Funding for Rapid, Local Testing Is Necessary to Facilitate Safe School Re-Opening: An Open Letter to State Governments
We are two physicians, experts in infectious diseases, epidemiology, and disease outbreak responses, and also mothers of elementary school-aged children. Together, we serve on our town’s school re-opening committee. As part of our participation in this committee, we have noted the need for additional funding to support an adequate testing program to facilitate the safest school re-opening.
Westyn Branch-Elliman, MD, MMSc and Elissa Perkins, MD, MPH
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July 20, 2020
We are writing to urge state governments to designate state funding and resources to towns to facilitate and streamline surveillance screening for COVID-19; this includes funding to expand access to rapid testing in order to facilitate in-person school opening.
Information, including case identification and contract tracing, is the cornerstone of outbreak management. Accurate prevalence data, at the school and district level, is crucial to understanding whether or not in-person schooling is safe. However, the current strategy of performing diagnostic testing only, with delayed turnaround times and through a decentralized system of unlinked providers, hinders our ability to understand in real-time what is happening in any given district.
Widespread availability of testing, with rapid turnaround, is essential to ensure that we have the safest possible school re-opening strategy and the best chance to ensure children are able to stay in the classroom. Designating local resources with the authority to conduct the testing is also essential, as primary care physicians, including pediatricians’ offices throughout the state, do not have the necessary infrastructure to manage population-based testing. Furthermore, a decentralized process- with each child receiving the testing at a different location, and a different organization responsible for collecting the sample, and obtaining and reporting the results, is likely to result in errors, including lost samples and failure of reporting. Thus, it is essential that a centralized system with an organized structure be created.
Strategies that utilize recurrent testing for epidemiologic purposes would be ideal. Testing all students and staff at a pre-defined frequency (weekly or even every two weeks) would allow a school to stay ahead of a potential outbreak. However, even if we are unable to support frequent testing at pre-defined intervals, COVID-19 testing in potential outbreak situations must be easily accessible, cheap, atraumatic for the child, and with a rapid turnaround time that is fast enough to identify cases in enough time to appropriately institute quarantines, and also fast enough to get children who do not have COVID back into the classroom to maximize opportunities for learning and growth.
Relying on pediatrician’s offices to perform diagnostic RT-PCR testing for both symptomatic students, as well as exposure testing for their asymptomatic close classroom contacts will quickly over-burden even the most efficient pediatricians. Additionally, the long turnaround time of this diagnostic testing modality — local pediatrician’s offices are reporting an 8–9 day turnaround time, and CVS announced recently that tests performed in their urgent care offices will take 6–10 days to result — will render these tests essentially useless. By the time the index case gets a positive test result, the close contacts (exposed) have been transmitting disease, unknowingly, for days. Then, they start their quarantine, only to be unable to end it via a test-based strategy, because they are nearly out of the quarantine period by the time they get tested and receive their results. In addition, if there is a cluster, rather than limiting spread throughout the school, asymptomatic children will continue to attend school, interacting with other children in other classrooms, and leading to a much larger impact not only within the school but potentially within the entire community, and state.
Fortunately, there are tests available that can be cheap, atraumatic, with a quick turnaround time, and easy to administer even with limited training. Point-of-care nucleic acid LAMP and rapid antigen tests both fit these criteria. Although there is some sacrifice of sensitivity when these tests are chosen over alternatives, the viral kinetics of SARS CoV-2 suggest during the period of exponential growth of the virus, when infectiousness is highest, there is only a limited window (on the order of hours) in which only the more sensitive RT-PCR test could diagnose individuals but the less sensitive tests would not. (https://www.medrxiv.org/content/medrxiv/early/2020/06/27/2020.06.22.20136309.full.pdf). When a student has symptoms compatible with COVID-19, these tests will be positive during the periods of infectivity, so will be able to quickly determine if it is in fact COVID-19, and the districts could immediately begin testing close contacts, with rapid answers. Critically, because these tests are easy to collect and process, there is the potential to implement them within school systems or townships, thus expanding access to testing, increasing speed of results, and also facilitating a centralized monitoring system that can be used to ensure nothing falls through the cracks.
The only way for these strategies to work is if the epidemiologic work is transferred from physician offices to the towns, or to the nursing programs already embedded within the schools. State or federal funding allocated to Local Boards of Health and earmarked for purchase of necessary supplies and implementation is crucial to safe school reopening.
Elissa Perkins, MD MPH is an Associate Professor of Emergency Medicine at Boston University School of Medicine and Boston Medical Center, where she is the director of Emergency Medicine Research. She is Co-Chair of the Society for Academic Emergency Medicine IG: Emergency Medicine Transmissible Infectious Diseases and Epidemics. Her research is focused on diagnosing and managing infectious diseases of public health significance.
Westyn Branch-Elliman, MD, MMSc is an Assistant Professor of Medicine at Harvard Medical School and a specialist in infectious diseases. She is a clinician investigator at the VA Center for Healthcare Organization and Implementation Research with expertise in epidemiology and implementation science. Her research is focused on measuring the risks and benefits of different infection prevention strategies and on expanding infection control beyond traditional inpatient settings.
Note: The views expressed are the authors’ own, and do not necessarily reflect those of their employers or the federal government.
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