Minimal SARS-CoV-2 Transmission After Implementation of a Comprehensive Mitigation Strategy at a School - New Jersey, August 20-November 27, 2020

Assessment of COVID-19 Messaging Strategies to Increase Testing for Students With Intellectual and Developmental Disabilities

BACKGROUND

Students with intellectual and developmental disabilities (IDD) were disproportionately impacted by the COVID-19 pandemic. This study's goal was to assess the effectiveness of 2 messaging strategies on participation in SARS-CoV-2 weekly testing.

METHODS

Cluster randomized trials were conducted at 2 school systems, the special school district (SSD) and Kennedy Krieger Institute (Kennedy) to assess messaging strategies, general versus enhanced, to increase weekly screening for SARS-CoV-2. Testing was offered to staff and students from November 23, 2020 to May 26, 2022. The primary outcomes were percentage of students and staff consented weekly and percentage of study participants who had a test performed weekly. Generalized estimating equation models were utilized to evaluate the primary outcomes.

RESULTS

Increases in enrollment and testing occurred during study start up, the beginning of school years, and following surges in both systems. No statistical difference was observed in the primary outcomes between schools receiving standard versus enhanced messaging.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Frequent and consistent communication is vital for families and staff. Weekly screening testing within schools is possible and highlighted the importance of utilizing equitable protocols to provide important testing to students with IDD.

CONCLUSION

Enhanced messaging strategies did not increase the number of participants enrolled or the percentage of enrolled participants being tested on a weekly basis.

Previous Infection and Effectiveness of COVID-19 Vaccination in Middle- and High-School Students

BACKGROUND AND OBJECTIVES

Understanding the real-world impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mitigation measures, particularly vaccination, in children and adolescents in congregate settings remains important. We evaluated protection against SARS-CoV-2 infection using school-based testing data.

METHODS

Using data from Utah middle- and high-school students participating in school-wide antigen testing in January 2022 during omicron (BA.1) variant predominance, log binomial models were fit to estimate the protection of previous SARS-CoV-2 infection and coronavirus disease 2019 vaccination against SARS-CoV-2 infection.

RESULTS

Among 17 910 students, median age was 16 years (range: 12-19), 16.7% had documented previous SARS-CoV-2 infection; 55.6% received 2 vaccine doses with 211 median days since the second dose; and 8.6% of students aged 16 to 19 years received 3 vaccine doses with 21 median days since the third dose. Protection from previous infection alone was 35.9% (95% confidence interval [CI]: 12.9%-52.8%) and 23.8% (95% CI: 2.1%-40.7%) for students aged 12 to 15 and 16 to 19 years, respectively. Protection from 2-dose hybrid immunity (previous SARS-CoV-2 infection and vaccination) with <180 days since the second dose was 58.7% (95% CI: 33.2%-74.4%) for students aged 12 to 15 and 54.7% (95% CI: 31.0%-70.3%) for students aged 16 to 19 years. Protection was highest (70.0%, 95% CI: 42.3%-84.5%) among students with 3-dose hybrid immunity, although confidence intervals overlap with 2-dose vaccination.

CONCLUSIONS

The estimated protection against infection was strongest for those with hybrid immunity from previous infection and recent vaccination with a third dose.

Testing Likely Response to Behavioral Nudges and Shoves to Promote COVID-19 Vaccine Uptake Amongst Segments of the Unvaccinated Population of South Africa

In early 2022, as the vaccination rate in South Africa slowed, there was a strong need for COVID-19 communications to evolve from mass information and education campaigns targeting the general population, to more targeted approaches to motivate uptake amongst population segments facing convenience, complacency, and confidence barriers.Project Last Mile (PLM) and Ipsos conducted a representative study of the population of South Africa to: (1) understand population segments with regards to their likelihood of getting the COVID-19 vaccine, (2) understand the drivers and barriers around getting the COVID-19 vaccine for each segment; and (3) test the likelihood of adoption of a range of enabling, incentivizing, and mandating behavioral interventions ("nudges and shoves").The study demonstrated that a significant proportion of the unvaccinated population is willing to get vaccinated, given the right conditions. Making it easy and convenient to get vaccinated (enabling) is likely to deliver moderate to strong impact. Ease of access, the ability to take time off from work, the provision of a reservation, and free transportation were the most influential factors in encouraging vaccination for the largest number of people.

Behavioral and Personal Characteristics Associated With Risk of SARS-CoV-2 Infection in a Spanish University Cohort

The aim of this study was to analyze the life habits and personal factors associated with increased severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) risk in a university environment with in-person lectures during the coronavirus disease 2019 (COVID-19) pandemic. To our knowledge, there are no previous longitudinal studies that have analyzed associations of behavioral and personal factors with the risk of SARS-CoV-2 infection on an entire university population. A cohort study was conducted in the 3 campuses of the University of Navarra between August 24, 2020, and May 30, 2021, including 14,496 students and employees; the final sample included 10,959. Descriptive and multivariate-adjusted models were fitted using Cox regression. A total of 1,032 (9.4%) participants were diagnosed with COVID-19 (879 students and 153 employees), almost 50% living with their families. COVID-19 was associated with living in college or residence (hazard ratio (HR) = 1.96, 95% CI: 1.45, 2.64), motor transportation (HR = 1.35, 95% CI: 1.14, 1.61), South American origin (HR = 1.43, 95% CI: 1.20, 1.72), and belonging to Madrid's campus (HR = 3.11, 95% CI: 2.47, 3.92). International students, especially from Latin America, mostly lived in university apartments or shared flats and cohabited with 4-11 people. Living in a big city (Madrid), was a significant risk factor.

