Hello,
This past week in the COVID pandemic brings new challenges and lots of organizational updates. In addition to some important news items, this issue takes a closer look at two topics: data regarding schools internationally and holiday travel struggles. We hope you find it helpful. If you would like to receive a copy of this newsletter by email, you may register for free here.
1) International School Data
Insights For Education has collected 6 months of data regarding school closures during the pandemic in 191 countries. Their latest report includes a list of myths and facts based on their research findings. They conclude:
- Myth: School closures lower infections, and openings lead to rising cases.
Finding: There is no consistent pattern between school status and infection levels. The
reality is much more complex. - Myth: Countries experiencing second waves of infection have kept schools closed.
Finding: Nearly all countries (89%) in a second COVID-19 wave are opened to students. - Myth: Countries where cases rise above first-wave levels are at risk of closing again.
Finding: Despite higher second-wave infection levels, countries seem determined to
keep schools open. - Myth: Schools in most countries are now open.
Finding: Many countries are still closed, or only partially open, most from lower income
and still undergoing an extended first wave of infection.
The report is full of comparisons between nations, their first and subsequent COVID-19 “waves” and their related school closures. It draws special attention to the fact that subsequent “waves” of infection do not correlate with school opening. There is also an excellent discussion of mitigation efforts seen in schools and the variety of methods adopted. Mask use continues to be the best measure though adoption is not universal. Routine testing of students and teachers is not common in most countries.
The same organization has published a COVID tracker online with a special focus on schools. It compares COVID cases with the timeline for school closures and re-opening in countries all over the world. For those interested in the comparison, it suggests that school cases are due to increases in community spread and not the cause. The developers hope to continue compiling their data and performing comparisons as the pandemic continues. It will be interesting to see what further conclusions they reach.
2) CHOP Guidelines for Schools
The Children’s Hospital of Philadelphia (CHOP) has released a revision to its guidelines titles “Evidence and Guidance for In-Person Schooling during the COVID-19 Pandemic“. They reinforce that:
- Overall, children and adolescents are at lower risk of serious infection and complications from SARS-CoV-2 than adults.
- Although children of all ages can spread COVID-19, young children are relatively inefficient drivers of transmission, while older teens appear to have transmission risks similar to those of adults.
- Schools across the U.S. have successfully reopened for in-person learning, though often in the context of low levels of community transmission.
- Strong school safety plans can, and have, mitigated risk for transmission, even within communities with moderate incidence.
- Most school-associated transmission has occurred outside of school or because of poor adherence to masking protocols.
- Youth sports have contributed to disease transmission in children, but exposures have most often been off the field of play.
- Teachers, staff and caregivers are most at risk from the consequences of outbreaks that originate from school buildings.
The document provides a robust discussion of the current evidence and reviews recommended mitigation strategies. These are the same strategies that we have been recommending and that many states have adopted. However, the document is still an excellent summary.
3) European CDC Report on Children and COVID-19
The European Center for Disease Control released a report titled “COVID-19 in children and the role of school settings in COVID-19 transmission“. It compiles data from the European Union countries and the U.K. and provides conclusions that agree with what other organizations have published.
- A small proportion (<5%) of overall COVID-19 cases reported are among children (those aged 18 years and under). When diagnosed with COVID-19, children are much less likely to be hospitalized or have fatal outcomes than adults.
- Children are more likely to have a mild or asymptomatic infection, meaning that the infection may go undetected or undiagnosed.
- When symptomatic, children shed virus in similar quantities to adults and can infect others in a similar way to adults. It is unknown how infectious asymptomatic children are.
- While very few significant outbreaks of COVID-19 in schools have been documented, they do occur, and may be difficult to detect due to the relative lack of symptoms in children.
- In general, the majority of countries report slightly lower seroprevalence in children than in adult groups, however these differences are small and uncertain. More specialised studies need to be performed with the focus on children to better understand infection and antibody dynamics.
- Investigations of cases identified in school settings suggest that child to child transmission in schools is uncommon and not the primary cause of SARS-CoV-2 infection in children whose onset of infection coincides with the period during which they are attending school, particularly in preschools and primary schools.
- If appropriate physical distancing and hygiene measures are applied, schools are unlikely to be more effective propagating environments than other occupational or leisure settings with similar densities of people.
- There is conflicting published evidence on the impact of school closure/re-opening on community transmission levels, although the evidence from contact tracing in schools, and observational data from a number of EU countries suggest that re-opening schools has not been associated with significant increases in community transmission.
- Available evidence also indicates that closures of childcare and educational institutions are unlikely to be an effective single control measure for community transmission of COVID-19 and such closures would be unlikely to provide significant additional protection of children’s health, since most develop a very mild form of COVID-19, if any.
