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Gavin: Hello, welcome to another episode of The Lancet Voice. We're addressing the biggest topics surrounding COVID 19 as Europe goes into another round of lockdowns. I'm Gavin Cleaver.
Jessamy: And I'm Jessamy Bagnall. One of the biggest questions of the last few months for us has been the failure of test and trace systems across much of Europe, the US.
Lots of countries have really struggled with this to effectively control the virus. I spoke with Rosanna Peeling, who we've spoken to before. She's the director of the International Diagnostics Centre and chair of diagnostics research at London's School of Hygiene and Tropical Medicine to discuss why testing in particular hasn't been able to avert lockdowns and how it might be fixed.
Rosanna, thanks so much for joining us again. I was just looking back at the last sort of seven, eight months, and I saw the opening remarks from the director general of the WHO from March 16th, 2020, which basically says, we're concerned that countries are not ramping up their testing capacity.
And we have one simple message for all countries. Test. Why is it That, seven months later, this seems to be so poorly done in many countries.
Rosanna: That's actually a hugely important question. I think all the countries would like to have a better capacity to doing testing, but scaling up of molecular testing is a really difficult thing because molecular tests, to detect the viral RNA is quite a complex procedure.
And so you, to begin with, you need to have the lab capacity with the technical expertise and competence, staff to, to do the work and to build that capacity is not something you could do overnight, right? And then you need the supplies and the reagents, and there's a global competition for supplies.
And even for swabs, right? And then a lot of countries are having a few testing centers where the testing is done and the specimens have to be transported from all different clinics, hospitals to the testing center. So that causes delay specimens are lost, etc. So the specimen transport system is something new that countries have to set up de novo for the pandemic response.
And of course there are different different problems that countries encounter. And then finally getting the results back to the patient in a timely manner from the lab. from the central testing lab services to all the different clinics, to the providers, to the patients, et cetera. That has been really difficult.
And so these are very basic pandemic preparedness basics, but it's, a lot of countries thought they are prepared, but not quite because I don't think we ever thought it would become a pandemic of this scale. And
Jessamy: right. And what is the relationship between contact tracing and testing?
And why are they hard to combine, or why are countries struggling to combine them?
Rosanna: Yeah, I think, contact tracing is one of the, traditional key public health measures to either slow down or stop or interrupt spread of an infection in the communities. We do this all the time for sexually transmitted diseases like HIV, chlamydia, gonorrhea, etc.,
right? But in most countries they, have only few people trained for contact tracing because it does require some skills and you really need to be able to train people to say, okay, how do you con trace the context of a confirmed case? What do you ask about symptoms? What do you ask about activities and travel before you tested positive?
And then how to reach all the people that you may be in contact with and what if they were in a shopping center and how wide is the net that you want to do? So there's a problem of just for contact tracing alone of human resources, not enough people trained to do that. And also not having an international standard on the, or national standard on the rules of, how wide a net, how fast, how detail you want to be.
And then once you track down someone are you going to offer testing? How are you going to offer testing to them? So that you would know whether they're infected or not, or whether you just tell them to self isolate for 14 days or all that. And so countries have started to try to innovate. I think in Singapore they started to utilize other people who are trained in tracking down, detective type work outside of health to try and help.
Which is very useful. And then other countries are using apps, right? Have electronic systems where people could find out if they have been near anywhere near a case. But of course, that comes with a lot of sort of privacy issues and whether people are willing to be identified. I think in some countries they identified the street.
Where people have become positive or in some in Canada, for example, they give the data by region in a city. So you use section of the city, whether you have higher number of positives or not, but that doesn't help you. I think sometimes they broadcast memos like there's been a case at a shopping center or a case at, some mass gathering or something.
So it is it's not something that you apply to most disease control work. So that's something, again, as part of. pandemic preparedness would be, we should be better prepared for the future.
Jessamy: And is that kind of failure to, to be able to combine those contact tracing and testing effectively, one of the major reasons that many well resourced countries have, responded to the pandemic fairly poorly, or are there lots of other issues going on
Rosanna: at play?
I think the most difficult thing for a country is that if they started to lock down or travel restrictions late and when they first test, they already have a huge number of cases, then it's beyond the capability of the country to trace down everyone, right? Whereas if they started the lockdown earlier, like in some countries in Asia that had, had the scare of what happened with SARS, they started earlier, they get on top of every single case and not let it go through without the contact tracing, then it's manageable.
But when it becomes, a certain number, maybe it won't be manageable.
Jessamy: And I guess that's where this sort of question about elimination versus suppression comes in. Where do you sit on that debate and sort of conversation?
Rosanna: I think there are a lot of factors to think about suppression or elimination and it's, there's no easy answer and I think that some countries, a few countries decided that maybe they won't try to suppress, they would just let people go on their everyday lives and detect the cases, try and do public health measures as much as possible and let it run through the course.
But we know now that could lead to quite a chaotic situation, right? And and there has to be a sort of a path happy medium between the two. And I think countries like Singapore and other countries now South Korea they have these circuit breakers. So you and circuit breakers are very good in a way that you, people, if people know that from, next Saturday for three weeks, we're in a lockdown situation, then they could plan for it, right?
And they are much more likely to be compliant with it than if you just say, okay, we're locked down now. And there's no telling when, and I remember I, in, in some countries when they imposed lockdown there was just no way that people will comply because they thought how are they going to make a living and if they don't comply, then, nothing, then all the public health measures are not effective because we always say, no one is safe until everyone is safe.