Prevalence and Risk Factors for School-Associated Transmission of SARS-CoV-2

Importance

School-associated SARS-CoV-2 transmission is described as uncommon, although the true transmission rate is unknown.

Objective

To identify the SARS-CoV-2 secondary attack rate (SAR) in schools and factors associated with transmission.

Design, Setting, and Participants

This cohort study examined the risk of school-based transmission of SARS-CoV-2 among kindergarten through grade 12 students and staff in 10 Massachusetts school districts during 2 periods: fall 2020/spring 2021 (F20/S21) and fall 2021 (F21). School staff collected data on SARS-CoV-2 index cases and school-based contacts, and SAR was defined as the proportion of contacts acquiring SARS-CoV-2 infection.

Exposure

SARS-CoV-2.

Main Outcomes and Measures

Potential factors associated with transmission, including grade level, masking, exposure location, vaccination history, and Social Vulnerability Index (SVI), were analyzed using univariable and multivariable logistic regression models.

Results

For F20/S21, 8 school districts (70 schools, >33 000 students) were included and reported 435 index cases (151 staff, 216 students, and 68 missing role) with 1771 school-based contacts (278 staff, 1492 students, and 1 missing role). For F21, 5 districts (34 schools, >18 000 students) participated and reported 309 index cases (37 staff, 207 students, and 65 missing role) with 1673 school-based contacts (107 staff and 1566 students). The F20/S21 SAR was 2.2% (lower bound, 1.6%; upper bound, 26.7%), and the F21 SAR was 2.8% (lower bound, 2.6%; upper bound, 7.4%). In multivariable analysis, during F20/S21, masking was associated with a lower odds of transmission compared with not masking (odds radio [OR], 0.12; 95% CI, 0.04-0.40; P < .001). In F21, classroom exposure vs out-of-classroom exposure was associated with increased odds of transmission (OR, 2.47; 95% CI, 1.07-5.66; P = .02); a fully vaccinated vs unvaccinated contact was associated with a lower odds of transmission (OR, 0.04; 95% CI, 0.00-0.62; P < .001). In both periods, a higher SVI was associated with a greater odds of transmission.

Conclusions and Relevance

In this study of Massachusetts schools, the SAR for SARS-CoV-2 among school-based contacts was low during 2 periods, and factors associated with transmission risk varied over time. These findings suggest that ongoing surveillance efforts may be essential to ensure that both targeted resources and mitigation practices remain optimal and relevant for disease prevention.

At-Home Versus Onsite COVID-19 School-based Testing: A Randomized Noninferiority Trial

OBJECTIVES

Equitable access to coronavirus 2019 (COVID-19) screening is important to reduce transmission and maintain in-person learning for middle school communities, particularly in disadvantaged schools. Rapid antigen testing, and at-home testing in particular, could offer substantial advantages over onsite testing from a school district's perspective, but it is unknown if engagement in at-home testing can be initiated and sustained. We hypothesized that an at-home COVID-19 school testing program would be noninferior to an onsite school COVID-19 testing program with regard to school participation rates and adherence to a weekly screening testing schedule.

METHODS

We enrolled 3 middle schools within a large, predominantly Latinx-serving, independent school district into a noninferiority trial from October 2021 to March 2022. Two schools were randomized to onsite and 1 school to at-home COVID-19 testing programs. All students and staff were eligible to participate.

RESULTS

Over the 21-week trial, at-home weekly screening testing participation rates were not inferior to onsite testing. Similarly, adherence to the weekly testing schedule was not inferior in the at-home arm. Participants in the at-home testing arm were able to test more consistently during and before returning from school breaks than those in the onsite arm.

CONCLUSIONS

Results support the noninferiority of at-home testing versus onsite testing both in terms of participation in testing and adherence to weekly testing. Implementation of at-home COVID-19 screening testing should be part of schools' routine COVID-19 prevention efforts nationwide; however, adequate support is essential to ensure participation and persistence in regular at-home testing.

Barriers and facilitators to COVID-19 testing among staff and parents from San Diego schools

COVID-19 testing is an important risk mitigation strategy for COVID-19 prevention in school settings, where the virus continues to pose a public health challenge for in-person learning. Socially vulnerable school communities with the highest proportion of low-income, minority, and non-English speaking families have the least testing access despite shouldering a disproportionate burden of COVID-19 morbidity and mortality. Through the Safer at School Early Alert (SASEA) program, we investigated community perceptions of testing in San Diego County schools, with a focus on barriers and facilitators from the perspective of socially vulnerable parents and school staff. Using a mixed-methods approach, we administered a community survey and conducted focus group discussions (FGDs) with staff and parents from SASEA-affiliated schools and childcares. We recruited 299 survey respondents and 42 FGD participants. Protecting one's family (96.6%) and protecting one's community (96.6%) were marked as key motivators to testing uptake. School staff in particular reported that the reassurance of a negative status mitigated concerns about COVID-19 infection in schools. Participants expressed that COVID-19-related stigma, loss of income as a result of isolation/quarantine requirements, and lack of multilingual materials were the most significant barriers to testing. Our findings suggest that the testing barriers faced by school community members are predominantly structural. Testing uptake efforts must provide support and resources to manage the social and financial consequences of testing while continuously communicating its benefits. There is a clear need to continue to incorporate testing as a strategy to maintain school safety and facilitate access for vulnerable community members.

