How do we handle COVID-19 in schools now? Testing and masking must be in the mix

Opinion: The fall semester brings new challenges with the delta variant and younger students who cannot yet be vaccinated. How will Arizona schools respond?

Kyle Freese
opinion contributor
Behind clear partitions for COVID-19 concerns, Yajaira Denisse Carmona Rojas, 11, does social studies work at Gateway Elementary School in Phoenix on March 18, 2021. Other than a brief return to in-person school in the fall, this was the first day the sixth graders were back in-person at the school since the COVID-19 pandemic began in March 2020.

In August 2020, I wrote about how rapid SARS-CoV-2 testing is one of the ways in which we could safely return our children to school.

Eleven months – and a full school year – later, we are still struggling to implement a systemwide, cohesive, sustainable strategy that balances the benefits of in-person instruction with the risks of infectious disease spread.

Protocols can vary between schools (e.g. temperature checks, mask wearing, distancing, physical barriers) and, as I have observed, are not applied consistently or correctly within a single institution.

It is no surprise that we still see positive cases and clusters of infections in summer schools; the fall semester will bring new challenges as larger groups get back together and start mixing.

Emerging variants, suboptimal adult vaccine uptake and a yet-to-be-authorized vaccine for young children are a few of the reasons why these conversations cannot stop.

Vaccines aren't a solution (yet) for younger kids

Though accessible COVID-19 vaccination has changed the equation for adolescents and adults (the FDA-authorized age for the Pfizer vaccine is 12 and older), elementary schools, daycares and preschools still have the challenge of managing risk using other public health tools, some of which are inconvenient and unpopular (e.g. masking and distancing).

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Fortunately, our epidemiologic understanding of COVID-19 among children is also better understood than last year.

  1. We know children can still become infected but are less likely to suffer severe outcomes from COVID-19.
  2. Children with SARS-CoV-2 infection can still shed and pass along the virus to others, which is why our preventive approaches (e.g. masking) should not differ between adults and children.
  3. Studies have shown that SARS-CoV-2 transmission is likely no different in schools than in noneducational settings.

But because asymptomatic disease is common in children and testing is not widespread for this group, it is plausible that current estimates of caseload and transmission underestimate the true burden.

Finally, as a recent research study found, school-based testing can help maintain in-person school operations.

We need other strategies to keep schools open

Individual-based testing can be expensive over the long term. Fortunately, there are other strategies for daily testing, one of which is pooled-sample testing, which uses a tiered approach of testing many samples at once and in the event of a positive result, individuals are tested.

While research needs to continue to confirm the most sustainable testing and disease mitigation methods, our collective experiences and observations over the past year can help us develop strategies to combat the spread of SARS-CoV-2 as we continue to navigate an ongoing pandemic.

Preventive measures in schools should reflect the burden of SARS-CoV-2 in the surrounding community.

The CDC said it best: “If community transmission is high, students and staff are more likely to come to school while infectious, and COVID-19 can spread more easily in schools.”

That brings us to testing. Though the testing landscape is much different than it was last August, implementing a systemwide, daily testing strategy in communities with low viral transmission is likely not a wise use of resources.

That includes testing, especially as cases rise

In “low risk” communities, maintaining the current CDC recommendations of masking and social distancing, and commonsense hygiene practices (such as frequent hand washing and staying home when sick) is likely sufficient in managing risk.

However, if community transmission increases, initiating rapid testing protocols within schools could serve to help maintain in-person school operations and eliminate the possibility of schools further amplifying infectious disease spread.

Importantly, these measures could be used temporarily until community transmission recedes. Dynamic approaches are needed to balance risk of infection and cost of intervention — as well as the cost of not intervening.

Overall, we need geographically sensitive and specific approaches. Advancements in data collection make these goals achievable; population-level SARS-CoV-2 and vaccination data are populated in near real-time and can help guide adaptive responses.

If we are serious about moving beyond COVID-19 – both to prevent direct morbidity and mortality but also the social, emotional and educational consequences for children – we need a unified, collaborative approach between public health, school administrators and members of individual communities.

Kyle Freese, MPH, PhD, is an epidemiologist with STChealth, a public health intelligence company in downtown Phoenix. Reach him at kyle_freese@stchome.com; on Twitter, @Epi_DrFreese.