And so if there is a one part of the community where people are not complying, then the whole community is at risk.
Jessamy: And which countries who you know, did not have a collective memory of SARS, have done well to develop their testing and contact tracing capacity? And what might other countries that are struggling with their current testing sort of levels learn from them?
Rosanna: I would say that in, in, in Europe Germany, has been, doing really well in terms of their ability to to cope with the pandemic. I think they started containment efforts quite early when they see the surge of number of cases in Italy and in Spain, right? And and so there was widespread testing.
They have lots of hospital and intensive care beds, so they were able to cope with the patient load. But I think more importantly is that the public complied with the recommended measures. And also, I think that people have to trust the government. And otherwise, your public communications messages are not effective if people don't trust the government.
Transparency, people like to know that the government is telling them the truth about what's happening and not hiding anything. And and that's, to gain public trust is difficult in a pandemic situation where you're trying to learn about the virus as you go. And so you may have to change policy because of new learnings.
When we first learned that people could be shedding virus before they become symptomatic. That changed everything about what we say about masks, about gatherings and all that. And so the public have to trust that the government is not just telling them a story. story, but that, so I think Germany did really well, I think and the other country that has done well and not being part of the SARS, having had a SARS memory is Senegal in Africa.
So I think that Senegal had a different kind of memory, which was Ebola. And they were they, there was a threat of an Ebola outbreak in 2014. And from there, they actually have a national blueprint on what to do about an outbreak. And that they applied, because it's a smaller country, so it's easier to apply.
And also, they have mobile labs. They have lots of testing capacity, as well as mobile labs, to make sure nobody is left behind. And that is a success, yeah. The testing capacity, the government being prepared, and the public trusting, yeah.
Jessamy: It's so interesting, isn't it? Because that kind of, the public health messaging in so many countries has been so poor, and obviously it's difficult for people in society to understand that things might change and that nothing's so clear cut.
But I think also that there does seem to be a kind of, even the fact that, there have been politicians within different countries that have been questioning the role of the state within public health is also very unhelpful when actually, historically, the role of the state within public health is, is very unhelpful.
is very fixed and has a very good history in terms of dealing with both, mass vaccination, reducing road traffic accidents, all of these kinds of things where, there's been state intervention to improve public health and this kind of political sort of uncertainty that certain politicians have been propagating seems to really undermine that and to make everybody feel a lot more uncertain.
Rosanna: Yeah, I think, there, there are three parties and, there's the public, there's the public health and the scientists, and then there's the politicians, right? And so I think that there has to be a Seamless sort of a sense of community. That we're all trying to do this together before it could, the countries where we've seen failures in the response are countries that where the politicians don't trust the scientists or don't take advice from the scientists or they actually, try to balance the economy In a way that is not good for public health in terms of control of the pandemic.
And and in doing so actually made it worse for both the economy and the disease control. And we have some examples of some really well resourced countries that have gone that route. And with the public now completely bewildered as to who they should trust, whether it's the voice of science and or the voice of the politician.
And the public, of course, wants the economy to recover. And so then, it throws all three parties that are so important in the pandemic response into disarray.
Jessamy: And just out of interest Rosanna, what's that been like as a scientist being on these various panels doing things? I mean it must be quite emotionally challenging in many ways.
It
Rosanna: is because you're always trying to balance what's ideal in terms of the science. with the reality. And the reality is more than just the biomedical intervention, right? There's the public there's a global competition of supplies and there's global competition for everything. And and so in terms of thinking about equitable access for testing, for example, and trying to recommend whether we should have a test that has this type of accuracy and this type of usability it's all in vain if countries cannot get access to it.
So on the one hand, having these recommendations that and the recommendations actually take weeks and months to make it was taking way too long. We should be just a little bit more pragmatic about the whole thing and and just, keep changing as we know more, right? But people don't work like that.
Systems don't work like that, right? And so we just learn to be more nimble, faster, and not let the perfect be the enemy of the good. And I think the, this pandemic has been a major teachable moment for us on how to. Make policy or how to move things a lot faster to control the situation.
Jessamy: Yeah, but it must be extremely emotionally wearing and challenging for you in, in, in that position trying to juggle all of those things and also. Just the responsibility.
Rosanna: Yeah. And also, and have friends phone up and said, why is it that my dollars cannot buy these tests versus dollars from the U S and UK and Canada?
So there, there's all kinds of inequities that are really at play here when it comes to, a pandemic.
Jessamy: And what do you think we can expect in terms of improvements? In testing capabilities and availability in technology and who can get it, who can access it over the next six months, we've talked a little bit about the sort of bottlenecks, but what are those bottlenecks that really need to be overcome over the winter months, in the
Rosanna: global north anyway.
So I think in terms of testing, I'm so envious of the vaccine groups. The vaccine groups are already talking about major fair allocation mechanisms and, being prepared for trials and everything for diagnostics. We have over 580 some brands of diagnostics. that are waiting to be evaluated, we have, we don't recommend people buy them before we know whether they work or not and then the supply chain, all the good tasks, once the publication came out that they are good, there's a Big competition for those, right?
And countries being caught with different, the U. S. are not allowed, U. S. companies are not allowed to export any until the U. S. markets. It's filled and, so there are many of these things that are difficult. And then still, countries are not moving as quickly as possible because the regulators and the policy makers are still asking the companies to do evaluations in their countries.
