We were among the earliest advocates of testing in schools, and this past summer we recommended implementation of a test-and-stay program that leveraged daily antigen testing to keep unvaccinated kids exposed to COVID-19 in school if they tested negative. But the context of the pandemic has changed — specifically, new variants and vaccine availability for all K-12 students — and these changes render the program obsolete.
It’s time to rethink strategies that worked well for the fall semester and to adopt policies — like self-directed at-home rapid antigen testing (for vaccinated, not just unvaccinated students and staff) — that are more aligned with the changing nature of the pandemic. This shift will also ease the workload of school nurses, who are among the most unsung heroes of the pandemic. The plan Governor Baker announced Tuesday is a step in this direction.
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Test-and-stay programs allow unvaccinated students who are close contacts of an in-school case to take daily rapid antigen tests at school as an alternative to mandatory quarantine. Students who test negative are able to stay in school and benefit from valuable in-person learning.
The Massachusetts test-and-stay program was a major policy success — we learned that even with the Delta variant, transmission in schools remained low, and very similar to rates seen last school year.
Evidence for the test-and-stay approach came from a large trial from the United Kingdom. This trial found that rates of transmission were similar in schools where kids were instructed to stay home after a classroom close contact and those where exposed kids were tested daily but remained in school. Data from the Massachusetts program, and from other programs from across the country, add to what we learned from the UK trial, and found that testing-to-stay did not lead to substantial increases in in-school transmission events.
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However, the test-and-stay program was conceived and designed before every school-aged child had access to a safe and effective vaccine, and Massachusetts families have stepped up — nearly half of children ages 5-11 have begun their vaccine series, in addition to the nearly 80 percent of kids age 12 and up. In December, acknowledging that the current phase of the pandemic focuses on mitigation rather than containment, Massachusetts significantly scaled back its contact tracing. Because the goal of the test-and-stay program was to limit quarantines, these changes have made in-school contact tracing and test-to-stay programs outdated.
Revamping testing and quarantine policy for all students is also supported by the newest K-12 school COVID-19 guidelines from the PolicyLab at the Children’s Hospital of Philadelphia and by the American Academy of Pediatrics chapter in Vermont, where this change has already been adopted. Along these same lines, Connecticut implemented “screen-and-stay” in the fall (daily symptom assessments rather than daily testing) and Rhode Island utilizes a more self-directed “monitor and stay.”
So what should the next phase of in-person school look like? Vaccination continues to provide powerful protection against severe COVID-19. Massachusetts families have done well, but we need to continue to do everything we can to ensure every student in the state has access to these safe and effective vaccines. All K-12 students who are vaccine-eligible should be immunized as soon as possible to protect their own health, and to facilitate as much time in the classroom as possible.
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We need to look toward paving a path to normalcy for our kids, and that will mean making in-person school more like every other aspect of society. We need to move toward treating COVID-19 like we treat every other endemic respiratory virus: Get vaccinated, stay home when you are sick, test yourself if you have symptoms, and protect yourself with a high quality mask if you are at increased risk for severe COVID-19. Expanding access to affordable at-home antigen tests is an essential element of this next phase.
The application of aggressive mitigation strategies in schools — while not doing the same anywhere else — sends the message that schools are inherently less safe than other settings, but we know that is not true. In fact, transmission is far more likely to occur at home or in the community than at school, so it doesn’t make sense to chase down low-risk exposures when we are not chasing down high-risk ones. COVID-19 is not the only important health outcome; living in constant fear is not safe or healthy for students.
Remote school is a failed and inequitable experiment, and keeping kids in classrooms should be a top priority. It is also true that change — and particularly change in the direction of using fewer mitigation strategies — is challenging and scary. Decades of scientific research tell us that as difficult as implementation is, de-implementation is harder.
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Mitigation measures are a visible sign that COVID-19 is being taken seriously — tangible markers of pandemic safety. All school-age children and adults now have access to the tools they need to keep themselves safe from severe disease. Change will be hard, but its time has come.
Westyn Branch-Elliman is an associate professor of medicine at Harvard Medical School. Elissa Perkins is the director of emergency medicine infectious disease management at Boston Medical Center/Boston University School of Medicine, where she is an associate professor of emergency medicine. 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.
Clarification: All three doctors are unpaid advisors to the Massachusetts commissioner of education; Dr. Doron also advises Governor Charlie Baker.
