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The Role of Health Surveillance for the SARS-CoV-2 Risk Assessment in the Schools

Chirico, Francesco MD

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Journal of Occupational and Environmental Medicine: April 2021 - Volume 63 - Issue 4 - p e255-e256
doi: 10.1097/JOM.0000000000002170
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To the Editor:

The risk score for educational institutions proposed by Granados et al1 is valuable and useful for the implementation of targeted preventive measures needed for protecting students, professors, and administrative support staff from the SARS-CoV-2 infection. In the literature, indeed, there is a paucity of SARS-CoV-2 workplace risk assessment strategies,2 and this is probably the first method designed to address SARS-CoV-2 as a biological hazard in the schools. SARS-CoV-2 should be considered an occupational biological hazard for schoolteachers, because this coronavirus has a high community transmission risk.3–5 As such, it should be addressed by occupational stakeholders in the framework of occupational health and safety regulations. Infection control measures, such as engineering and administrative controls, safe work practices, and personal protective equipments to prevent worker exposures, should be based on a thorough risk assessment.6 An effective risk assessment, as is well known, is a major prerequisite for effective risk management.2,6,7 However, occupational risk assessment for biological hazards is particularly challenging because of the high level of variability in exposures, sampling method limitations, differences in worker susceptibility, and a lack of epidemiological data to support developing occupational exposure limits.2,8

In the model proposed by Granados et al,1 the final risk score is drawn by a risk assessment matrix, in which the probability of contagion, as determined by the risk of occupational exposure and type of transportation, is combined with the probability of more severe COVID-19 illness outcomes and mortality, determined by age and comorbidities of the persons. The final score obtained allows to determinate the final level of risk (low, medium, and high) and, thus, to manage and prioritize the preventive measures on the basis of a risk level calculated at the individual level. Evaluating correctly the factors that Granados et al have identified is therefore decisive for an effective risk assessment and management process. During this COVID-19 pandemic time, in which the application of evidence-based medicine in public health is much debated,9,10 these factors are worthy of more detailed examination.

With regard to the first factor, it is obvious that the evaluation of the “probability of severe COVID-19 illness outcomes and mortality” pertains to occupational physicians (OPs). This is not a detail of the little account. OPs are appointed by school managers for conducting health surveillance programs targeted to all occupational risk factors, including biological hazards and others, that may be present in this workplace and that primary preventive measures (eg, organizational, technical, and procedural) have failed to eliminate. One of the most important tasks carried out by OPs is that to collaborate with employers, health and safety managers, and workers’ representatives for an effective risk assessment process. This collaboration takes place especially during the periodic safety meeting, where anonymous and aggregate health data drawn by OPs through the medical examinations are elaborated to indicate the adequacy of primary control measures.6,7

In Italy, the Ministry of Education has invited school managers to appoint OPs to handle the COVID-19 emergency, through fitness-for-work assessments on “vulnerable” (i.e., those affected by cardiovascular diseases, chronic obstructive pulmonary diseases, diabetes mellitus, conditions of immunosuppression, or other conditions associated with a higher risk of COVID-19 related complications and mortality) employees, like are teachers because of contact with the pupils.3 This confirms the decisive contribution that OPs can give in the fight against SARS-CoV-2, as well as against other known occupational biological hazards that can be equally encountered at school, and confirms the health surveillance carried out by OPs is a valid method of biological hazard surveillance.11,12 Sadly, to date health surveillance in Italian schools has been often neglected by school managers, due to a combination of low economic investments, no explicit requirement to activate health surveillance in this workplace and poorly managed Risk Assessment Documents. As a consequence, there is no guarantee that all school managers may now appoint OPs for carrying out health surveillance for tackling SARS-CoV-2.

The second factor, that is, the type of occupational exposure (high/medium/low), is also worthy of clarification. Among the criteria specified in the method by Granados et al,1 are cited the contact with “people known or suspected to be infected with SARS-CoV-2,” and contact with “the public.” It is not clear if “the public” for teachers are the pupils. However, it is difficult that people “known to be infected” with the coronavirus are at school. In my experience as OP, on the contrary, it would be more useful to size the SARS-CoV-2 risk of occupational exposure, by school level and type of activity. For example, in Italian schools, pupils aged more than 6 years, as well as teachers and administrative school workers are all obliged to wear disposable surgical masks at school. On the contrary, teachers at contact with preschoolers and children with disabilities may have unprotected exposure to SARS-CoV-2 and, as a consequence, they have a higher risk of occupational exposure, reason why they should be given priority protection, by requiring them to wear KN95/FFP2 filter masks, especially in epidemic conditions of the high transmission rate of SARS-CoV-2.3

Finally, the third factor, which is the type of transportation (public vs private), is probably the most important characteristic to be analyzed for an effective SARS-CoV-2 risk assessment and management. To reduce the transmission of COVID-19, many countries instituted large-scale or national closure of schools by March, 2020.13 In Italy, the first lockdown in March, 2020 began with the closure of schools of all levels and of all non-essential activities. This closure has been successfully marked as the beginning of the end of the first wave.14 In September, 2020, the reopening of the schools has been considered by the Italian government as “an absolute priority.” Since that, despite the implementation of accurate health and safety measures by all Italian schools, the second COVID-19 wave began, because of a crowded and, often poorly managed, public transport, which was considered however needed to ensure the reopening of schools and businesses.15 In the following months, despite the weak evidence of the contribution of school closures to transmission control,13 and indications for their re-opening given by the World Health Organization,16 in all the countries where governments decided to establish a lockdown, the first workplaces to close were the schools.13 Actually, the transport public, which is likely the most decisive factor in the risk assessment model proposed by Granados et al,1 is a factor that cannot be amended either by employers (ie school managers) nor by employees (ie teachers), but only by the public health competent authority. Thus, pupils, as well as their parents, who are subject to a high risk of getting infected in crowded public transport, can then transmit the virus at school and at home.14 This unsolved issue will very likely result in the failure of well-designed, and often expensive, preventive measures implemented by school managers inside the schools.


Including all sources of support: none.


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