So one product, one rapid test that was really good, the company told me, we're being asked by 40 countries to do trials in their country. And so this is slowing down. And the time for access for the people. And also, it's actually a huge cost to the company. So the final cost of goods would be a lot higher than if we had streamlined all that and we have major convergence or reliance of this kind of information on how good the tests are, rather than every country demanding to have their own trial.
So there are lots of these bottlenecks that we need to figure out on supply. And then the other bottleneck is for everybody to come to a consensus on how to use them, where to use them. We have now the very sophisticated molecular tests. We have the point of care molecular tests, we have the rapid antigen tests to detect viral proteins, we have antibody tests, some can just detect total antibodies, some can detect antibodies that may be neutralizing, so we have this whole portfolio of tests and as I said over 500 of them. We need, countries need some guidance, or they could figure out and share with other countries how they intend to use them and where to use them, who to use them on. For example, if you use the rapid antigen test at border crossings.
When your expected number of positives are low you're going to get more false positives than real positives, even if the specificity is very high. And I think that countries need to be very careful about how they use these tests. And unfortunately it's not an easy thing to do and yeah.
Gavin: I think what I really got from the Rosanna interview is that so much of the kind of conversation about test and trace that's dominated the media generally lacks those nuances that Rosanna got across. That in European countries, for example, we allow the virus to spread too widely for anything approaching a comprehensive test and trace system to pat it back down. Whereas the more successful countries got on top of it early and then that case, they, the testing and tracing systems didn't have to cover so many cases and could obviously work a lot more efficiently. Now that seems obvious when you talk about it, this kind of exponential nature of the resources needed for a testing and tracing system in relation to the number of cases they're monitoring, but it's not something much of a discussion of in the news generally.
Jessamy: Yes, I think that's true. And that sort of, reasonable expectations of how can you reasonably expect a contact tracing system to be, doing the contact traces of thousands and thousands of cases is a narrative that we don't very much discuss. And I think that's something that came across clearly with Germany when they were considering going into lockdown about their reasons of going into lockdown now, or, last week or in the last week or so.
was to try and get those numbers in control so that they could then rely again on their contact trace system. I think the other thing that really came across for me from that interview was just how many tests there are and how important it is. to get this right. Because, even when we have a vaccine, people are still going to need to be tested.
We're still going to be heavily reliant on understanding who is infected, where they're infected, where the transmission is. And we really need to focus on that as much as we're focusing on therapeutics, as much as we're focusing on vaccines. And we're not at the moment. certainly not something that we hear lots and lots about other than, oh, we can't get our contact tracing system, going.
Gavin: Yes, it almost feels like phase two of testing is to finally start identifying the asymptomatic patients. That cases have been so widespread across Europe that we never really got as far as working out who were the asymptomatic. the walking well, and It was more a case of putting the resources to where they were needed right now, which was people who are on well, but actually to get to the next stage of the epidemic we're going to need to identify those asymptomatic patients and isolate them as well.
Jessamy: Yes, it's incredibly hard because obviously, there's been a sort of range of estimations of how many people are asymptomatic. We've seen studies from 20 percent to 60%, and that will change across age groups. This is a sort of something that's been developing over the last couple of months.
And I think there has also been this focus on trying to get the most accurate test. And that's where I think that Roserna's suggestion, and I think it's something that's coming through more and more, particularly as we see Liverpool doing mass testing, is that actually what's clear is that in many countries, contact tracing, the way we're trying to do it at the moment, is not working.
And we need to try something else, and that might be then trying different tests that are potentially, not quite so precise, but allow a much more frequent testing, are easier to do, and can give us some kind of ability to, get a handle on things quickly.
Gavin: I feel like you're dancing around the word moonshot here without actually using it.
Jessamy: I can't use the word moonshot. We'd have to use warp speed, all of these aeronautical terms would have to come into play.
Gavin: I do think as well, one one thing that I've always been keen to point out to people that ask me generally about, testing system, what's gone wrong in Europe is that Europe generally, feels less likely to accept the kind of authoritative measures that have been put in place by Eastern governments in relation to quarantine and taking people out of society.
And I was reminded of this recently of, as you were mentioning, Liverpool there, I was reminded of Slovakia. And what they've done in Slovakia with testing the whole country is said that you can refuse the test if you want, but if you refuse the test you have to quarantine and you can't go to work. So Those are the kind of methods where it's skirting more towards the kind of authoritative government measures, I think, in the East that that you just don't see generally in European governments.
But I think it will be interesting to see once we have an extremely comprehensive testing system that can test entire cities or entire countries in a matter of days, along with the vaccine, to what extent governments then I want to say push their luck on that level. But yes,
Jessamy: I do. I do think it's interesting because I think that this sort of concept of the state involvement in public health and how in European countries, it's Hands off. It's not really fair. Even, just looking back over the last 70 years For instance in the UK there were things called fever vans where you know children who had scarlet fever were literally taken in these fever Vans from their family and put into hospital and their family weren't allowed to see them again I feel that we've lost any sense of a collective memory of what it's like to deal with an infectious disease on a large scale.
In fact, governments have been forever trying to make their population safe from infectious diseases with some, pretty involved measures. And that's, that sort of precedent is very much set and one that I struggle to see. Quite why it's such an issue at the moment.