Evaluation of a COVID-19 rapid antigen testing program among student athletes in a public high school district

PURPOSE

The purpose of this study is to evaluate a COVID-19 rapid antigen testing program among high school athletes through testing data and qualitative analysis from key stakeholders.

METHODS

Testing data was obtained by the partnering school district. Testing staff, coaches, and parents participated in a focus group using a semi-structured focus group guide. Transcripts were analyzed using a grounded theory approach to produce the themes of the study.

RESULTS

Rapid antigen tests quickly identified a COVID-19-positive student athlete, which allowed for quick isolation and zero transmission to teammates. Focus groups with parents, testing staff, and coaches indicated the testing program improved perceived safety and demonstrated the ability for school staff to implement a widespread COVID-19 screening program with minimal training.

CONCLUSIONS

As schools continue to respond to various waves of COVID-19 infections, targeted testing for high-risk activities in school settings such as sports programs may help prevent school outbreaks during times of high community transmission rates. This evaluation adds to a body of literature that will aid schools and policy makers in their decision on how to best keep student athletes and school communities safe for future waves of COVID-19 infection and other pandemics.

SARS-CoV-2 Screening Testing Programs for Safe In-person Learning in K-12 Schools

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening testing is a recommended mitigation strategy for schools, although few descriptions of program implementation are available.

METHODS

Kindergarten through 12th grade (K-12) students and staff practicing universal masking during the delta and omicron variant waves from five schools in Durham, North Carolina and eight schools in Kansas City, Missouri participated; Durham's program was structured as a public health initiative facilitated by school staff, and Kansas City's as a research study facilitated by a research team. Tests included school-based rapid antigen or polymerase chain reaction testing, at-home rapid antigen testing, and off-site nucleic acid amplification testing.

RESULTS

We performed nearly 5700 screening tests on more than 1600 K-12 school students and staff members. The total cost for the Durham testing program in 5 public charter K-12 schools, each with 500-1000 students, was $246 587 and approximately 752 h per semester; cost per test was $70 and cost per positive result was $7076. The total cost for the Kansas City program in eight public K-12 schools was $292 591 and required approximately 537 h in personnel time for school-based testing; cost per test was $132 and cost per positive result was $4818. SARS-CoV-2 positivity rates were generally lower (0-16.16%) than rates in the community (2.7-36.47%) throughout all testing weeks.

CONCLUSIONS AND RELEVANCE

Voluntary screening testing programs in K-12 schools are costly and rarely detect asymptomatic positive persons, particularly in universally masked settings.

CLINICAL TRIAL REGISTRATION

NCT04831866.

In-person classroom instruction and risk of SARS-CoV-2 infection among undergraduates at Indiana University, Fall 2020

Objective: To examine how in-person classroom instruction was related to risk of SARS-CoV-2 infection in undergraduate students. Participants: Indiana University undergraduate students (n = 69,606) enrolled in Fall 2020, when courses with in-person and remote instruction options were available. Methods: Students participated weekly in mandatory SARS-CoV-2 RT-PCR asymptomatic testing by random selection, supplemented with symptomatic testing as needed. We used log-binomial regression models to estimate the association between number of in-person credit hours and the risk of SARS-CoV-2 infection over the course of the semester. Results: Overall 5,786 SARS-CoV-2 cases were observed. Increased in-person credit hour exposures were not associated with increased risk of SARS-CoV-2 overall [aRR (95% CI): 0.98 (0.97,0.99)], nor within specific subgroups (Greek affiliation and class). Conclusions: In-person instruction did not appear to increase SARS-CoV-2 transmission in a university setting with rigorous protective measures in place, prior to mass vaccine rollout and prior to delta variant emergence.

Effect of Wearing a Face Mask on Hand-to-Face Contact by Children in a Simulated School Environment: The Back-to-School COVID-19 Simulation Randomized Clinical Trial

IMPORTANCE

Wearing a face mask in school can reduce SARS-CoV-2 transmission but it may also lead to increased hand-to-face contact, which in turn could increase infection risk through self-inoculation.

OBJECTIVE

To evaluate the effect of wearing a face mask on hand-to-face contact by children while at school.

DESIGN, SETTING, AND PARTICIPANTS

This prospective randomized clinical trial randomized students from junior kindergarten to grade 12 at 2 schools in Toronto, Ontario, Canada, during August 2020 in a 1:1 ratio to either a mask or control class during a 2-day school simulation. Classes were video recorded from 4 angles to accurately capture outcomes.

INTERVENTIONS

Participants in the mask arm were instructed to bring their own mask and wear it at all times. Students assigned to control classes were not required to mask at any time (grade 4 and lower) or in the classroom where physical distancing could be maintained (grade 5 and up).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of hand-to-face contacts per student per hour on day 2 of the simulation. Secondary outcomes included hand-to-mucosa contacts and hand-to-nonmucosa contacts. A mixed Poisson regression model was used to derive rate ratios (RRs), adjusted for age and sex with a random intercept for class with bootstrapped 95% CIs.

