When children were forced to stay home as the COVID-19 pandemic took the world by storm, numerous voices called out in protest. In contrast to adults, children did not appear to be suffering from either a high burden of infection or a risk of severe complications, and the consequences of school closures were numerous, from worsening of socioeconomic disparities including food insecurity and increased rates of physical abuse to a substantial loss in learning.
Many experts agree that the school closures due to the COVID-19 pandemic will have far reaching negative ramifications for years to come.
As a strategy to keep kids in school in spite of the pandemic, routine surveillance testing within schools was widely recommended. This past week, the U.S. Center for Disease Control and Prevention relaxed their recommendations, no longer recommending universal surveillance testing within schools, but instead suggesting schools consider surveillance testing under certain circumstances such as when students return from vacation.
But as of this writing, the California Department of Public Health continues to recommend routine surveillance testing of asymptomatic students and staff for the 2022-2023 school year.
Is routine COVID-19 testing within schools still necessary? Does it provide any benefit? Or is it actually harmful by way of unnecessarily keeping children out of school and adding undue costs onto an already strained educational systems?
The argument that most strongly kept children out of schools was the concern that young children may spread the infection within their homes and communities, exacerbating the hospitalizations and deaths attributable to COVID-19.
Thus, schools adopted the practice of surveillance testing to identify cases early and reduce the opportunities for within school transmission. But that practice has persisted even after novel strains of the virus that causes COVID-19 emerged, which were shown to have markedly lower risk of death. That practice persisted even after effective hospital-based treatment became available and after out-patient medications preventing severe disease became widely used. And it persisted after effective vaccines were recommended in both adults and children.
Currently, though more infectious, the omicron variant and subvariants cause 66% fewer deaths than the delta variant. Thus, the benefits of identifying a SARS-CoV-2 infected child is rapidly diminishing.
Next, consider the harms of routine testing. First, as discussed above, keeping children out of school disproportionately affects students and families of lower socioeconomic status both because of a higher prevalence of infection among such communities and because such families are inherently less able to compensate for the costs of a child staying home from school – a parent missing work, an additional meal, mental health services, and so on.
Further, the lost social and educational opportunities due to a positive COVID test and home isolation has likely contributed to a secondary epidemic of childhood mental illness. Finally, routine testing of asymptomatic children accrues massive educational system costs.
Compounding those harms, our own work has shown that the antigen tests used in schools have have a notable rate of false-positive results – meaning that a non-trivial proportion of the children kept out of school because of a positive COVID-19 test will not actually have COVID-19. Thus, the harms of surveillance testing within schools likely far exceeds the benefits.
There are further questions beyond surveillance testing. The California Department of Public Health does not recommended quarantine of asymptomatic individuals exposed to someone with COVID-19. That is an important step towards normalcy which will prevent a huge number of missed school days, and the associated socioeconomic burdens. But it is not enough.
Symptomatic children should be tested in a healthcare setting, where direct linkage to highly effective treatment is more readily accessible. Schools do not need to be a part of that process. The allocation of funds to support school testing would likely be better spent supporting schools to provide health services for more common conditions mental health services as well as services for sexual and reproductive health.
Some school districts have changed their guidance. The Massachusetts Department of Elementary and Secondary Education announced plans to stop routine asymptomatic testing within schools. The California Department of Public Health should do the same.
When we were facing a global pandemic with a relatively unknown mortality, limited treatment options, and no immunizations, routine COVID-19 testing within schools was a more defensible precautionary strategy. But we have come a long way since then in our ability to prevent and treat COVID-19.
It is time to consider the harms we are imposing on our children and on society by continuing to regularly test children for COVID-19 in schools. It is time to stop testing asymptomatic children in schools for COVID-19.
Lao-Tzu Allan-Blitz, MD, is chief resident physician at Brigham and Women’s Hospital and Boston Children’s Hospital. Jeffrey D. Klausner, MD, MPH, is USC Professor of Medicine and Public Health, former CDC medical officer and former San Francisco City and County deputy health officer.
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