Yes,
Gavin: I agree And I think the topic of collective memory is a really interesting one when we spoke a few episodes ago with Kenji Shibuya About the response in Japan. That was one of the things that he spoke quite a lot about was the collective memory of the recent SARS and MERS outbreaks in the east and How mask wearing was this kind of thing that had been going on for so long in Japan That it was a completely accepted normal part of everyday life now, whereas countries like the UK are just coming to this now, these kind of developing this memory, developing an idea of how we a memory of how we deal with this sort of pandemic.
So yes, I do think that collective memory is a really important part, but I also do think that kind of mask wearing and adherence to these kinds of measures is improving in the UK as we go on, as it becomes more of a normal part of our lives.
Jessamy: Definitely. And I suppose it is just that balance of, there's so much economic difficulty that is associated with coronavirus, particularly for people who are in informal labor or aren't covered by some of these job schemes.
We have to make that much, much better because that's the only way that you can really expect people to be. adhering to some of these guidelines and to be, willing to be tested to be really trying to use their contact tracing apps is if they are able economically and safely to follow the rules after that, after they test positive, otherwise it's all for nothing.
Gavin: Yes, making the imposition as convenient as possible, so to speak.
Another major question has been the logic behind keeping schools open while other preventative measures are in place. How big are the risks? How can we stop children falling behind? What's current best practice for keeping schools open? Jessamy spoke with Melinda Bunton, who's the Chair of Health Policy at Vanderbilt University, to talk generally about schools and COVID 19.
Jessamy: Melinda, thanks so much for talking with us. Perhaps you might start by telling us a little bit about yourself.
Melinda: So after I earned my PhD, I went to work for the original think tank Rand Corporation which was a nonpartisan organization. And I did research as part of big teams there about things like how to pay rehabilitation hospitals and what's the effect of high healthcare costs on U.
S. competitiveness. And from there, I went to the multi billion dollar initiative to upgrade health IT in the U. S. And from there, the Congressional Budget Office, which gives non partisan advice to the U. S. Congress about the costs and other implications of each piece of legislation they're considering.
And from there, I went to Vanderbilt, where I'm part of a major academic medical center. I've really been able to see all sides of health policy and all sides of the U. S. healthcare system. Executive branch, legislative branch, non profit think tank, and now clinical operations.
Jessamy: Exactly. And that's what's really struck me when I was reading your bio, is that you must have such a kind of in depth view of all these different aspects of healthcare in the U.
S. which, particularly now seems to be a pretty good skill set to have.
Melinda: Healthcare is so complicated that no one can have a truly in depth view of what's going on in nearly 20 percent of the economy. But I can say I've had a number of different vantage points and that does help me.
Jessamy: Yeah, no, that's great. And today you're going to talk to us a little bit about schools and children, transmission of COVID 19. And I thought we might start by just talking about where our understanding of the role that children play in transmitting flu and other coronaviruses. comfort from and what that kind of meant for how we thought about the initial responses to school closures.
Melinda: Absolutely. It's such a great question. I do think that the initial response of school closures was based in the best information we had at the time. So we know from prior research that Children are often key transmitters of diseases. like influenza because they spend prolonged time in close contact with other children.
They do sports, things like that. And even prior studies had identified associations between school closures and reduced transmission, again, of diseases like influenza. So it was logical to think that we should close schools initially. However what we're learning now is that as we gain experience is that there are mitigation strategies that do seem to work.
And so we have better insights into how to reopen schools, which are so critical for school children's development in ways that are safer.
Jessamy: Yeah, exactly. And It's interesting about the sort of the evidence that is accruing and what's coming out. And there still seems to be some disagreement about the role that children play in transmission and whether there's a sort of relationship between severity of the disease and how potentially, therefore likely you are to transmit it to others.
So if children get milder immune response, are they more or less likely to be infectious? What's your reading of the evidence and what that sort of, what the implications are?
Melinda: I used this opportunity to ask a good friend and colleague, Kathy Edwards, who's a pediatrician and infectious disease expert about this, because I too had a lot of questions.
I thought the evidence was a little bit conflicting. And what she told me is that several studies have now shown that the viral loads in children and adults are comparable. But, there's an apparently reduced contagiousness in younger children and that's not yet well explained. She said there are some theories, for example, there's a theory that it's due to children having less forceful coughs or things like that, but it's just really not clear.
So again, I say when we don't know something what do we know and how can we use that information? So what we do know is that children, adolescents, and young adults can get sick from COVID 19 and they can transmit it even if at lower rates and even if younger children are more likely to be asymptomatic.
So what we should do is that we should practice physical distancing, mask wearing, hand washing, and self isolating of children who've been exposed to infected people or who are known to be infected. So we can do things, even though we don't have all the answers.
Jessamy: Yeah, exactly. And I think that's, been the sort of situation throughout the virus is that people are, we're struggling to.
get our heads around the different bits of evidence that are coming out and what that means practically about how we live our lives and obviously the huge implications that has for people who don't have a voice, like children. So what do you think the sort of evidence that we need now to inform policymakers more and to make them feel more confident about the decisions that they're making.
I feel like in the UK, we've got to the point where we've pretty much decided that primary schools and secondary schools should remain open. We, we still have real issues with university outbreaks and how that's been managed. So what do you think it is that we need so that people can feel more confident about?
the types
Melinda: of decisions they're having to make. In Boston in the Northeast U. S. They've just paused their plans to reopen schools because their test positivity rate went up. So what I think is important is to state in advance something like criteria or a tiering system. Then make decisions when the data tell you that conditions on the ground have shifted as they did in Boston.