RESULTS

A total of 174 students underwent randomization and 171 students (mask group, 50.6% male; control group, 52.4% male) attended school on day 2. The rate of hand-to-face contacts did not differ significantly between the mask and the control groups (88.2 vs 88.7 events per student per hour; RR, 1.00; 95% CI, 0.78-1.28; P = >.99). When compared with the control group, the rate of hand-to-mucosa contacts was significantly lower in the mask group (RR, 0.12; 95% CI, 0.07-0.21), while the rate of hand-to-nonmucosa contacts was higher (RR, 1.40; 95% CI, 1.08-1.82).

CONCLUSIONS AND RELEVANCE

In this clinical trial of simulated school attendance, hand-to-face contacts did not differ among students required to wear face masks vs students not required to wear face masks; however, hand-to-mucosa contracts were lower in the face mask group. This suggests that mask wearing is unlikely to increase infection risk through self-inoculation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04531254.

Missing science: A scoping study of COVID-19 epidemiological data in the United States

Systematic approaches to epidemiologic data collection are critical for informing pandemic responses, providing information for the targeting and timing of mitigations, for judging the efficacy and efficiency of alternative response strategies, and for conducting real-world impact assessments. Here, we report on a scoping study to assess the completeness of epidemiological data available for COVID-19 pandemic management in the United States, enumerating authoritative US government estimates of parameters of infectious transmission, infection severity, and disease burden and characterizing the extent and scope of US public health affiliated epidemiological investigations published through November 2021. While we found authoritative estimates for most expected transmission and disease severity parameters, some were lacking, and others had significant uncertainties. Moreover, most transmission parameters were not validated domestically or re-assessed over the course of the pandemic. Publicly available disease surveillance measures did grow appreciably in scope and resolution over time; however, their resolution with regards to specific populations and exposure settings remained limited. We identified 283 published epidemiological reports authored by investigators affiliated with U.S. governmental public health entities. Most reported on descriptive studies. Published analytic studies did not appear to fully respond to knowledge gaps or to provide systematic evidence to support, evaluate or tailor community mitigation strategies. The existence of epidemiological data gaps 18 months after the declaration of the COVID-19 pandemic underscores the need for more timely standardization of data collection practices and for anticipatory research priorities and protocols for emerging infectious disease epidemics.

Implementation of Test-to-Stay programming to minimize learning loss in a pre-K-8 school district

Objectives

Determine if a school-based Test-to-Stay (TTS) program designed to minimize learning loss reduced the incidence of COVID-19 in a US primary school district.

Study design

Observational, simple summary analysis of attendance and effectiveness of a TTS program implemented in a California school district.

Methods

Retrospective analysis of nested medical and demographic data. Survival curves were plotted using a cumulative hazard function to compare the probability of infection among close contacts exposed at school at different points of time between participants who participated in TTS versus those who did not participate in TTS. A Cox proportional hazards regression model with time-dependent covariates was used to estimate the association of TTS status with the incidence of SARS-CoV-2 infection.

Results

Univariate Cox regression analysis revealed that after adjustment, enrollment in TTS was negatively correlated with the risk of SARS-CoV-2 infection (hazard ratio 0.096; 95% confidence interval [CI], 0.024–0.390; P < 0.001).

Conclusions

TTS is an effective component of a layered protection strategy to prevent COVID-19 transmission in schools and communities, while minimizing the loss of in-person instruction in primary schools.

Rapid Antigen Screening of Students and Staff for SARS-CoV-2 in Rural School Districts, Pierce County, WA, 2020

During fall 2020 in rural Pierce County, Washington, school districts and the county health department offered weekly rapid antigen screening to students and staff. Asymptomatic screening identified 42.5% of confirmed cases from the population. Parents reported it was a positive experience for their children. The program supported decisions to return to in-person learning, but screening ended because of resource and technical limitations. When planning in-school screening, stakeholder engagement and resource sustainability are important factors to consider. (Am J Public Health. 2022;112(8):1134-1137. https://doi.org/10.2105/AJPH.2022.306875).

Testing and Nonpharmaceutical Interventions for Prevention of SARS-CoV-2 in 20 US Overnight Camps in Summer 2021

Objectives:

Overnight camps are a setting where COVID-19 can easily spread without the diligent use of layered public health interventions. We evaluated 20 camps in the United States to examine COVID-19 transmission and mitigation strategies during summer 2021.

Methods:

For this descriptive cross-sectional study, we examined self-reported information from 20 camps in 6 predominantly northeastern states on geographic information, tests and testing cadences, vaccination rates, and number of COVID-19 cases during summer 2021. Because the camps had hired public health consultants to guide them on reducing COVID-19 introduction and spread, all camps implemented similar interventions, including encouraging behaviors that lower the risk of COVID-19 transmission prior to camp arrival, use of cohorts, testing before and after arrival, and strong encouragement of vaccination among eligible campers and staff members.

Results:

A total of 9474 attendees at the 20 camps came from geographically diverse regions. Camps generally tested before and at arrival, as well as once or twice after arrival. Rates of vaccination were high among staff members (84.6%) and campers (76.2%). Camps identified 27 COVID-19 cases, with 17 (63.0%) detected after arrival, 3 (7.4%) detected on arrival, and 8 (29.6%) detected prior to arrival.

Conclusions:

The spread of cases detected after arrival to overnight camps was limited by the use of 3 key interventions: (1) high vaccination rates, (2) a rigorous and responsive testing strategy, and (3) ongoing use of public health interventions. These findings have implications for successful operation of overnight camps, residential schools and colleges, and other similar settings.