- Decisions on control measures in schools and school closures/openings should be consistent with decisions on other physical distancing and public health response measures within the community
4) CDC Holiday Recommendations
Last week we shared the link to the CDC Holiday Travel recommendations. Unfortunately, the link was broken, so it is provided here again. They published a good discussion of the risks of holiday travel, and some guidelines for Halloween, Thanksgiving, and other holidays. The guidelines provide a method to gauge the risk and a list of ways to reduce exposure if traveling.
5) Quarantine… is there a way to end it early?
There have been numerous questions about quarantine and testing, especially with the upcoming holidays. An understanding of what we know and how it has been interpreted by different organizations and states is important.
First, quarantine is a 14 day period of isolation in order to monitor a person for symptoms of COVID-19. During that time, a person is expected to be home or in isolation and away from public spaces. If a person is completing their quarantine in a home with others, it is recommended they isolate in a separate room, wear a mask even indoors, and stay away from family or roommates as much as possible.
The CDC clearly states “even if you test negative for COVID-19 or feel healthy, you should stay home (quarantine) since symptoms may appear 2 to 14 days after exposure to the virus.” The rationale behind this decision is provided by data showing that most people who become infected after exposure do so within a 14 day period. In addition, the ability of a test to detect the presence of the virus relies on viral load, the quantity of virus in the sample. This increases the first few days then decreases again. A negative test only means a person did not have a detectable quantity of virus at the time of the test. It does not mean someone will not become symptomatic at a later time. The 14 day period is considered a window of time during which this may occur. Therefore, a single negative test is inadequate.
COVID cases are high in most areas of the U.S. and multiple states have released travel advisories using case positivity as a measure for quarantine. In response to the increased number of people in quarantine, some have developed their own standards for ending or bypassing quarantine by using testing. New York state does not have a testing option to bypass the quarantine period. However, Connecticut does have such an exemption if the traveler can provide a negative PCR test result performed 72 hours prior to arrival or anytime after. Additionally, organization like Yale University have further adapted state regulations to add multiple tests. Currently, Yale Health requires two negative tests after travel, one on arrival and one 4 days later. Other notable examples come from organization like the NFL where exposure requires 8 days of isolation with daily testing.
Some private schools have adopted similar guidelines, utilizing negative testing as a means to bypass quarantine. However, there is currently no scientific evidence that supports a timeframe for testing to safely end quarantine. Based on the limited data available, we know that the median incubation period (exposure to symptoms) is 5 days and that 97% of people who will develop symptoms will do so within 11.5 days. We also know that testing is more likely to be positive after someone is symptomatic. Therefore, we concur with the CDC and do not recommend testing as a method to end quarantine early. If you choose to adopt such an approach it is critical to consider local government advisories to be sure you are in compliance.
Also, it is important to note that we DO recommend testing after exposure in order to detect those who are asymptomatic carriers. This has consequences for subsequent exposures and isolation, but this is not performed as a method to end quarantine.
6) Masks Mandates
An interesting study from Kansas University compared COVID case trends in Kansas counties with and without mask mandates. They found that counties with mask mandates benefited from lower case counts after the mandate, and maintained lower counts during subsequent “spikes” state wide. Though the study was limited to Kansas counties, it does provide useful information about the benefits of mask mandates on a large scale. A similar discussion was published by Prevent Pandemics and noted a benefit in counties with mask mandates in Alabama, Kansas, Oklahoma, South Carolina and Texas.
7) Mortality Rates Are Improving
Two studies, on in the U.S. and one in the U.K. show that mortality (death) among people admitted to the hospital with COVID-19, is decreasing. This is welcome news. In an interview with the study authors, an NPR publication noted that “Patients in the study had a 25.6% chance of dying at the start of the pandemic; they now have a 7.6% chance.” This decrease reflects improvement in how we treat patients with COVID-19 coupled with benefits from medical therapies like steroids, high flow oxygen, and newer experimental medications.
8) Vaccine Trials Resume
The Astra Zeneca and Johnson & Johnson vaccine trials have been allowed to restart after being paused due to reported participant illnesses. Astra Zeneca reported a neurological disease in a U.K. participant and restarted the trial in the U.K. on Sept 12th. It received FDA approval to resume the trial in the U.S. on Oct 23rd. That same day, Johnson & Johnson announced its preparations to resume its trial after a two week pause to investigate a patient illness. Details of the illnesses in both cases are limited and expected to be released with the full trial data upon completion. Additionally, Astra Zeneca recently reported that preliminary data shows its vaccine causes an immune response in younger and older adults. It is a positive sign. We look forward to examining the data when it is released.
9) Eli Lilly Antibody Treatment
Eli Lilly released a statement on Oct 26th noting that its antibody treatment was not found to benefit hospitalized patients. It continues its trial of the medication in patients diagnosed with COVID-19 but not hospitalized, in hopes that it will prevent progression of the infection.
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Stay Safe !
Sam