And then learn from what other places are doing about what works and then adjust either your criteria or your response to different levels of these things. And this is just going to have to be a continual learning process. We don't know everything we need to know to do this perfectly. So we just need to be data driven and then adjust when new evidence comes out.
Jessamy: Yeah. And I guess that is the, that, that's the really hard thing, particularly when we're talking about children and adolescents, which spans now for such a long period of time. Our understanding of adolescence goes up to 24 or 25. And I suppose that's, where I'm interested to see what happens with the cutoff.
When do we start thinking that actually physiologically within how they respond to COVID 19 and perhaps how they are transmitting it within a community, we decide that they're more like adults. and therefore need to be treated more like adults rather than saying okay you can still go to school and all of those kind of things seem extremely difficult to untangle and to feel confident about so it does seem such a difficult situation.
Melinda: It does but one of the things that has been discussed a lot in the U. S. context and in fact there are some estimates about it is of course children live in households with adults. When you talk about sending children back to school in person, then you are talking about potentially exposing the adults in their household as well as the adults who are professionals in those schools.
And so really a key part of this decision that I don't think is getting enough attention is that we have to make judgments about the risk to communities, not just to children in schools. And so I think there may be a dichotomy there about cutoffs and thresholds and things like that. That's not considering the whole context in which children live.
And so for example there have been estimates of the proportion of children that live in households where there's someone who might be at high risk due to being immune compromised, obese, having heart conditions, and it may be as many as half of U. S. children.
Jessamy: Yeah, it's interesting, isn't it? And then there's all the other knock on notifications to think about, about, whether parents are then able to work and, blah, blah, blah, it goes on and on, isn't it?
And you touched briefly about Boston, but maybe you could just summarize the situation in the U. S. at the moment with regards to schools being open and universities and what's happening as far as obviously you can't tell us each state and each place, but broadly.
Yes.
Melinda: So broadly speaking there are just a few of the larger school systems in the U S that are starting to open. For example, New York is starting to open New York City. Obviously they were hard hit early in the pandemic. They are opening though under a situation where they're doing very extensive testing.
And they are watching numbers very closely and ready to shut down. schools, classes, things like that. In contrast, in Miami Dade, I don't think they're opening with exactly the same level of testing, contact tracing, and other things that need to go hand in hand and they're seeing more cases.
Again though, there are many large school districts, for example, San Francisco, just not even going to open it before 2021. So there's really a wide variation across the U. S. on what's going on. Here in Nashville we just started reopening the schools last week.
Jessamy: Wow, yeah. So it just seems to be just disproportionate kind of effects to different people, just postcode lottery, as we would call it here almost.
And broadening it more out now to think globally, it seems to me that the measurements and data of which countries are able to provide Some level of education during the pandemic seems to be a little bit lacking. I know that UNICEF have been trying to monitor this and do create reports, but what's your understanding of how we might be able to get a sort of better grip on the global situation of education for young people?
Yes, I would
Melinda: say that, you UNESCO who has a nice tool, the data are lacking, not just globally, but within countries, even within districts. about what exactly is going on. For example, here in Tennessee, the vast majority of districts are having what they're calling a hybrid model, where parents can choose whether to send their children in person or have them do remote learning.
We don't have that kind of information globally. We don't know how much time children are actually spending in the classroom. We don't know if they have The right tools to be doing remote learning, if that's the choice made on their behalf. There's so much we don't know. Even if we have some rough measure of what schools are theoretically open or closed.
'cause open and closed just isn't enough. There's quality of extra education, there's models of education and things like that. I am very worried that we're not collecting these data systematically and thus we're really not going to know the impact on children and be able to figure out ways to ameliorate what is certainly going to be some kind of loss this year.
Jessamy: Totally. I suppose that takes us on to the next question, quite nicely that I wanted to talk about, which is that, there's a lot of discussion about the sort of many vulnerable groups that are feeling the impact of COVID 19, but do seem to be particularly affected both, physically, mentally, educationally, economically, and socially, potentially for years to come in terms of, the sort of long term economic consequences for them.
What are your sort of real concerns? And how do you think we can give young people a sort of better voice in this and have them more as a priority.
Melinda: Yes. So my colleague Kyle Gavigal and I wrote a piece in the JAMA Hall forum about this very question. And there's We cited a lot of literature about children's worsened mental health, reduced access to nutritious foods, and how this might be, these adverse effects are being experienced by underserved communities disproportionately.
So we thought about reopening schools should start with the groups most likely to be disadvantaged by the pandemic and based 5 students may be the least able to primary students may be least able to learn remotely. Children with disabilities may need extra and in person help. Children who are already behind grade level might be specially targeted.
Families that don't have access to the internet or ability to do remote learning, which may include low income families who are at risk of eviction, for example. And then there's a whole group of youth who are in home environments that cause us great greater concern. For example LGBTQ youth may be in a home environment that's not conducive to learning.
And one of my colleagues has recently been writing about that in the context of college students who may be staying at home. So all of these groups, I think we should think carefully about them and how do we bring them back in person safely and quickly. But we also, as you just said, we need to listen to children and in particular, if we're going to bring kids back to a safe environment, it's going to have to be different than what they're used to.
They're going to need to wear masks. They're going to need to social distance. And so we need the voices of students to figure out how to make this safe. socially acceptable, how to make this part of a school culture where they can all be safe and keep each other safe. And if we don't listen to kids about how to do that, we definitely won't get it right.
