School districts are increasingly reopening schools for face-to-face instruction after a year of virtual learning. But they are under immense pressure to keep COVID-19 from spreading in their buildings. That pressure will continue next fall, as most students aren鈥檛 likely to start receiving vaccines until late 2021 or early 2022.
Many schools are using mitigation strategies such as universal masking, physical distancing, and improved ventilation. Testing their own students and staff for the virus is another strategy that鈥檚 won broad support, but relatively few districts so far have shouldered that role.
School-based testing for COVID-19 isn鈥檛 easy; it鈥檚 heavy with technical considerations and fraught with complex logistics and trade-offs. With the help of experts, we help break down the basics.
Are most school districts already doing COVID-19 testing?
No, but the numbers are growing. In a nationally representative in late February, 32 percent of district leaders鈥攗p from 17 percent in October鈥攔eported that they鈥檙e testing at least some staff members for the virus, or will do so when they return to in-person learning. Only 16 percent of district leaders said they were testing students, an increase from 7 percent in October.
COVID-19 testing is one of schools鈥� least-chosen mitigation strategies, according to the survey. More than 8 in 10 district leaders said they鈥檙e using tactics such as contact tracing, cleaning, and masking.
Are schools running these programs themselves, or having outside partners do it?
A ., one of a , suggests that few schools or districts take on the challenges of testing without partners to help them.
Many districts have had support and guidance from their states because they participated in state programs to pilot the Abbott BinaxNOW rapid antigen tests distributed last year by the U.S. Department of Health and Human Services. A few have operated programs on their own. Others team up with local health departments or labs to run their programs. Some outsource the entire operation to universities or testing companies.
Running a COVID-19 testing program is undoubtedly a heavy lift, with scores of logistical hurdles to clear. Many experts suggest districts don鈥檛 do it alone.
鈥淲e think the most sustainable and scalable model is when schools and districts partner with testing vendors and services that offer start-to-finish approaches that offload most of the logistics from schools,鈥� said Dr. Laura J. Faherty, who led the RAND study and is an assistant professor of pediatrics at the Boston University School of Medicine.
Organizations have designed a range of resources for districts considering or planning COVID-19 testing programs. The Rockefeller Foundation created a , and the superintendents鈥� group Chiefs for Change assembled a , to help districts think through the process. Rockefeller COVID-19 advisor Mara Aspinall led a group that drew up a as they interview test vendors. Johns Hopkins University鈥檚 Center for Health Security has .
How do districts pay for COVID-19 testing programs?
The most recent round of federal COVID-19 relief money, the American Rescue Plan, signed March 11, includes $129 billion for K-12 schools, which could be used for testing programs (as well as a wide variety of other programs and services for pandemic recovery). States can also draw on other money provided in the law: devoted to stepping up COVID-19 testing generally, and of that amount that鈥檚 aimed at helping districts set up screening programs to detect the virus early.
Federal funding from last spring鈥檚 CARES Act has supported many districts鈥� testing programs. They鈥檝e also used state funds, drawn on their own operating budgets and local philanthropic support, and partnered with organizations, such as universities, that have carried part of the cost. California was recently approved to use Medicaid funds to pay for COVID-19 testing for low-income students.
Many districts took advantage of free Abbott BinaxNOW rapid antigen tests distributed to states by the federal government last year, too.
How much do testing programs cost?
It鈥檚 tough to put a total price tag on districts鈥� programs, since they often include staff time, and some costs might be carried by partners. But when it comes to the cost of tests and analysis, prices vary widely.
Benjamin Master, a co-author of the RAND study of districts鈥� testing programs, said some schools have been paying as much as $120 per test for molecular tests, such as the gold-standard PCR, which must be processed in labs. Others have found PCR prices as low as $20. Prices for pooled testing鈥攚here multiple samples are combined and processed together鈥攃an go as low as $10, he said.
Rapid antigen tests, which can be processed where they鈥檙e administered, without a lab, are available for as little as $5 per test, but that鈥檚 a bulk rate, Master said. Districts shopping on their own for such tests could pay $20 or $30 each.
What鈥檚 the difference between diagnostic, screening, and surveillance testing?
Diagnostic testing aims to detect active infections, so staff or students who show symptoms, or have had close contact with an infected person, can be isolated and their contacts traced.
Screening aims to catch infections before people show symptoms, so schools can prevent outbreaks. Districts typically screen by offering tests to everyone and hoping for good opt-in rates. They can also randomly test a subset of their students or staff, or test just some groups, such as student athletes.