Prospective Pilot Study Evaluating SARS-CoV-2 Transmission-Limiting Measures in an On-Site School

OBJECTIVES

The purpose of our study is to evaluate the feasibility and reliability of a comprehensive set of preventive measures in limiting secondary transmission of COVID-19 in schools.

METHODS

A prospective cohort study was conducted to evaluate SARS-CoV-2 transmission in an independent K-8 school in San Mateo County, California. The research was conducted between September 14, 2020 through March 22, 2021 and consisted of: 1) demographic and epidemiological questionnaires; 2) daily symptom reporting; 3) weekly RT-PCR testing; and 4) periodic on-site qualitative observations.

RESULTS

One hundred eighty (79%) students and 63 (74%) on-site staff/contractors were enrolled. Participants reported symptoms in 144 (<1%) daily surveys of the 19,409 collected. Among those who reported symptoms and exposures, none tested positive during the 22-week study period. Of all participants, a total of 6 tested positive for SARS-CoV-2 at least once by RT-PCR; all were asymptomatic at time of testing. No in-school transmission occurred. Mask adherence was high among all grades, and incidents of improper mask use mostly occurred during noninstruction time. Physical distancing was well-enforced during class time and snack breaks, although adherence during noninstruction time waned as the school year progressed.

CONCLUSIONS

Our comprehensive, prospective study following COVID-19 transmission over 22 weeks in a K-8 school demonstrates that: 1) surveillance testing is important for detecting asymptomatic infections in schools; 2) monitoring symptoms may not be necessary and/or sufficient for COVID-19; and 3) younger children can adhere to key mitigation measures (eg, masking) which have the potential to limit transmission.

SARS-CoV-2 Circulation in the School Setting: A Systematic Review and Meta-Analysis

The contribution of children to viral spread in schools is still debated. We conducted a systematic review and meta-analysis of studies to investigate SARS-CoV-2 transmission in the school setting. Literature searches on 15 May 2021 yielded a total of 1088 publications, including screening, contact tracing, and seroprevalence studies. MOOSE guidelines were followed, and data were analyzed using random-effects models. From screening studies involving more than 120,000 subjects, we estimated 0.31% (95% confidence interval (CI) 0.05–0.81) SARS-CoV-2 point prevalence in schools. Contact tracing studies, involving a total of 112,622 contacts of children and adults, showed that onward viral transmission was limited (2.54%, 95% CI 0.76–5.31). Young index cases were found to be 74% significantly less likely than adults to favor viral spread (odds ratio (OR) 0.26, 95% CI 0.11–0.63) and less susceptible to infection (OR 0.60; 95% CI 0.25–1.47). Lastly, from seroprevalence studies, with a total of 17,879 subjects involved, we estimated that children were 43% significantly less likely than adults to test positive for antibodies (OR 0.57, 95% CI 0.49–0.68). These findings may not applied to the Omicron phase, we further planned a randomized controlled trial to verify these results.

Transmission of SARS-CoV-2 in educational settings in 2020: a review

OBJECTIVES

School closures have been used as a core non-pharmaceutical intervention (NPI) during the COVID-19 pandemic. This review aims at identifying SARS-CoV-2 transmission in educational settings during the first waves of the pandemic.

METHODS

This literature review assessed studies published between December 2019 and 1 April 2021 in Medline and Embase, which included studies that assessed educational settings from approximately January 2020 to January 2021. The inclusion criteria were based on the PCC framework (P-Population, C-Concept, C-Context). The study Population was restricted to people 1-17 years old (excluding neonatal transmission), the Concept was to assess child-to-child and child-to-adult transmission, while the Context was to assess specifically educational setting transmission.

RESULTS

Fifteen studies met inclusion criteria, ranging from daycare centres to high schools and summer camps, while eight studies assessed the re-opening of schools in the 2020-2021 school year. In principle, although there is sufficient evidence that children can both be infected by and transmit SARS-CoV-2 in school settings, the SAR remain relatively low-when NPI measures are implemented in parallel. Moreover, although the evidence was limited, there was an indication that younger children may have a lower SAR than adolescents.

CONCLUSIONS

Transmission in educational settings in 2020 was minimal-when NPI measures were implemented in parallel. However, with an upsurge of cases related to variants of concern, continuous surveillance and assessment of the evidence is warranted to ensure the maximum protection of the health of students and the educational workforce, while also minimising the numerous negative impacts that school closures may have on children.

Factors affecting the transmission of SARS-CoV-2 in school settings

Background

Several studies have reported SARS‐CoV‐2 outbreaks in schools, with a wide range of secondary attack rate (SAR; range: 0–100%). We aimed to examine key risk factors to better understand SARS‐CoV‐2 transmission in schools.

Methods

We collected records of 35 SARS‐CoV‐2 school outbreaks globally published from January 2020 to July 2021 and compiled information on hypothesized risk factors. We utilized the directed acyclic graph (DAG) to conceptualize risk mechanisms, used logistic regression to examine each risk‐factor group, and further built multirisk models.

Results

The best‐fit model showed that the intensity of community transmission (adjusted odds ratio [aOR]: 1.11, 95% CI: 1.06–1.16, for each increase of 1 case per 10 000 persons per week) and individualism (aOR: 2.72, 95% CI: 1.50–4.95, above vs. below the mean) was associated higher risk, whereas preventive measures (aOR: 0.25, 95% CI: 0.19–0.32, distancing and masking vs. none) and higher population immunity (aOR: 0.57, 95% CI: 0.46–0.71) were associated with lower risk of SARS‐CoV‐2 transmission in schools. Compared with students in high schools, the aOR was 0.47 (95% CI: 0.23–0.95) for students in preschools and 0.90 (95% CI: 0.76–1.08) for students in primary schools.