Jessamy: Yeah, exactly and they won't be able to enjoy it, I mean it's school when it's at its best is such a sort of wonderful time. My, my son's gone to preschool now and he is adoring it. To think that he would be missing out on that experience is so sad, that sort of whole kind of mental development is so crucial.
Melinda: I was talking to a friend of mine the other day and she she was talking about her five year old who is dressed up at five in the morning, every morning to go to school. She can't believe how excited she is to finally be allowed to go to school.
Jessamy: Exactly. Exactly. And I'm just, I think it's going to be so funny about this sort of narrative that they look back on when they're 90, when they're in their 80s and 90s, looking back on this period of time, it will be fascinating to see what they see it as.
I think my son will probably see it as quite a kind of peaceful, quiet time, but a very strange one. We also spoke with Ines Hassan, policy researcher at the Global Health Governance Programme at the University of Edinburgh, and the main contact for the UK school pandemic policy in the Royal Society's DELVE initiative, which feeds its work into the UK government and SAGE.
So
Ines: I'm a senior policy researcher. at the Global Health Governance Program at the University of Edinburgh. And I also have a more kind of a longer kind of background working for healthcare, started off as a biochemical engineer, worked for many years in kind of the broader healthcare industry. And I'm also a member of the Delve Data Evaluation for Viral Epidemics group, which was set up by the Royal Society at the start of the pandemic.
So we've been working with them very closely trying to try and develop rapid policy recommendations with regards to the COVID 19 pandemic. And yeah, I was assigned schools and looking at how the health of children in schools and how that might possibly impact the transmission rates in, in the wider community as well.
I also do consulting work for the World Health Organization as well.
Jessamy: Great, so you're very well placed to be talking to us at the moment because in the UK, we are just about to enter another lockdown, schools are to remain open initially we thought that, the evidence that we had to close schools, my understanding is at the beginning of the last lockdown was based on flu, where we think that closing So schools can make a meaningful role in reducing transmission, but we now think that because of the sort of transmission dynamics of COVID 19 in children, that closing schools might not be that effective and the sort of disadvantages, of keeping children at home and not having education outweigh the advantages, although obviously the jury's still out.
What is the strength of evidence that we have now about whether children should be going to school or staying home?
Ines: Yeah, it's a really tricky one. One fact that I always remember that I think in August, there was an estimate that 1 billion children were thought to be out of school across the globe, and roughly 400 million of them had lost access to free school meals, and also a much publicized problem we have in the UK as well.
So I think there are Also, and there were so many other health considerations such as physical education, mental health, long term loss of skills and earnings to consider. So it isn't just so easy to to close a school. So I think we need to always remember that. Also, it's important to remember that transmission of COVID 19 remains low in schools, if, and that's a big if, that community transmission is low.
So as we've seen experiences in countries like Israel and several states in the U. S., they've shown that if cases jump quickly and community transmission is high, then it's very difficult to keep schools open safely. You get continual outbreaks and cases of, COVID 19 in schools, which also then obviously affect the confidence of the wider community, teachers and parents, even if the risk is relatively low compared to kind of other areas.
We even had a report, I think earlier in the year, in August, I think it was from Public Health England, which examined the outbreaks of COVID 19 at English schools in June, and they found a very strong correlation between the number of school outbreaks and the regional incidents of COVID 19. And I think this is also reflected in more recent stats with regards to school attendance.
So it's an issue, but there's lots that we can do. And I think that the ultimate recommendation that we gave us, especially as a Delve group that we gave to the government, is that kind of the last thing that should close and the first thing that should open are our schools, because of all these.
Broader disadvantages that are associated with school closures breaking chains of transmissions after cases emerging schools is incredibly important. And I think we've emphasized this again and again, but the thing that's really important is having a robust testing and tracing system, which is really integrated well within community.
And one of the things that's important is that these sort of tracking and tracing and testing systems, they work. Especially well when community transmission levels are manageable, so they need to be low enough. The other thing also to consider is that we know that older kids and teenagers, they can transmit and some studies have shown the same to the same levels as adults.
So we have seen that evidence that there are older teen infection rates rising substantially since schools have opened. So just to re emphasize the point that we need infections low enough that the risk in schools do not rise So much within this particular age group as well, but the other thing to also notice that they also probably more likely to catch it out of school.
So where they're socializing. So even so perhaps something like a lockdown would also help. Another important point is that what we really need to do is stop conflating schools with universities. Those are. two very different environments, and we as a group in Delve, we recommended that schools go back, but we did not recommend that universities go back.
I think universities are a completely different environment. And the kind of the disadvantages of not opening universities. The universities are not the same as not opening schools. It's completely different. And also the universities are very much responsible for spread. Not necessarily through kind of the education areas in lecture halls but primarily in accommodation of course, especially because, of course, people have coming from different parts of the country.
More readily increasing the risk of transmission. So I think that's something we really need to emphasize. The government really needs to stop talking about schools and universities as one. They are completely different.
Jessamy: Yeah, I think that's absolutely right. That narrative is so wrong, isn't it?
Because, they're just the two completely different kinds of fish and to the, to a large part, you're talking about adults really getting together, in terms of Actual sort of physiology and how they're dealing with the disease. You're talking about adults getting together. In a large place and kind of, coming from various parts of the country and then and living together, so it is a completely different ballgame, it's
Ines: a completely different ballgame, 100 percent and also just to remember the negative aspects of them not being university, yes, it's, detrimental, but just not to the same extent as we are seeing with schools and the last point I want to make is that the MPIs that we have that the different interventions that we can use to reduce the risk of transmissions.
