Testing & School Reopening

Authors of a New England Journal of Medicine perspective this week propose that making routine Covid-19 testing available in schools should be a top national response priority, and they critique the lack of inclusion of testing guidance in most advice directed to, and strategies adopted by, school districts as they work to reopen.  According to the authors,

“Most reopening plans instead focus on screening for Covid-19 symptoms. Yet recent research indicates that symptom screening alone will not enable schools to contain Covid-19 outbreaks. Because an estimated 40% of Covid-19 cases are asymptomatic and 50% of transmissions occur from asymptomatic persons, we believe that screening testing is critical.”

CDC guidance to schools released earlier this month indicates “that schools ‘might choose’ to offer voluntary testing and that their decisions ‘should be guided by what is feasible, practical, and acceptable’ and should prioritize symptomatic persons and close contacts of persons diagnosed with Covid-19.” Furthermore, while data collection around school-related infections is incomplete and disjointed, early assessments of the data that is available appears to indicate that schools may not, thus far, be a significant source of the current surge in cases.

Challenges in implementing widespread testing in schools include:

1. the many obstacles to access to testing, such as cost, resource disparities, and local availability;
2. management of test results, including privacy and reporting concerns, as well as test result lag times, as “a modeling study showed that same-day results can prevent 80% of new transmissions, whereas a 7-day delay stops only 5%.”; and
3. the logistical challenges of implementing a complete and effective system to test, isolate positive cases, quarantine close contacts, while also maintaining stable curricula delivery.

Restrictions on Churches, Businesses, In Person Gatherings

Many states are increasing the stringency of emergency gathering rules in light of significant, sustained rises in coronavirus cases. At the same time, there are an increasing number of challenges being filed against these emergency restrictions, and in some cases, courts are overturning state efforts to slow the virus’ spread through restricting gatherings.

Colorado has implemented an amendment to the state’s “safer at home” order that now limits personal gatherings in 59 of the state’s counties to 10 people from no more than two households. Meanwhile, a Colorado federal judge has found the state’s emergency policy placing limits on the size of religious gatherings violates the U.S. Constitution.

A Wisconsin appellate court has denied that state’s request to keep in place restrictions on indoor public gatherings in sites including bars pending legal review of the governor’s emergency order, halting the state’s ability to “restrict indoor public gatherings to 25% of a building or room’s capacity or 10 people in places without an occupancy limit.” At the same time, Republican legislators are challenging the validity of the governor’s mask order. Wisconsin has one of the nation’s highest coronavirus infection rates.

Illinois’ Governor recently announced that state police will be used to patrol bars and restaurants in four areas of the state where more stringent gathering rules have been implemented due to rising local rates of coronavirus. The police will be authorized to disperse crowds and issue citations. Chicago also has implemented more stringent rules, including requiring that nonessential businesses close by 10pm, bars and restaurants stop selling liquor at 9pm nightly, and that bars that do not serve food stop serving customers indoors.

Eviction Moratorium

The nationwide eviction moratorium remains in place; however, the lack of an additional federal stimulus agreement means neither renters nor property owners can expect further federal financial support in the near future, numerous lawsuits have been filed challenging the federal action, and landlords appear to be continuing to evict renters. The CDC cited the public health concern of widespread evictions causing increased risk of coronavirus spread. As reported in Bloomberg News, according to one recent modeling study,

“When tenants are evicted, they often move in with other family members, increasing the size of households and the chance for viral transmission. Levy’s model predicts that a 1% eviction rate would result in a 5% to 10% higher incidence of infection, leading to approximately 1 death for every 60 evictions.”

Community Engagement

UNICEF has published a research brief on the evidence surrounding community engagement in the development and implementation of Covid-19 infectious disease control programs. The brief offers the following findings:

1. Early discussions and negotiation with communities is critical for understanding socio-cultural contexts and developing culturally appropriate prevention and control strategies
2. Community engagement (CE) should be an on-going process to re-assess and modify activities to deal with the dynamic community-level pandemic plans and meet community’s evolving needs and situation
3. CE can help the health workforce, as it allows a multi-sectoral approach, drawing on local resources and expertise to carry out critical health system functions and create innovative solutions
4. CE can help build trust in the health system to counter resistance and non-compliance from the communities facing top-down biomedical and epidemiological control measures during an epidemic
5. Meaningful engagement activities need to be embedded within systems, and not abandoned after the peak crisis time, as they may have the ability to support recovery and resilience efforts
6. There is a need for frequent and open dialogue within CE activities; communities should be treated as active participants in, as opposed to passive recipients of, health response efforts
7. Actors in CE for infectious disease prevention and control are diverse, but the most prevalent are community leaders, community groups (including faith groups), and individuals
8. CE process usually involves identifying groups and individuals at the local level (pre-existing or new); building capacity and sustained leadership through training, technical support like planning, developing interventions, inter-sectoral action, monitoring and evaluation
9. CE is most often used for social and behavior change communication (SBCC) and risk communication, though it has also supported consultation, surveillance, design and planning, logistics and administration and community entrance. CE can also support referrals via follow-up visits
10. SBCC and risk communication messaging at household level should utilize local leaders, influential community persons or people who have experienced COVID-19, combined with mass media messages tailored to communities’ socio-cultural norms, realities and experiences
11. During emergencies, the resilience and capacity of CE actors can be supported by ensuring clarity in regards to roles, and compensation, by providing trainings and equipment, and creating space for dialogue between health workers and CE actors
12. CE strategies have been implemented mainly in low-income countries (LIC) during Ebola epidemics, and in high-income countries (HIC) where it has been used to target minority populations for H1N1 and Zika. It can be adapted and replicated among wider population groups
13. There is a need for more documentation of CE activities especially from more diverse geographic settings and with different populations. Implementers, policy makers and researchers are encouraged to share learnings from past CE initiatives and document on-going CE for COVID-19 activities
14. COVID-19’s global presence and social transmission pathways require social and community responses. All countries are encouraged to assess existing community engagement structures, conduct contextual assessments, and co-design appropriate strategies for appropriate COVID-19 prevention and control measures.

Covid-19 Vaccine Testing

Pfizer will be the first drug company to enroll minors in their coronavirus vaccine trials. They seek to sign up 3,000 participants between 16-18 years old in the coming months.  The FDA’s group of outside advisors on vaccine development and safety met last Thursday to discuss the process being used to assess and approve potential coronavirus vaccines, raising concerns about relying on the proposed, relatively low safety and efficacy thresholds for a vaccine Emergency Use Authorization.