Coronavirus (COVID-19): Advisory Sub-Group on Education and Children's Issues - children, schools, early learning and childcare settings - evidence summary

Annex A

Asymptomatic Testing

Advice from Public Health Scotland, supported by senior clinicians, is that there would be little benefit in continuing with routine asymptomatic testing of children and young people and school/ELC staff in mainstream and special schools.

The following key factors have informed this advice:

• expert advisers are now of the view that, at the current time, the population has much stronger protection against COVID-19 than at any other point in the pandemic, due to the vaccination programme and the development of natural immunity to the infection. In addition, severe health outcomes are now far less likely to arise due to this protection, availability of and access to antiviral treatments, and increased scientific and public understanding about how to manage risk
• due to the very low risk of harm to children from COVID-19 infection, the Harm 1 public health goal of identifying cases asymptomatically in this age group was with the plausible aim of interrupting any transmission to vulnerable adults (the elderly and otherwise immunocompromised), rather than to prevent transmission within the age group
• children are much less likely to suffer severe health outcomes as a result of catching COVID than adults. Identifying them as asymptomatic cases and asking them and their household contacts to self-isolate when they otherwise feel well comes at a cost to them (isolation of children and anxiety for children and parents) and is likely to result in educational or developmental harms to those individuals (or those they teach or care for)
• while we do not yet know the full impact of the disruptions to education on children's and young people's learning, health and wellbeing, and it is not possible to tie this directly to asymptomatic testing, there is evidence to suggest that for primary school-aged children attainment is reduced and the inequalities gap increased during the pandemic. There has been a rise in child development concerns at the 13-15mths and 27-30mths health review points, with these being particularly marked at the 27-30mth review and for those children in the most deprived areas. Ongoing disruption to learning is likely to exacerbate any existing challenges. Being in school or ELC settings also provides essential services for children who are at increased risk of poor outcomes e.g. free school meals or funded healthy snacks
• the ends justifying these means have been substantially weakened by evidence gathered since the emergence of Omicron, which has shown itself in Scotland and international evidence to be a weaker virus; and the success of Scotland's booster programme coupled with high levels of previous infection, leading to a far smaller pool of susceptible older hosts
• vaccination coverage in education staff is very high with an estimated 88% of school teachers and 72% of ELC staff having had their third/booster dose
• vaccines have shown very good effectiveness against harm from COVID-19 infection. The latest UKHSA evidence summary is that a primary course and a booster are between 75% and 95% effective against hospitalisation dependent on the booster and time since boosting; and 95% against mortality. A recently published rapid evidence review from UKHSA also found that vaccinated people were less likely to develop prolonged symptoms ('long COVID') following infection
• while we saw a significant rise and fall in under 16 infection rates since the return to school during the Omicron wave (January 2022), we saw a far smaller increase in adult / parent age cases. This reinforces the public health view that adults, including parents or others in households, are relatively protected through vaccination
• in addition, where we have seen potential transmission from children to adults, who are more vulnerable to COVID-19 infection than children, this has not translated to public health harm e.g. hospitalisation, ICU admission or death of the same scale as previously seen
• the body of evidence on the role of children in transmission continues to point to household transmission as the primary driver. Consistent with previous PHS analysis, a recently updated systematic review found that the secondary attack rate was markedly lower in school compared with household settings, suggesting that household transmission is more important than school transmission (Ismail et al, Lancet Infect Dis. 2021 Mar;21(3):344-353). School infection prevalence has been found to be associated with community infection incidence, supporting hypotheses that school infections broadly reflect community infections
• Omicron is demonstrably less likely to result in individual health harm than Delta (UKHSA estimate 59% less likely to result in hospital admission, 69% less likely to result in death). Omicron (BA.1 and BA.2) account for almost all COVID-19 infections in Scotland. BA.2, whilst more rapidly spread and contributing to an increasing proportion of cases compared to BA.1, is showing no evidence of more severe health outcomes compared to Omicron BA.1, and it has not to date been flagged as a variant of concern by UKHSA and remains only under investigation
• the PHS view is that COVID-19 will continue to circulate in children in future years and there is evidence that infection provides some protection against future infection in both the vaccinated and the unvaccinated
• Throughout the pandemic we have seen higher numbers of cases present in ELC settings when community transmission is high, but there is no evidence of increased or disproportionate transmission within these settings when compared to the wider community. Although clusters of cases do occur in ELC settings the average size of these clusters is low and large outbreaks are uncommon, especially when compared to schools with older children or adult workplaces or hospitality venues. With our wider communities and businesses now largely open, e.g. hospitality, leisure centres, soft plays and children's parties, it can be challenging to identify where transmission has occurred, and focused action in one setting is unlikely to have a significant impact on overall transmission
• with regard to ending regular testing in special schools, the following points summarise advice from PHS, confirmed by senior clinicians:
  • despite likely hosting a higher proportion (or density) of clinically vulnerable children than mainstream schools, children in special schools remain at low absolute risk from COVID-19. This absolute (and relative) risk has fallen since the introduction of the vaccination programme and the emergence of Omicron. We are not in the same public health situation we were when the asymptomatic testing programme was introduced
  • to prevent direct health harm to children PHS would recommend focusing on individual clinical risk rather than broad brush community asymptomatic testing of those they come into contact with. Vaccination remains our best route to minimising individual health risk in a proportionate way. Continuing asymptomatic testing in special schools is unlikely to significantly reduce the risk to children in these settings, and may risk harming them (see final bullet below)
  • in an otherwise open society, asymptomatic testing of children in special schools is also highly unlikely to be effective in preventing transmission to staff who work in these settings, and therefore unlikely to minimise educational disruption in these settings
  • there are significant potential harms associated with focusing testing in special schools including: inequity including potential for increased rather than decreased educational disruption; the harms of repeatedly testing otherwise well children; the challenges with isolation of asymptomatic children with special educational needs; increased anxiety in children, parents and staff
  • PHS would propose alignment of special schools and mainstream schools in terms of this policy, from a public health point of view