They do work. So let's use all of them. We recommended in our report that masks are worn in schools, but from, they were always, they were never made mandatory in schools. And even from what I hear from teachers is that some schools, they're not allowed to wear masks. So wearing of masks, we encourage the proper use of proper testing, where even asymptomatic cases can also be measured would really make a huge difference.
I know in places like Scotland, they prioritized at the beginning of when schools first started to open, they prioritized on demand testing for teachers, nurseries and other school staff who thought that they might have been exposed to the virus that could also help. And then, yeah, and then the use of proper testing.
We're wearing masks as well. So anything that we haven't been, we're not using because all of these MPIs will almost have a group of a tools, that all of them will help reduce the risk.
Jessamy: That's what our paper that we published, but way back in March showed about all of these different, masks, social distancing, eyewear, everything, has a cumulative effect, and that's, I think that's what we often forget, isn't it, that it's that sort of, the group of measures that can really affect us.
push things down percentage by percentage.
Ines: Exactly. So they're all cumulatively can have an effect. And I think one of the important things to remember is it's very difficult to know exactly what the effect of a single MPI might be versus another, because sometimes it's. unethical to carry out these types of studies.
Obviously, like a scientist, we would love there to be, a randomly controlled trial where, one set of children wore masks, the other didn't wear masks, obviously that's unethical, so we can't do it. And because we know keeping schools open is so important, because we know the detrimental effects of closing are so important, we need to do everything possible just to try to cover our bases.
And then so the last point related to that is that we need to ensure that schools have the right resourcing to make sure that they can use all of these interventions, things like, for example, we've mentioned masks a lot, but also because we need to keep the airflow, and we that not every school will have good ventilation.
So of course, what we'll want them to do is keep windows open, but as we get closer to winter, it's getting colder and colder. So what. what else do we need to do? What do we need to think out of the box? Do we need to make sure kids have appropriate clothing? Do we need to bring in blankets? All those kind of extra things need to be considered to ensure we can implement all of those MPIs.
Jessamy: Yeah, absolutely. And I suppose that kind of takes me onto my next question about this sort of natural experiment that's going on now, because, one of the, one of the key issues and public health specialists have been saying it from the very beginning, as soon as, we started going into the situation in early March, the key is going to be to try and understand which NPIs are most effective and when they should be placed and all the rest of it.
And disentangling that seems so difficult. So in terms of a, almost a natural experiment that's going on now in the UK in terms of keeping those schools open, how best should we be monitoring this over the next four weeks so that we can understand what the contribution is and try and, really get some clarity on it?
Because this may not be the last time that we have to, be in this sort of situation.
Ines: Yeah, exactly. I think one of the pieces of advice we gave before schools reopened in August is that what we really need to do is we need to assess the outcome from schools relative to the counterfactual, so what would have happened to local infection rates if schools had remained closed.
And so to do this, we said, It required testing of pupils who were at school and those who were were at home because at the time we had, some primary school children back in school, some at home. So we didn't really take the advantage of that particular opportunity, but there have been some studies.
The public health in England did run the COVID surveillance. and kids program as a kind of proof of concept study that aims just to test staff and schools, I think in about 100 schools in the summer and kind of an initial analysis of that data collection protocol suggested that it would not have been conclusively we weren't, wouldn't have been able to conclusively demonstrate a difference in the risk for attending schools, even if the risk.
was double that of non attendance. And I think that was because the sample size was too low at the time and because they'd only tested children attending school and not those out of school. So a case control study of children, both in school and not in school would have allowed us to compare.
attending school effects of what the difference is. And we would really be able to see if a school is actually a source of kind of transmission. So expanding that potentially could be useful, although now most all of the children are back in school. So that could have been a useful study.
There are like some There were some plans for further studies to happen, but again, the ethical questions have come into play. So there's a few kind of stumbling blocks. I think the ethics of collecting samples one of kind of the approaches they wanted to use was collect samples, but not test them for a few weeks to observe asymptomatic transmission.
I'm not involved in these studies, but from what I've discussed with colleagues, and I think the ethics of that was questioned. And also they carried out some focus groups, which has suggested that parents actually and headteachers and unions would have been happy to do this. But there was also some hesitancy to subject children to repeated testing.
So I think what we wanted to do is continually test children, to see, because obviously we know most children are asymptomatic, especially in primary school children to see When they do become positive and how quickly that they might the disease might be transmitted throughout the school But there was hesitancy to subject those children to repeated swab testing So perhaps there are like a few less intrusive tests which are being explored So that potentially might make things a little bit easier.
Jessamy: Yeah, it's interesting Isn't it to see how that will play out because certainly, you know for the rest of the winter This is such a crucial issue We all want to see schools we don't all want to see schools keeping open, but many people do want to see schools open and the kids able to go.
And keeping that seems to be, one of the key things that we need to get on top of and really understand the evidence behind it and get some really strong data. So it's a difficult one, isn't it? It's
Ines: a difficult one, but also if we, because we are going to be in lockdown, so hopefully fewer people within the wider community will need to be tested.
And if we can still prioritize the children. the teachers in that time where hopefully less of us will be infected with COVID 19, then that would also be a good use because, really understanding how asymptomatic transmission works is incredibly important.
