Reopening schools – a societal imperative

A pandemic, as its name suggests, is an epidemic that is everywhere. It affects countries all over the world and many communities. And while we all have our individual part to play — be it by adhering to social distancing, wearing masks, washing hands frequently and well, avoiding crowds and closed spaces as much as possible, for example — this will only take us so far. You can’t fight a pandemic as an individual. We need collective, coordinated responses, at the level of institutions, businesses and states. 

In my community of Athens, GA, right now there is a heated debate about schools, with parents and teachers weighing in on how we should have only online school as the coronavirus spread in the community is accelerating, or we need to open at all costs because schools are not a luxury. And while these two points of view feel contradictory, I agree with both. We do need schools to be open (online school will hugely underserve the community and create even more inequalities) and opening at any cost seems irresponsible. Nothing will ever be 100% safe but we need to reach a level of risk where most of the community feels that the benefits outweigh the risks.

We need to make opening schools the priority for our society and see what else needs to happen for that to be a reality. 

Helen Jenkins here has a good Twitter thread about this:

What are we as a society, as a community willing to give up in order to open schools? I would argue that bars need to close, indoor dining, any large indoor gatherings, etc. Several public health specialists have talked about a “risk budget”. If schools are a priority, what else do we need to do to “balance the books”?

In the words of infectious disease doctor Dr. Bhadelia:

Ideally, our national and state leaders should be stepping up and taking responsibility rather than shifting it and pushing it down to the individuals. We would want them to ensure PPE for everyone that needs it, a basic income for people even if they cannot work (so they don’t have to risk their health, or they don’t have to go to work sick, or be able to care for a family member), to develop a national testing strategy, to coordinate large rigorous studies into what treatments work, etc. 

It is infuriating to see people struggle with really difficult decisions, often of life vs. livelihood because our leaders will not step up, standing by as the pandemic rages on.

If our elected leaders will not, I would ask as a community – what can we do?

Can we push for measures that will keep ALL our community safer?

For example, we know that to control community spread test-trace-isolate is essential. Can we test the schools community, regularly, easily and cheaply to ensure that any outbreaks are quickly contained? 

Do we need to lobby for further testing budgets? Can we push for a budget for fast point-of-care tests to regularly monitor the school population as has been advocated for universities? Are there labs with testing capacity that are under utilized? Can we shine a light on this and encourage better logistics? Where are the contact tracers? If they haven’t been hired, why not? Are people not wanting to speak to contact tracers? Can we organize some information sessions about why this matters? Can we organize hotel rooms for people that want to isolate (voluntarily) but cannot in their current living arrangements to limit in-household spread?

We can also engage in risk mitigation. We know the risks are lower outdoors, at a distance and masked. Especially for the younger kids, who might find it harder to distance and stay masked, could we have them spend most of their time outside, be it on the playground or maybe using other resources in the community like covered pavilions at local parks? If we have to go inside, use larger spaces and with windows and good ventilation (a window isn’t enough, you need good airflow but there are ways of doing that). Maybe for higher risks groups we use even smaller “pods” and more risk mitigation strategies. 

If you are already starting at a low level of risk because COVID-19 is not widespread in a community, there will be a lot less risk mitigation needed to reach what might be an acceptable level of risk to the community.

For some people, even this might be too high-risk so we need to make sure that these individuals — be it students or teachers — are not an afterthought. (If you are reading this from Athens, GA, yes I have many concerns and questions about both the CCSD plans and the emails that went out to teachers and parents and have engaged separately on that.)

Education and schools are priorities and they need to be central to our reopening plans. But it will need more than masks and a promise of social distance to make this a safe reality for all. If we cannot limit community spread, we might not be able to open schools.

Further reading

Clarifying the WHO’s comments on asymptomatic transmission

On Monday, a WHO official, Dr Maria van Kerkhove, said in a statement that asymptomatic transmission of COVID-19 was “very rare.” Subsequent media reports added to the confusion.

CNBC opened a story on this stating that “Coronavirus patients without symptoms aren’t driving the spread of the virus, World Health Organization officials said Monday, casting doubt on concerns by some researchers that the disease could be difficult to contain due to asymptomatic infections.”

While the messaging from the WHO was very confusing, the CNBC paragraph above is misleading. On Tuesday, the WHO walked back the comments and gave some further context but I still saw some people asking for clarificartion on social media.

Where does the confusion stem from?

There is a difference between asymptomatic, presymptomatic and paucisymptomatic:

  • Asymptomatic: is someone that has COVID-19 AND is not currently showing symptoms AND will not eventually have symptoms. These people NEVER have symptoms, and they are very hard to find by most studies.
  • Presymptomatic: is someone that has COVID-19 AND is not currently showing symptoms BUT will eventually have symptoms. Studies might sometimes classify these as asymptomatic if there isn’t a follow up further on.
  • Paucisymptomatic: is someone that has COVID-19 AND currently has symptoms BUT they are so mild that maybe they don’t register (such as a very mild fever or a mild cough that could be confused with alolergy symptoms). They can get classified as asymptomatic in studies.