Conclusions

Preventive measures in schools (e.g., social distancing and mask wearing) and communal efforts to lower transmission and increase vaccination uptake (i.e., vaccine‐induced population immunity) in the community should be taken to collectively reduce transmission and protect children in schools.

Implementation of School-Based COVID-19 Testing Programs in Underserved Populations

Evidence suggests that coronavirus disease 2019 (COVID-19) testing in schools can add a layer of protection to reduce the spread of Severe Acute Respiratory Syndrome Coronavirus 2 and facilitate a safer return to in-person learning. Despite this evidence, implementation of testing in school settings has been challenging initially because of a lack of funding and limited availability of testing, but, as the pandemic has progressed and more funding and resources have been devoted to testing, other implementation challenges have arisen. We describe key implementation barriers and strategies that have been operationalized across 5 projects working to help schools with predominantly underserved populations who have faced significant COVID-19-related health disparities. We leveraged a key framework from the implementation science field to identify the challenges and used a matching tool to align implementation strategies to these challenges. Our findings suggest that the biggest obstacles to COVID-19 testing were the perceived relative advantages versus burden of COVID-19 testing, limited engagement with the target beneficiaries (eg, families, students, staff), and innovation complexity. Common strategies to overcome these challenges included identifying and preparing testing champions, altering incentive and allowance structures, assessing for readiness, and identifying barriers and facilitators. We aim to augment existing implementation guidance for schools by describing common barriers and recommended solutions from the implementation science field. Our results indicate a clear need to provide implementation support to schools to facilitate COVID-19 testing as an added layered mitigation strategy.

SARS-CoV-2 Seroprevalence and Reported COVID-19 Cases in U.S. Children, August 2020—May 2021

Background

Case-based surveillance of pediatric coronavirus disease 2019 (COVID-19) cases underestimates the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among children and adolescents. Our objectives were to estimate monthly SARS-CoV-2 antibody seroprevalence and calculate ratios of SARS-CoV-2 infections to reported COVID-19 cases among children and adolescents in 8 US states.

Methods

Using data from the Nationwide Commercial Laboratory Seroprevalence Survey, we estimated monthly SARS-CoV-2 antibody seroprevalence among children aged 0–17 years from August 2020 through May 2021. We calculated and compared cumulative incidence of SARS-CoV-2 infection extrapolated from population-standardized seroprevalence of antibodies to SARS-CoV-2, cumulative COVID-19 case reports since March 2020, and infection-to-case ratios among persons of all ages and children aged 0–17 years for each state.

Results

Of 41 583 residual serum specimens tested, children aged 0–4, 5–11, and 12–17 years accounted for 1619 (3.9%), 10 507 (25.3%), and 29 457 (70.8%), respectively. Median SARS-CoV-2 antibody seroprevalence among children increased from 8% (range, 6%–20%) in August 2020 to 37% (range, 26%–44%) in May 2021. Estimated ratios of SARS-CoV-2 infections to reported COVID-19 cases in May 2021 ranged by state from 4.7–8.9 among children and adolescents to 2.2–3.9 for all ages combined.

Conclusions

Through May 2021 in selected states, the majority of children with serum specimens included in serosurveys did not have evidence of prior SARS-CoV-2 infection. Case-based surveillance underestimated the number of children infected with SARS-CoV-2 more than among all ages. Continued monitoring of pediatric SARS-CoV-2 antibody seroprevalence should inform prevention and vaccination strategies.

Global research priorities on COVID-19 for maternal, newborn, child and adolescent health

BACKGROUND

This research prioritization aimed to identify major research gaps in maternal, newborn, child and adolescent health (MNCAH) to help mitigate the direct and indirect effects of the COVID-19 pandemic.

METHODS

We adapted the Child Health and Nutrition Research Initiative methodology. We defined scope, domains, themes and scoring criteria. We approached diverse global experts via email to submit their research ideas in MNCAH and MNCAH-related cross-cutting/health systems area. We curated the research ideas as research questions (RQs) and sent them to the consenting experts for scoring via the online link. For each RQ, the research priority score (RPS) was calculated as an average of individual criterion scores and ranked based on RPS in each area.

RESULTS

We identified top-ranked 10 RQs in each maternal, newborn, and child and adolescent health and 5 in the cross-cutting/health systems area. In maternal health, indirect effects on care, measures to improve care, health risks and outcomes, and preventing and managing SARS-CoV-2 infection/COVID-19 disease were priority RQs. In newborn health, clinical characterization and managing SARS-CoV-2 infection/COVID-19 disease, mode of transmission and interventions to prevent transmission were the focus. For child and adolescent health, top-ranked RQs were indirect effects on care, clinical status and outcomes, interventions to protect against SARS-CoV-2 infection/COVID-19 disease, and educational institute-related RQs. The cross-cutting RQs were the effects of the pandemic on availability, access, care-seeking and utilization of MNCAH services and potential solutions.

CONCLUSIONS

We call on partners, including governments, non-governmental organizations, research institutes, and donors, to address this urgent research agenda.

