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From New Yorker

From Vox

Test the kids.

It’s a situation nearly all parents have found themselves in at some point during this pandemic: There’s a positive Covid-19 case in your child’s class, so everyone needs to stay home and quarantine.

That means kids have to switch to remote instruction, if their school is even still offering a remote option. And parents, already ground down by more than 18 months of online or hybrid learning, have to miss work to care for their child, often for as long as 14 days. “Quarantines are incredibly disruptive,” Alyssa Bilinski, an assistant professor of health policy at the Brown School of Public Health, told Vox.

The alternative, however, isn’t great either: Some schools are simply allowing students to come to school if they’ve been exposed, with no precautions in place. This risks spreading the virus to kids and adults, with no way to track or control it.

It feels like one of those pandemic situations where there are no good options — except in this case, maybe there is one.

Schools in Utah, Massachusetts, and elsewhere have started using an approach called “test to stay,” where close contacts of a student who tests positive can still stay in school, as long as they get a daily negative test for a certain period of time. The approach has encouraging research behind it: A recent UK study found it was comparable to quarantines in terms of controlling infection rates in schools.

But it’s still not being used in many American districts. There are a lot of reasons for this, but one stands out: The US hasn’t truly embraced testing as a way to control the pandemic. And that’s what it has to do, many experts say, if schools and the rest of American society are to return to any semblance of normal.

Quarantines are onerous. There’s another way.

Right now, if a student at a US school tests positive for Covid-19, here’s what typically happens: First, staff try to identify the student’s close contacts. Depending on the situation and the school’s protocols, that could range anywhere from kids who sat near the infected student to everyone in the classroom. Then those students are asked to quarantine, typically for 10 to 14 days.

This process changes if some of the students involved are vaccinated, and more than 50 percent of 12- to 17-year-olds now have at least one shot. But for families of students who can’t yet get vaccinated — those 11 and younger — quarantines are a familiar and stressful part of life. In Los Angeles, for example, 3,500 students were quarantined as close contacts in the first week of the school year alone.

Quarantines can interrupt kids’ learning, especially since many school districts have scaled back or even eliminated remote education this year. They can also interrupt parents’ work, a very real challenge for families already stretched thin by the demands of the pandemic. Moms, who have borne a disproportionate share of the burden of remote schooling, have left the labor force in high numbers since the pandemic began, and some say they can’t go back to work when it’s impossible to predict when they’ll need to care for a child in quarantine. Widespread quarantines can be “incredibly harmful to parents, especially women and mothers,” Bilinski said.

On the flip side, some districts have either done away with quarantine or made it optional, without putting anything in its place. This is especially concerning because those districts are likely to be in the same areas where masks are not required and vaccine rates are low.

Then there’s Massachusetts: The state adopted a test- to-stay protocol for participating districts at the beginning of the 2021–22 school year. If a student in those districts tests positive for Covid-19, close contacts of that student no longer have to automatically quarantine. Instead, they can continue coming to school, provided they take a rapid test each day for seven days. If they test positive or develop symptoms, they’ll need to quarantine. Otherwise, they don’t need to miss class.

Rapid tests have raised some concerns about accuracy, since they are not typically as sensitive as slower PCR tests. But many experts say testing daily is a way to alleviate those concerns. “If you’re having kids test every day, you may miss it one day and catch it the next day,” Joshua Salomon, a professor of medicine at Stanford, told Vox.

That’s still enough to limit spread, testing proponents believe. The UK study, published in the Lancet earlier this month, found that schools using a test-to-stay protocol had similar rates of symptomatic Covid-19 infection to those using quarantines. “Daily contact testing is a safe alternative to home isolation for school-based contacts,” the study’s authors wrote.

The approach is growing in popularity, with districts in Georgia, Illinois, and elsewhere offering test-to-stay or similar programs, according to the New York Times. New York City recently announced that it would implement weekly testing and relax quarantine rules, though it is not yet using daily tests as a substitute for quarantines. Schools in Utah have used a form of test-to-stay since the 2020–21 school year, and researchers credit the approach with keeping kids in school even during Covid’s winter surge. Just 0.7 percent of students tested positive as part of the protocols, which researchers estimate saved 109,752 student days of in-person instruction.

Overall, widespread quarantines “aren’t necessary if we know who is infectious and who is not infectious,” Bilinski said. “We don’t need to have that level of disruption in order to prevent further onward transmission.”

To make it work, the US needs to embrace testing

But many districts around the country have yet to adopt any form of test-to-stay and are sticking with the quarantine approach — or no approach at all.

Part of the reason is that the CDC has yet to endorse test-to-stay, citing a need for more research. That creates something of a chicken-and-egg situation. “Some schools that we’ve talked to have said, ‘We’re not going to embrace test-to-stay because the CDC doesn’t yet endorse it,’” Salomon said. But “the CDC is saying [it wants] to collect more data from schools that are doing this.” The result, for now, is inaction.

Then there’s the shortage of testing supplies. As anyone who’s tried to buy a rapid test at a drugstore in the last few weeks knows, the tests can be nearly impossible to come by. Some of the shortage is due to regulatory hurdles — the FDA has approved relatively few rapid tests, using what some argue are inappropriately high standards. The result is that prices are high and demand outstrips supply, with school districts, like ordinary people, sometimes struggling to get their hands on enough tests.

This is part of a bigger problem. In America, “A lot of people thought vaccines were going to take care of everything and that we wouldn’t need any kind of testing infrastructure,” Bilinski said. As a result, the country is far behind other countries such as Germany as well as the UK, where rapid tests are readily available and cheap, or even free. The availability of rapid testing in Germany, for example, allows people to keep the tests in their homes and administer them to visitors, and has helped day cares and other venues stay open.

But the problem in the US is far from insurmountable, experts say. Leadership from the CDC would be a start. “I’m hoping that the trial from the UK will add to the evidence base” and help sway the agency, Salomon said. Clearing regulatory hurdles to help more tests enter the market could help as well.

Schools also need help beyond buying supplies. Many schools don’t have the staff or space to administer tests on-site, and they’ll need either more people or access to outside testing resources. “Schools really do need logistical support in addition to financial support,” Salomon said.

Beyond that, the country needs to recognize that testing matters. For Salomon and Bilinski, who recently wrote an op-ed on the subject at Stat News, it’s not just about quarantines: It’s also about continuously monitoring schools to see what’s working and what isn’t, as well as ramping up interventions when cases are rising in a school and easing up on them when they (eventually) begin to go down. Ideally, they’d like regular testing not just of close contacts but also of all students, teachers, and staff.

In schools, “We kind of make very reactive decisions, and we make them in crisis mode, and we make them in real time,” Bilinski said. “Having data so that we can make them more deliberately and plan ahead would be helpful for thinking about a longer-term decision-making process in the context of Covid.”

But that process can happen only if we acknowledge that vaccines aren’t everything. We need a multilayered approach that includes testing if we want to go back to living — and learning — in person.

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