Right now we don’t know either how many people are TRULY asymptomatic or how big a contribution they have to the spread of the disease. The WHO was indicating that the spread from TRULY asymptomatic people might not be that common, not that just because someone is not showing symptoms that they are not spreading the disease.

A STAT News article on Tuesday described what led to the confusion: “To some, it came across as if the WHO was suggesting that people without symptoms weren’t driving spread. Some studies, however, have estimated that people without symptoms (whether truly asymptomatic or presymptomatic) could be responsible for up to half of the spread, which is why the virus has been so difficult to contain.”

Dr Natalie E. Dean, Assistant Professor of Biostatistics at the University of Florida specializing in emerging infectious diseases and vaccine study design, tweeted this short thread on the topic:

Several other scientists also took to Twitter to clarify. Another good thread on the topic:

The Science Media Centre also gathered reactions from scientists to the WHO announcement.

So what does that mean for an individual? Has anything changed in how we behave or think about risk? Not really and Popular Science had a handy explanation chart:

Some good articles on the topic to delve deeper:

Testing for COVID-19 after protests

[Update: This Perspective in the New England Journal of Medicine on False Negative Tests for SARS-CoV-2 Infection — Challenges and Implications was just published on June 5 2020, which adds a good perspective on this discussion. Dr Carlos del Rio, Emory University, commented on Twitter: “A very good perspective in @NEJM but it unfortunately fails to mention Pre-analytical problems, such as poor specimen collection, as major cause of “false negatives”.”]

As protests spread nationwide, public health experts have weighed in on how to reduce the risks of spreading COVID-19 while protesting. But with large groups converging, it is likely to come into contact with someone that is an asymptomatic carrier.

On Thursday, four days after leading a protest in downtown Athens for racial justice and against police violence, Commissioner Mariah Parker disclosed she had tested positive for COVID-19. She also urged others that had come in contact with her to get tested.

Multiple discussions on local Facebook groups referred to this fact and people also expressed doubts as to when the best time to get tested was.

Should everyone that attended the protest get tested? Only people that came into close contact with a confirmed case? Only those showing symptoms? And when is the best time to go get tested?

This same Thursday, the Minnesota Department of Health issued a recommendation through Twitter that “any Minnesotan who has attended a protest, vigil, or community clean-up get tested for #COVID19. If you start to feel sick, get tested right away. If you do not feel sick, get tested as soon as you can, but no later than 5-7 days after the event.” and also that “if the test is negative and you are worried you might have been exposed, get another test 12-14 days after the event, even if you do not feel sick.”

But we know that COVID-19 tests have high false negative rates, especially soon after exposure (on the day of symptom onset, which is day 5 on average, the probability of a false-negative in an infected person is around 38%, but this can vary widely). The best estimates show that the least number of false-negatives come when testing 8-10 days after exposure (around 20% probability of a false-negative at the minimum).

The Minnesota approach will mean that if a lot of people get tested only 5 days after being exposed there will be many false negative cases. At a population level this might be very helpful because any cases you catch will be less likely to infect others. However, for an individual it might not give them that much information, as false negative rates are still high 5 days after exposure.

It might also still be too soon for all those infected to have started showing symptoms, and the tests always have some false negatives. So any negative results from such a COVID-19 test need to be taken with a pinch of salt, and be coupled with risk-reducing behavior (such as wearing a mask, maintaining a distance from others, and frequent hand-washing). And a follow-up test might also be helpful if someone was close to a confirmed case.

When contacted the Georgia Department of Health did not have such recommendations but did say that “anyone who wants to be tested for COVID-19, regardless of symptoms, can schedule an appointment at one of our 140+ SPOCs around the state by calling their local health department. If people believe they’ve been in contact with someone positive for COVID-19, they should self-quarantine and monitor for symptoms, and seek medical treatment if needed.”

If people are able to self-isolate following protests for 14 days that would definitely be the first step to take. But many people won’t be able to do that, so risk mitigation and focusing on harm reduction, an approach strongly advocated by infectious disease epidemiologist Dr Julia Marcus, should be the priority. Whether someone decides to get tested early on to see if they can get a quick answer or decides to wait to get a more accurate reflection of the risk of being infected with COVID-19, it is important to understand what a test can and cannot tell you and continue to observe good infection control practices.

The Georgia Department of Health added that regarding the effects of the protests on the spread of the disease, “the incubation period for COVID-19 can be as long as 14 days, so it’s a little early to know what the increases might be. However, DPH will closely watch for increases from the events of the past week the same way we monitor for hotspots or increases from any large gatherings such as Memorial Day weekend.”

It is also important to remember with any discussion of the protests and the effects on COVID-19 transmission that while COVID-19 is a public health crisis so is police violence and systemic racism, as individual and organizations of public health experts have repeated over the last few days. A recent NPR article referred to this, saying that “the risks of congregating during a global pandemic shouldn’t keep people from protesting racism, according to dozens of public health and disease experts who signed an open letter in support of the protests.”

More information about testing and false-negatives: