Discussion
The aim of this study was to explore an organisational mode (the
“school hot spot”) for SARS-CoV-2 testing based on the spontaneous
presentation of paediatric patients by analysing the results of tests
for SARS-CoV-2 carried out in the HS and comparing these results with
SARS-CoV-2 tests performed in other paediatric hospital settings.
We found that the age group from 6 to 10 years attended school more in
presence than older children (Ordinance n. 112,
20/10/2020)24 and, therefore, may have more chances of
contagion and consequently may be more likely to be
tested25. In addition, we found that sex was not
associated with a higher probability of being tested in paediatric
population, as reported in the literature25. In our
sample, the swabs tested positive more frequently among children in the
age group between 11 and 13 years. This might be partially explained by
the fact that, in Italy, these group of children attended face to face
school more than older children24 and are more likely
to be swabbed26,27.
Compared with other settings, the HS was probably frequented more by
children attending face-to-face learning compared with older ones. This
could be due to the fact that face-to-face learning requires more
frequent testing because the probability of having contact with positive
people is higher. In literature, it is known that face-to-face learning
increases the risk of contagion in children27.
We found a greater likelihood of testing positive in patients who
swabbed at the HS compared with other settings. Indeed, the HS was aimed
at patients with COVID-19 symptoms or with a history of close contact
with a positive COVID-19 case, while the other settings had a different
target population. In the emergency department, the only patients who
were not tested were those who had a short outpatient visit and had no
history of close contact with COVID-19 patients. In DH service, only
patients who had a negative history for COVID-19 symptoms or contact
with COVID-19 patients were tested, while, if the medical service was
deferrable, patients with a history of COVID-19 were postponed. For this
reason, in emergency department and DH, the prevalence of positive swabs
was lower. Last, swabs performed in the hospital wards reported a
greater probability of being positive than the DH service because they
also include swabs performed in the COVID-19 ward of the paediatric
hospital. Thus, we can hypothesize that the HS organizational model has
been used in an appropriate manner because the probability that a
COVID-19 positive patient was swabbed at the HS was higher compared with
other examined settings, suggesting that patients and their families are
able to understand when the swab is needed without asking a doctor or
they are properly addressed by their GP or paediatrician.
Moreover, the multivariable models revealed other remarkable
associations. First, in agreement with the
literature28, our study found that new-borns are more
likely to become infected than other paediatric patients. Then, we found
that adolescents in the 11 to 13 age group had higher probability to
test positive than patients in the 14 to 19 age group. A possible
explanation for this could be that this age group attended face-to-face
school more frequently and, consequently, was more exposed to the
infection and was tested more27,29,30. Surprisingly,
children aged between 3 months and 2 years and children aged between 3
years and 5 years had lower probability to test positive than
adolescents (14-19 years age group). Although this age group went to
school for more time in presence than adolescents, COVID-19 cases are
less easily identifiable because young children tend to have milder
symptoms as reported in literature11.
Understandably, children who received RADT were less likely to test
positive. Indeed, this test was performed to patients only in the
emergency department in case of a large influx of patients or when there
was no time to wait for the result of the NAAT swab for the patient’s
emergency conditions.
Finally, a higher mean of pooled Rt in the 14 days preceding the swab
was associated with higher probability of being positive to the swab. In
line with this, as shown in Figure 1, also the proportion of swabs that
tested positive and the number of total swabs performed in the HS
followed the trend of the SARS-CoV-2 pandemic. As it is easy to
understand, when the viral circulation is greater the probability of
being symptomatic or having had contacts may also increase.
The present paper had some strengths and limitations that should be
acknowledged. To the best of our knowledge, this was the first study
that described a direct access testing modality for paediatric patients
attending school. Furthermore, we analysed a large sample of paediatric
patients spread over two waves of pandemics. However, the limitations
were mainly related to the impossibility of correlating the patients’
history and symptoms with the result of the tests obtained. Moreover, we
do not know how many patients contacted a doctor before presenting to
the school hotspot and consequently we do not know the percentage of
patients who presented spontaneously.
Nevertheless, the proposal of a new strategy of testing is urgent,
especially among children and adolescents. As reported in the
literature, there is limited evidence of the effectiveness of school
closures in containing the pandemic and, given the important health
implications of school closures on young people’s lives, it is important
to implement preventive measures in order to reduce COVID-19
transmission and keep schools open11. Indeed, it is
essential to test symptomatic cases and contact tracing should be
initiated promptly following identification of a confirmed case in order
to isolate positive patients31. This is even more
important with the spread of the Delta variant (declared a Variant of
Concern in May 2021).32 The Delta variant is the
dominant strain, characterized by a higher transmission
rate.33 Children are not vaccinated or are
under-vaccinated and therefore there is an increasing number of
SARS-CoV-2 cases reported.34 Moreover, with the
increasing number of infections, also cases of hospitalization among
children and adolescents can increase.34 Thus,
increasing testing capacity appears necessary and the possibility of
undergoing a swab for SARS-CoV-2 in direct access mode, as in our HS,
could be implemented to carry out as many tests as
possible35. Indeed, exploring this testing modality,
we found a high rate of paediatric patients positive at the HS compared
with other hospital testing settings (emergency department, DH and
Hospital wards).
The free presentation mode can be effective in identifying a high number
of positive patients but also to be able to exclude the diagnosis of
COVID-19 in many paediatric patients in order to allow a quick return to
school36. Particularly, this testing system should be
aimed at older children because they are more likely to be infected in
school settings36,37. In a context of pandemic
emergency and limited medical personnel, this testing modality saves
doctors who, instead of carrying out the patient history before deciding
whether to carry out the nasopharyngeal swab, can devote themselves to
other clinical activities. In view of the restart of face-to-face
learning activities, public health authorities should implement this
testing modality in order to help reduce the spread of SARS-CoV-2 in
school settings.