A ‘test-to-stay’ strategy can keep our kids in school

Martha Fulford is an infectious diseases physician at McMaster University. Alanna Golden is a family physician and former social worker. Andrew Latchman is a pediatrician at McMaster Children’s Hospital.

With COVID case counts once again spiking, parents and children are on edge, worried that in-person schooling won’t return after the holidays. But just because the virus is circulating in our communities, it doesn’t mean that schools should close. In fact, a closer look at data shows that in-person school attendance may not be a major driver of transmission after all.

A report released by the Royal Society of Canada notes that due to pandemic education disruptions, Canadian children and youth have experienced disengagement, chronic attendance problems, declines in academic achievement and decreased credit attainment. Disadvantaged groups have been the most affected. According to the Hospital for Sick Children, the COVID-19 pandemic has presented a new level of urgent need for mental health services for children and youth, with a 55 per cent increase in eating disorder admissions and a 30 per cent increase in psychiatry admissions.

Despite persistent concerns regarding in-school transmission, studies have not shown this to be a significant issue. A 2020 study of COVID-19 transmission in Vancouver schools found that the trend in new cases among the school population mirrored that of the general population. When school-based transmissions occurred, the number of identified secondary cases was small, representing 0.04 per cent of individuals working in or attending school. Staff members were more likely to bring the virus into the schools, when compared with students.

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An Australian study of 39 cases at schools found the infected students and staff had thousands of contacts between them, but there were only 33 secondary positive cases. A Mississippi study found that school attendance was not associated with positive test results. However, close contacts with people with COVID-19, attending gatherings and having visitors in the home were associated with infections among children and adolescents. Several additional studies have concluded that students are not the primary source of exposure to COVID among adults in a school setting.

In an effort to avoid classroom and school closures, a “test-to-stay” strategy can be used whereby children remain in the classroom following a close contact exposure. A study published in The Lancet found that daily testing of school-based contacts was equivalent to self-isolation for control of COVID-19 transmission, with similar rates of symptomatic infections among students and staff. Infection rates in school-based contacts were low, with very few school contacts testing positive.

An earlier study conducted by the Centers for Disease Control and Prevention looked at two high school COVID-19 testing programs to sustain in-person instruction and extracurricular activities. Over a six-month period, the program regularly tested almost 60,000 students, facilitating the completion of 95 per cent of extracurricular activities and saving more than 100,000 days of in-person instruction. A more recent CDC study also supports test-to-stay as an effective and safe strategy. This Illinois-based study allowed 1,035 students to remain in school, with only 16 contacts infected, and no further in-school spread. On Friday, the CDC said students who have been exposed to the coronavirus can remain in school as long as they receive two negative tests during the following week.

In October, Ontario announced that expanded testing options would be available to reduce disruption and absenteeism in schools. One such strategy was the launch of a new test-to-stay approach for asymptomatic students, using rapid antigen screening tests to support in-person learning and avoid school shutdowns. However, these expanded testing options do not apply to close-contact exposures. Furthermore, there have been at least 10 schools closed since September, suggesting that this expanded testing option has not been widely implemented.

At this critical juncture, public health officials must strongly consider the use of a test-to-stay strategy where students remain in the classroom following a close-contact exposure. Regular use of rapid antigen testing in this context can be administered in-school or at home. Local public health units could be deployed to assist with this testing in schools, and school personnel and nursing staff could be trained to correctly administer these tests. Information sessions could be offered to parents to provide instruction on testing, and results could be confirmed with PCR tests where applicable.

Children and youth need to be in school and should no longer be subjected to extended absences and closures. By using this method, we can avoid repeating the harms that children experienced earlier in the pandemic.

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