Jessamy: Yeah. Yeah, absolutely. We spoke to Rosanna Peeling about this sort of thorny issue of testing.
We've spoken a little bit about it already. You've mentioned it and highlighted how crucial it is to, The sort of overall endgame, and we discussed this need for high income countries that are currently struggling with testing to pivot away from highly accurate tests to one that, that can be done more frequently and more easily, and in Liverpool, we're just seeing this sort of mass testing strategy coming out.
Could you tell us your thoughts on this and again, how this relates to schools, and we've already said that we need to prioritize school testing and teachers and children but how this might change over the winter?
Ines: Yeah, I'm actually glad to see that mass testing is being explored in Liverpool.
I think the cost benefit analysis for screening of asymptomatic pupils is complicated, but on balance, I'd also recommend it. I think routine testing is important. One thing I didn't also mention before, I think it was estimated that COVID transmission is estimated to account so asymptomatic COVID transmission is estimated to account for 40 percent of community transmission and possibly more in, in school aged children.
So just to emphasize that. Incredibly important. The other thing to remember is that to bring infections down more quickly than in the original lockdown, mass testing could really help especially in areas where there's high daily incidents and a higher R number as being as being seen in places, cities like Liverpool.
Otherwise there's a risk that it will take even longer to bring infection rates down. When mass testing is done using both PCR tests and lateral flow tests as being done in Liverpool, you need to bear in mind that a negative result from a lateral flow test is not a guarantee that they're free from infection.
As lateral flow tests are, I think, around 20 percent less sensitive than PCR tests, so they still need to follow things like that. Are the other kind of interventions, like social distancing, even if you get a negative result? Yeah. But the great benefit of mass testing is being able to quickly identify lots of people who are infected so that they can be asked to self isolate immediately, thereby breaking chains of transmission.
And if you find positive one positive case in, for example, a group of people, then you can do you can use more expensive tests to try and try and really find out, who is really positive. But it's, I think it's a great development. And I'm glad to see that we're starting to use those sorts of tests
Jessamy: in the UK schools.
Oh, keeping open over lockdown is quite controversial at the moment. And there seems to be a major divide between some of the teachers unions who feel that it's not safe for teachers and some parents who are worried that it's not safe, but many parents who feel that this is the best thing for children to try and keep some sense of education and to not disadvantage them too much.
Gavin: When you look at it in those terms, it's quite a holistic measure, almost keeping the schools open, isn't it? Because it's a kind of it's something that has these whole life effects on a child. And even missing a few months of school can have these Deleterious knock on effects that are felt years later, decades later in life.
But it is quite difficult to express that in the face of something as obviously dangerous as a pandemic.
Jessamy: Again, going back to the sort of inequality, digital divide, wealthy families being able to be quite comfortable at home with fast Wi Fi and they've got parents who can do homeschooling or whatever, have hot food, meals, food.
It. It does seem in many ways to be the fairest thing to keep schools open,
Gavin: but that does also touch on something that in was talking about with you in that interview, which is that these school closures have a massive impact on the more disadvantaged childrens, the ones that rely on the free school meals, and obviously they're gonna be many households across the country that simply aren't gonna have the equipment to connect to the school for lessons.
Jessamy: Exactly. So I do feel that the evidence has accumulated sufficiently, obviously we're not 100 percent certain, but I do think that there has been accumulating evidence that closing schools is different. for COVID 19 than it is to flu, where it can be very effective, in 2009. And I think we have seen very effective use of closing schools in previous sort of epidemics and pandemics.
But for COVID 19, I do think that the evidence is at a state where we can probably say for now school staying open is safe. And I think that one of Melinda's points and Ines's points, they make two great points. And one of it, is that the narrative shouldn't be around keeping schools open, is it a risk, but about minimizing the risk so that we can keep schools open.
And I think the other thing is this issue of universities and schools and not lumping them all together, because it's ridiculous to lump them all together. It's a completely, they're completely different sort of set ups, completely different adults and children. It's very hard to put them all together where, but I feel that at the moment that is the narrative that they're all lumped together.
Gavin: But I would like to express extraordinary amounts of sympathy for the first year of university students currently in the UK. Oh God,
Melinda: totally. Who faced
Gavin: the A level results problems over the summer and then went straight into student halls and many of them ended up locked in the student halls. zooming into their lectures.
It's for that one particular year of students, it's been the most unbelievable few months that must, that's going to affect them for years to come.
Jessamy: I think there is also evidence that Those children or those adults that start universities or going through universities as you go into a recession bear the brunt of that recession for decades to come in terms of their, earnings and their job opportunities.
So it is extremely hard for that age group.
Gavin: And I think what we're getting at here is something that's really important to bear in mind is that there's there's no good solutions. There's not one solution that's going to tackle everything. These are all bad outcomes. It's just a case of balancing the bad outcomes you're prepared to bear with the ones that you're not.
Jessamy: Yeah, and obviously at the moment we're looking at it from children's point of view, but there are also teachers. And I think there has been some evidence to suggest that, teachers have got infected. Fairly frequently in many settings of schools and obviously that's an incredibly important issue, these are vital people in our society.
So it's again all about this sort of balancing the risks and I think for now in the UK at least all we can do is really try and monitor it and set up a system where we can try and disentangle this relationship of schools and how it plays into transmission of COVID 19.
Gavin: Thanks for listening to this episode of The Lancet Voice.
We'll see you again next time.