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Assessment of a Program for SARS-CoV-2 Screening and Environmental Monitoring in an Urban Public School District

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Does weekly testing of kindergarten through 12th grade students and staff improve detection of SARS-CoV-2 infection and understanding of the epidemiology of SARS-CoV-2 in urban public school settings?

Findings  In this quality improvement study, weekly school-based saliva polymerase chain reaction testing at 3 urban public schools was associated with increased case detection among staff and students compared with symptom-based strategies, exceeding county-level case rates. SARS-CoV-2 was detected in school wastewater samples each week as well as air and surface samples from choir classrooms.

Meaning  This study suggests that routine SARS-CoV-2 testing may identify infected staff and students who are not identified through conventional case detection and may provide insight into disease burdens of undertested communities.

Abstract

Importance  Scalable programs for school-based SARS-CoV-2 testing and surveillance are needed to guide in-person learning practices and inform risk assessments in kindergarten through 12th grade settings.

Objectives  To characterize SARS-CoV-2 infections in staff and students in an urban public school setting and evaluate test-based strategies to support ongoing risk assessment and mitigation for kindergarten through 12th grade in-person learning.

Design, Setting, and Participants  This pilot quality improvement program engaged 3 schools in Omaha, Nebraska, for weekly saliva polymerase chain reaction testing of staff and students participating in in-person learning over a 5-week period from November 9 to December 11, 2020. Wastewater, air, and surface samples were collected weekly and tested for SARS-CoV-2 RNA to evaluate surrogacy for case detection and interrogate transmission risk of in-building activities.

Main Outcomes and Measures  SARS-CoV-2 detection in saliva and environmental samples and risk factors for SARS-CoV-2 infection.

Results  A total of 2885 supervised, self-collected saliva samples were tested from 458 asymptomatic staff members (mean [SD] age, 42.9 [12.4] years; 303 women [66.2%]; 25 Black or African American [5.5%], 83 Hispanic [18.1%], 312 White [68.1%], and 35 other or not provided [7.6%]) and 315 students (mean age, 14.2 [0.7] years; 151 female students [48%]; 20 Black or African American [6.3%], 201 Hispanic [63.8%], 75 White [23.8%], and 19 other race or not provided [6.0%]). A total of 46 cases of SARS-CoV-2 (22 students and 24 staff members) were detected, representing an increase in cumulative case detection rates from 1.2% (12 of 1000) to 7.0% (70 of 1000) among students and from 2.1% (21 of 1000) to 5.3% (53 of 1000) among staff compared with conventional reporting mechanisms during the pilot period. SARS-CoV-2 RNA was detected in wastewater samples from all pilot schools as well as in air samples collected from 2 choir rooms. Sequencing of 21 viral genomes in saliva specimens demonstrated minimal clustering associated with 1 school. Geographical analysis of SARS-CoV-2 cases reported district-wide demonstrated higher community risk in zip codes proximal to the pilot schools.

Conclusions and Relevance  In this study of staff and students in 3 urban public schools in Omaha, Nebraska, weekly screening of asymptomatic staff and students by saliva polymerase chain reaction testing was associated with increased SARS-CoV-2 case detection, exceeding infection rates reported at the county level. Experiences differed among schools, and virus sequencing and geographical analyses suggested a dynamic interplay of school-based and community-derived transmission risk. Collectively, these findings provide insight into the performance and community value of test-based SARS-CoV-2 screening and surveillance strategies in the kindergarten through 12th grade educational setting.

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Article Information

Accepted for Publication: June 27, 2021.

Published: September 22, 2021. doi:10.1001/jamanetworkopen.2021.26447

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Crowe J et al. JAMA Network Open.

Corresponding Author: M. Jana Broadhurst, MD, PhD, Department of Pathology and Microbiology, University of Nebraska Medical Center, 985900 Nebraska Medical Center, Omaha, NE 68198 (jana.broadhurst@unmc.edu).

Author Contributions: Dr Broadhurst had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Crowe, Schnaubelt, SchmidtBonne, Staffend, Conner, Ray, Lawler, Campbell, Lowe, Santarpia, Wiley, Brett-Major, Logan, Broadhurst.

Acquisition, analysis, or interpretation of data: Crowe, Schnaubelt, SchmidtBonne, Angell, Bai, Eske, Nicklin, Pratt, White, Crotts-Hannibal, Staffend, Herrera, Cobb, Conner, Carstens, Tempero, Bouda, Lawler, Campbell, Lowe, Santarpia, Bartelt-Hunt, Wiley, Brett-Major, Broadhurst.

Drafting of the manuscript: Crowe, Schnaubelt, SchmidtBonne, Bai, Eske, Pratt, Crotts-Hannibal, Cobb, Tempero, Ray, Lawler, Lowe, Santarpia, Wiley, Brett-Major, Broadhurst.

Critical revision of the manuscript for important intellectual content: Crowe, Schnaubelt, SchmidtBonne, Angell, Nicklin, Pratt, White, Staffend, Herrera, Conner, Carstens, Bouda, Lawler, Campbell, Lowe, Bartelt-Hunt, Wiley, Brett-Major, Logan, Broadhurst.

Statistical analysis: Crowe, Angell, Conner, Brett-Major, Broadhurst.

Obtained funding: Crowe, Schnaubelt, SchmidtBonne, Logan, Broadhurst.

Administrative, technical, or material support: Crowe, Schnaubelt, SchmidtBonne, Eske, Nicklin, White, Crotts-Hannibal, Staffend, Herrera, Cobb, Conner, Carstens, Tempero, Ray, Lawler, Campbell, Lowe, Santarpia, Brett-Major.

Supervision: Crowe, Schnaubelt, SchmidtBonne, Campbell, Lowe, Bartelt-Hunt, Wiley, Brett-Major, Broadhurst.

Conflict of Interest Disclosures: Ms Carstens reported receiving grants from Omaha Public Schools during the conduct of the study. Dr Lawler reported receiving grants from the Susan Buffett Foundation during the conduct of the study, stock options for an advisory role from Kinsa Health, and personal fees from Takeda Pharmaceuticals for membership on a scientific advisory committee outside the submitted work. Dr Campbell reported receiving partial funding for the NULirt software platform used in this study through the Nebraska Public Health Laboratory and the University of Nebraska Medical Center (NULirt is a registered invention with the University of Nebraska Medical Center). Dr Santarpia reported receiving grants from the Sherwood Foundation during the conduct of the study. Dr Bartelt-Hunt reported receiving grants from Omaha Public Schools during the conduct of the study. Dr Wiley reported being CEO of PraesensBio LLC outside the submitted work. Dr Broadhurst reported receiving grants from Omaha Public Schools during the conduct of the study. No other disclosures were reported.

Funding/Support: This project received funding from the Sherwood Foundation.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors would like to thank the clinical partners at One World Community Health Centers; volunteers from the UNMC Colleges of Allied Health Professions, Pharmacy, Nursing, Dentistry, and Medicine; volunteers from Creighton University Schools of Medicine, Pharmacy, Dentistry, and College of Nursing; UNMC Global Center for Health Security program management staff; and OPS school building leadership for their efforts and dedication to the success of this project. One World Community Health Centers received compensation.

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