Almost a year ago, we led a group of physicians across Massachusetts in writing to Governor Baker with a plea to implement COVID-19 testing in schools — as a way to keep infected children out of classrooms. But now, with the advances in technology and knowledge that over a year of the coronavirus pandemic has brought us, we are instead advocating to use testing as a way to keep unmasked and unvaccinated kids in school.
In a June 18 press conference, Baker stated that “we should expect that when kids go back in the fall, they’re going to be going back to a school that looks and feels a lot like the one they went to before COVID.” He went on to say that he did not believe masks will be necessary for children in school — even if children remain unvaccinated — provided that COVID-19 case counts and hospitalizations are low.
Earlier this week, updated guidance from the American Academy of Pediatrics included a blanket recommendation for universal masking, regardless of local data and vaccination status. Subsequently, in a July 22 press conference, Baker reiterated that his administration has no plans to reinstate mask mandates for schools this fall. We know from over a year of schooling during the pandemic that the data-driven approach to infection control policies in schools is not a one-size-fits-all approach, but rather one that is informed by current local COVID-19 case incidence, rates of hospitalizations, and deaths. These metrics can be used to guide decisions about masking and other interventions. This is the evidence-based way to implement infection control policies in schools, especially given the highly successful vaccination campaigns throughout the Northeast region.
As Bay Staters think about how masking and distancing policies may be updated, especially with the emergence of the Delta variant, we also need to think about how testing policies should evolve along with them. In the spring, the Department of Elementary and Secondary Education stood up a pooled testing program and found low rates of COVID-19 cases in schools, with little evidence of in-school transmission. It was an effective way to reassure the public that schools are safe. But it will be less useful if implemented this coming academic year, when disease prevalence, and especially prevalence of severe disease, is expected to be lower in the state due to vaccination. However, the infrastructure and processes developed for asymptomatic screening last year can be used this year in creative new ways – especially if unmasked students are considered close contacts of a classmate or teacher who tests positive, and, without testing, would be kept out of school until a full quarantine period is over.
Last week, the Centers for Disease Control and Prevention updated guidance to specify that students masked, in classrooms, three feet apart are not considered close contacts if someone tests positive, and therefore do not need to quarantine. We scientists strongly advocated for this policy, and it was adopted in Massachusetts in the spring. The CDC continues to recommend masking for unvaccinated individuals in indoor settings in schools; however, we know that several states, including Vermont, Iowa, and South Carolina, are not mandating mask requirements for students attending traditional, in-person school. If schools do indeed go back to looking like they did before COVID, without distancing and masking, testing programs could be used to help keep schools open in two complementary ways: a rapid diagnostic program for students or staff with symptoms, and a daily testing program for unmasked and unvaccinated close classroom contacts of a known case who last year would have been subject to quarantine and remote schooling.
Already this summer there has been a surge of non-COVID viral respiratory illness. Students in summer programs are missing all the fun while they stay home and await results of COVID tests that, here in New England, are still mostly negative. A diagnostic testing program for students and staff that tests both for COVID and for influenza, which will probably return this fall and winter as pandemic precautions continue to be rolled back, would help to balance safety and in-person schooling. Schools will need to know — and fast — if a child with respiratory illness is infected with COVID-19 or influenza — or neither. In the latter case, the infected student would be sent home and wait to return to in-person learning until symptoms resolve, but usual school operations could continue uninterrupted for all of the other students and staff and without quarantines or closures. Polymerase chain reaction (PCR) technology, which detects viral genetic material and is the preferred diagnostic test, has advanced dramatically — there are sensitive assays available with turnaround times under 30 minutes. Such tests should be made available in schools to support rapid and informed decision making.
A positive COVID diagnosis in a student or school staff member who is not masked or vaccinated could result in many potential exposures requiring quarantine for a lot of people. But, due to a phenomenon called the “dispersion factor”, most COVID-19 infections never result in a single transmission. With research and clinical studies on a pediatric COVID vaccine currently ongoing, it is not at all certain that a vaccine for children under 12 will be available in the near future, and with cases expected to rise and fall over the next school year, it is critical to provide an alternative path for keeping exposed individuals in schools — if school districts think about the role of testing in schools differently. The infrastructure developed for the screening testing program piloted in Massachusetts this past spring could be leveraged to monitor close contacts to detect the development of infection early while keeping classrooms open and full. Specifically, rapid and repeated (daily) testing of unvaccinated close contacts, a strategy referred to as “test-to-stay” and endorsed by The PolicyLab at Children’s Hospital of Philadelphia, would allow them to remain in live, in-person instruction (with a mask on until the end of the daily testing period), provided no cases of transmission to anyone else are identified.
If additional cases are identified using the daily testing program, a scenario that would be more or less likely to occur depending on the specific setting (e.g. how well ventilated a school is) or the transmissibility of the currently circulating viral variants, quarantine with a temporary shift to remote schooling might then be warranted to ensure the cluster is contained. Daily testing of exposed individuals — rather than automatic quarantine and classroom closure — would balance safety and outbreak control with the importance of keeping children where they belong – learning in-person, in classrooms and not in front of a computer.
Unfortunately, COVID will continue to be part of our world, and we need to learn to live with it. Sending children to school during a pandemic has required adaptation and innovation — the Delta variant only makes that more true. It’s time to innovate how we use testing — as a way to keep kids in schools, not out of them.
Dr. Shira Doron is an infectious disease physician and the hospital epidemiologist at Tufts Medical Center. She is an associate professor of medicine at Tufts University School of Medicine. Dr. Elissa Perkins is director of Emergency Medicine Infectious Disease Management at Boston Medical Center/Boston University School of Medicine. She is an associate professor of emergency medicine. Dr. Westyn Branch-Elliman is an assistant professor of Medicine at Harvard Medical School.