of Medicine perspective that most school reopening plans focus on screening for Covid-19 symptoms. Yet recent research indicates that symptom screening alone will not enable schools to contain Covid-19 outbreaks.
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On August 17, 2020, the Los Angeles Unified School District launched a program to test more than 700,000 students and staff for SARS-CoV-2. The district is paying a private contractor to provide next-day, early-morning results for as many as 40,000 tests daily. As of October 4, a total of 34,833 people had been tested at 42 sites. The program is notable not only because it’s ambitious, but also because it’s unusual: testing is conspicuously absent from school reopening plans in many other districts. Typically, exhaustive attention has instead focused on physical distancing, face coverings, hygiene, staggering of schedules, and cohorting (dividing students into small, fixed groups). Although the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, the National Academies of Sciences, Engineering, and Medicine, and state officials have urged schools to prepare for Covid-19 cases, they have offered strikingly little substantive guidance on testing. Immediate attention to improving testing access and response planning is essential to the successful reopening of schools.

Available guidance documents typically instruct schools to gain access to testing by contacting local public health departments, and few schools appear to have solidified a strategy — especially one that extends beyond testing of symptomatic persons. For instance, public schools in Boston and in Miami-Dade County will not conduct screening testing and are placing responsibility on parents for testing symptomatic children. New York State strongly recommends that schools not conduct testing. However, after its teachers union threatened to strike over safety concerns, New York City added monthly random screening testing for 10 to 20% of staff and students, with more frequent testing in hot spots.

Most reopening plans instead focus on screening for Covid-19 symptoms. Yet recent research indicates that symptom screening alone will not enable schools to contain Covid-19 outbreaks.1 Because an estimated 40% of Covid-19 cases are asymptomatic and 50% of transmissions occur from asymptomatic persons, we believe that screening testing is critical. Nevertheless, until October 13, the CDC recommended against screening testing in schools, citing constraints on testing capacity and the unavailability of real-world studies of its effectiveness. The newer guidance states that schools “might choose” to offer voluntary testing and that their decisions “should be guided by what is feasible, practical, and acceptable” and should prioritize symptomatic persons and close contacts of persons diagnosed with Covid-19.

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