Considerations for the Safe Operation of Schools During the Coronavirus Pandemic

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, providing safe in-person schooling has been a dynamic process balancing evolving community disease burden, scientific information, and local regulatory requirements with the mandate for education. Considerations include the health risks of SARS-CoV-2 infection and its post-acute sequelae, the impact of remote learning or periods of quarantine on education and well-being of children, and the contribution of schools to viral circulation in the community. The risk for infections that may occur within schools is related to the incidence of SARS-CoV-2 infections within the local community. Thus, persistent suppression of viral circulation in the community through effective public health measures including vaccination is critical to in-person schooling. Evidence suggests that the likelihood of transmission of SARS-CoV-2 within schools can be minimized if mitigation strategies are rationally combined. This article reviews evidence-based approaches and practices for the continual operation of in-person schooling.

Retrospective cohort study of COVID-19 among children in Fulton County, Georgia, March 2020-June 2021

OBJECTIVE

To describe case rates, testing rates and percent positivity of COVID-19 among children aged 0-18 years by school-age grouping.

DESIGN

We abstracted data from Georgia's State Electronic Notifiable Disease Surveillance System on all 10 437 laboratory-confirmed COVID-19 cases among children aged 0-18 years during 30 March 2020 to 6 June 2021. We examined case rates, testing rates and percent positivity by school-aged groupings, namely: preschool (0-4 years), elementary school (5-10 years), middle school (11-13 years), and high school (14-18 years) and compared these data among school-aged children with those in the adult population (19 years and older).

SETTING

Fulton County, Georgia.

MAIN OUTCOME MEASURES

COVID-19 case rates, testing rates and percent positivity.

RESULTS

Over time, the proportion of paediatric cases rose substantially from 1.1% (April 2020) to 21.6% (April 2021) of all cases in the county. Age-specific case rates and test rates were consistently highest among high-school aged children. Test positivity was similar across school-age groups, with periods of higher positivity among high-school aged children.

CONCLUSIONS

Low COVID-19 testing rates among children, especially early in the pandemic, likely underestimated the true burden of disease in this age group. Despite children having lower measured incidence of COVID-19, we found when broader community incidence increased, incidence also increased among all paediatric age groups. As the COVID-19 pandemic continues to evolve, it remains critical to continue learning about the incidence and transmissibility of COVID-19 in children.

Experiences with opt-in, at-home screening for SARS-CoV-2 at a primary school in Germany: an implementation study

Background

Over the course of the pandemic, many countries have repeatedly closed schools and shifted schoolchildren to remote learning. However, evidence for negative mental and physiological health consequences of such measures for schoolchildren is increasing, highlighting the need for evidence-based recommendations on how to safely reopen schools. This study aims to assess implementation experiences, acceptability and feasibility of opt-in, at-home SARS-CoV-2 screening using rapid diagnostic tests (RDTs) to facilitate safe face-to-face teaching during a pandemic.

Methods

We present data from a prospective study implementing an RDT-based screening programme at a primary school in southwest Germany. In addition to quantitative data collected to assess screening diagnostic yield (number of participants, tests handed out to participants, positive RDT results reported), we conducted qualitative in-depth interviews with participating pupils, parents and school stakeholders to elicit implementation experiences and screening perceptions.

Results

The screening intervention was highly accepted and appreciated among participants; no screening-associated positive RDT was reported over the duration of the study. Self-testing at home before coming to school was feasible, but more positive consequences of screening participation (eg, easing of mask mandates) besides a personal feeling of safety would have been appreciated across respondent groups. Participants preferred home-based RDTs over some other measures, particularly mask mandates. Despite the RDTs being licensed as self-tests in Germany, additional training can help avoid mistakes, and ensuring intervention ownership and improving pre-implementation communication can facilitate buy-in.

Conclusions

Antigen-RDT-based SARS-CoV-2 screening programmes relying on self-testing at home are a feasible and acceptable supplement to the public health toolbox to facilitate a safe return to face-to-face teaching at schools.

Trial registration number

DRKS00024845.

Factors affecting the transmission of SARS-CoV-2 in school settings

BACKGROUND

Several studies have reported SARS-CoV-2 outbreaks in schools, with a wide range of secondary attack rate (SAR; range: 0-100%). We aimed to examine key risk factors to better understand SARS-CoV-2 transmission in schools.

METHODS

We collected records of 39 SARS-CoV-2 school outbreaks globally published through July 2021 and compiled information on hypothesized risk factors. We utilized the directed acyclic graph (DAG) to conceptualize risk mechanisms, used logistic regression to examine each risk-factor group, and further built multi-risk models.

RESULTS

The best-fit model showed that the intensity of concurrent community transmission (adjusted odds ratio [aOR]: 1.2, 95% CI: 1.17 - 1.24, for each increase of 1 case per 10,000 persons per week), individualism (aOR: 1.72, 95% CI: 1.19 - 2.5, above vs. below the median) were associated higher risk, whereas preventive measures (aOR: 0.22, 95% CI: 0.17 - 0.29, distancing and masking vs. none) and higher population immunity (aOR: 0.28, 95% CI: 0.22 - 0.35) were associated with lower risk of SARS-CoV-2 transmission in schools. Compared to students in pre-schools, the aOR was 0.35 (95% CI: 0.23 - 0.54) for students in primary schools and 1.3 (95% CI: 0.9 - 1.88) for students in high schools.

CONCLUSIONS

Preventive measures in schools (e.g. social distancing and mask-wearing) and communal efforts to lower transmission and increase vaccination uptake (i.e. vaccine-induced population immunity) in the community should be taken to collectively reduce transmission and protect children in schools. Flexible reopening policies may be considered for different levels of schools given their risk differences.

