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Test-To-Stay: Attending Mask-optional School Days During the COVID-19 Pandemic

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As caregivers, we are acutely aware of the deleterious impacts that missing school can have on a child’s academic and social development. As practitioners, we are also aware of the short- and long-term impacts a COVID-19 infection can have on our patients’ health. 

In a timely article by Campbell et al being early released this week in Pediatrics, the authors share prospective data suggesting that a test-to-stay strategy using on-site rapid antigen testing can be a potentially safe way to limit school absence, even in the context of high community transmission of COVID-19 in schools where masking is optional (10.1542/peds.2022-058200). 

Data were collected over 13 months, before and after the emergence of the Omicron COVID-19 variant in January 2022, among a group of 2,400 student participants. Testing was conducted on site at the schools by a trained sample collector. Investigators’ primary outcome measures were the days of school saved and the within-school tertiary attack rate (defined by the authors as a positive COVID-19 test result among a close contact with a student testing positive in the test-to-stay cohort)

The authors observed 89% fewer missed days (934 missed from a predicted 8,206 days). The cost for days saved was captured by the tertiary attack rate of 10% which was slightly higher (13%) among elementary and high school students but lower (5%) for middle school students. In other words, there was 1 additional within-school COVID-19 case for every 29 students who were able to attend school as a result of the test-to-stay model.

The study raises other questions for school districts interested in such an approach. How feasible will it be to conduct testing on-site at schools? Also, given the relatively lower sensitivity of rapid antigen testing relative to PCR, how do we know that the patients were truly negative? (In other words, how many false negatives were there?) In the end, the question perhaps is not whether to test but how many tertiary contacts/exposures is society willing to accept in order to have children attend in-person classes? 

There are obvious risks and benefits regardless of the choice that a given school district makes.  However, this article gives school administrators helpful data to make a more informed decision.

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