COVID-19 Transmission during Transportation of 1st to 12th Grade Students: Experience of an Independent School in Virginia

BACKGROUND

In-school transmission of COVID-19 among K-12 students is low when mitigation layers are used, but the risk of acquiring COVID-19 during school bus transportation is not well defined. Given the operational limitations of many school districts, more data is needed to determine what mitigation is required to keep COVID-19 transmission low during bus transport.

METHODS

An independent school in Virginia monitored 1154 students in grades 1 to 12 with asymptomatic PCR testing every 2 weeks from August 24, 2020 to March 19, 2021, during the highest community transmission. Fifteen buses served 462 students while operating at near capacity of 2 students in every seat, using a physical distancing minimum of 2.5 ft, universal masking, and simple ventilation techniques.

RESULTS

A total of 39 individuals were present on buses during their COVID-19 infectious period, which resulted in the quarantine of 52 students. Universal testing and contact tracing revealed no transmission linked to bus transportation.

CONCLUSIONS

This study demonstrates a model for the safe operation of school buses while near capacity. COVID-19 transmission can be low during student transport when employing mitigation including simple ventilation, and universal masking, at minimal physical distances and during the highest community transmission.

Risk of infection and transmission of SARS-CoV-2 among children and adolescents in households, communities and educational settings: A systematic review and meta-analysis

BACKGROUND

There is uncertainty with respect to SARS-CoV-2 transmission in children (0-19 years) with controversy on effectiveness of school-closures in controlling the pandemic. It is of equal importance to evaluate the risk of transmission in children who are often asymptomatic or mildly symptomatic carriers that may incidentally transmit SARS-CoV-2 in different settings. We conducted this review to assess transmission and risks for SARS-CoV-2 in children (by age-groups or grades) in community and educational-settings compared to adults.

METHODS

Data for the review were retrieved from PubMed, EMBASE, Cochrane Library, WHO COVID-19 Database, China National Knowledge Infrastructure (CNKI) Database, WanFang Database, Latin American and Caribbean Health Sciences Literature (LILACS), Google Scholar, and preprints from medRixv and bioRixv) covering a timeline from December 1, 2019 to April 1, 2021. Population-screening, contact-tracing and cohort studies reporting prevalence and transmission of SARS-CoV-2 in children were included. Data were extracted according to PRISMA guidelines. Meta-analyses were performed using Review Manager 5.3.

RESULTS

Ninety studies were included. Compared to adults, children showed comparable national (risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.71-1.060 and subnational (RR = 0.81, 95% CI = 0.66-1.01) prevalence in population-screening studies, and lower odds of infection in community/household contact-tracing studies (odds ratio (OR) = 0.62, 95% CI = 0.46-0.84). On disaggregation, adolescents observed comparable risk (OR = 1.22, 95% CI = 0.74-2.04) with adults. In educational-settings, children attending daycare/preschools (OR = 0.53, 95% CI = 0.38-0.72) were observed to be at lower-risk when compared to adults, with odds of infection among primary (OR = 0.85, 95% CI = 0.55-1.31) and high-schoolers (OR = 1.30, 95% CI = 0.71-2.38) comparable to adults. Overall, children and adolescents had lower odds of infection in educational-settings compared to community and household clusters.

CONCLUSIONS

Children (<10 years) showed lower susceptibility to COVID-19 compared to adults, whereas adolescents in communities and high-schoolers had comparable risk. Risks of infection among children in educational-settings was lower than in communities. Evidence from school-based studies demonstrate it is largely safe for children (<10 years) to be at schools, however older children (10-19 years) might facilitate transmission. Despite this evidence, studies focusing on the effectiveness of mitigation measures in educational settings are urgently needed to support both public health and educational policy-making for school reopening.

COVID-19 Testing to Sustain In-Person Instruction and Extracurricular Activities in High Schools - Utah, November 2020-March 2021

Cessation of kindergarten through grade 12 in-person instruction and extracurricular activities, which has often occurred during the COVID-19 pandemic, can have negative social, emotional, and educational consequences for children (1,2). Although preventive measures such as masking, physical distancing, hand hygiene, and improved ventilation are commonly used in schools to reduce transmission of SARS-CoV-2, the virus that causes COVID-19, and support in-person instruction (3-6), routine school-based COVID-19 testing has not been as widely implemented. In addition to these types of standard preventive measures, Utah health and school partners implemented two high school testing programs to sustain extracurricular activities and in-person instruction and help identify SARS-CoV-2 infections: 1) Test to Play,* in which testing every 14 days was mandated for participation in extracurricular activities; and 2) Test to Stay,^† which involved school-wide testing to continue in-person instruction as an alternative to transitioning to remote instruction if a school crossed a defined outbreak threshold (3). During November 30, 2020-March 20, 2021, among 59,552 students tested through these programs, 1,886 (3.2%) received a positive result. Test to Play was implemented at 127 (66%) of Utah's 193 public high schools and facilitated completion of approximately 95% of scheduled high school extracurricular winter athletics competition events.^§ Test to Stay was conducted at 13 high schools, saving an estimated 109,752 in-person instruction student-days.^¶ School-based COVID-19 testing should be considered as part of a comprehensive prevention strategy to help identify SARS-CoV-2 infections in schools and sustain in-person instruction and extracurricular activities.