Another approach鈥攕urveillance testing鈥攁ims to understand how prevalent COVID-19 is in the school community. Districts do this by testing samples of staff or students, but they don鈥檛 send individual results back. Instead, they use results to inform decisions such as whether schools should offer in-person instruction or teach in remote-only mode.
Which COVID-19 tests are districts using?
Two types of tests detect active COVID-19 infections: antigen and molecular.
Antigen tests are faster, typically returning results in 15 to 30 minutes. Nasal or throat swabs can be processed on the spot, rather than in a lab. But they鈥檙e less able to detect low-level infections; confirmation with a molecular test is often recommended.
Molecular tests return results in 1 to 3 days, since their nasal, throat, or saliva samples are usually processed in a lab. They鈥檙e considered the gold standard because of their accuracy. The most widely known type of molecular test is the PCR.
PCRs can be 鈥減ooled,鈥� meaning that multiple samples are combined for analysis, saving time and money. Pooling is particularly useful in 鈥減od鈥� or cohort instructional settings. If a pool鈥檚 results are negative, all those tested can be presumed to be negative. If a pool is positive, however, retests鈥攐r reanalysis of individual samples鈥攎ust be conducted to isolate positive cases. Pooled tests , too, since virus levels can be diluted in the batch.
How a district does testing depends on its needs and goals. For diagnostic testing, using a highly accurate test is important, experts say. For screening purposes, the ability to test frequently and get results quickly can be paramount.
鈥淵ou鈥檙e going to miss people [who have the virus]. That will be the trade-off, whatever methodology you use,鈥� said Gigi Gronvall, an immunologist and senior scholar at the Johns Hopkins Center for Health Security. 鈥淚t can鈥檛 be the only thing you do to stop [COVID-19] spread, but it鈥檚 important that you do it.鈥�
Do schools need to do all three kinds of testing?
Most public health experts鈥攊ncluding the Centers for Disease Control and Prevention鈥攁dvise districts to prioritize diagnostic testing. But if districts can manage a screening, or asymptomatic, testing program as well, many public-health experts encourage it, especially in regions where COVID-19 levels are moderate or high.
Screening is particularly helpful because such a large proportion of COVID-19 cases鈥斺�攁re spread by people without symptoms. Screening can also build confidence among staff, students, and families that school settings are as safe as possible.
How can you tell if COVID-19 screening is effective?
One way is to measure the proportion of cases the program detects. The RAND researchers, for instance, found that across five districts, 44 percent of the COVID-19 cases detected in schools, on average, were caught in screening programs. (Additional cases were identified in school-based diagnostic testing programs.)
Another way is to measure whether they affect families or staff members鈥� confidence in returning to in-person learning. In the Wellesley, Mass., school district, 12 percent of the staff reported feeling 鈥渞eassured鈥� about the safety of in-person instruction before the district began its testing program, but that number rose to 82 percent after the district started a screening program. Similarly, parent confidence rose from 39 percent to 87 percent.
What does CDC guidance say about testing?
In in K-12 schools: masking, social distancing, hand and respiratory hygiene, cleaning of facilities, and contact tracing followed by quarantine. COVID-19 testing was not on that list.
But the CDC鈥檚 guidance outlines a valuable role for testing programs in schools鈥攊ncluding the ability to offer more in-person instruction鈥攚hen used in combination with the five other mitigation strategies.
At a minimum, the CDC said, schools should refer people with COVID-19 symptoms or exposure for diagnostic testing if they don鈥檛 conduct it themselves.
Districts 鈥渕ay also elect,鈥� the guidance says, to use screening programs 鈥渁s an additional layer of mitigation,鈥� particularly in communities hit hard by the virus. Districts might also consider prioritizing staff over students, and older students over younger ones, given the higher risk of serious illness among adults, the CDC said.
Some advocates of school testing were dismayed that the CDC did not give testing a higher priority in its guidance to districts. 鈥淭hey totally punted,鈥� one critic said.
But Greta Massetti, who leads the CDC team that creates guidance for schools and other institutions, said the agency examined studies from the U.S. and abroad, and interviewed school and public health officials, and saw a clear pattern emerge: Schools kept COVID-19 transmission rates low with the five strategies it prioritized, and 鈥渢esting was often not part of that package.鈥�
That led the CDC to conclude, Massetti said, that while COVID-19 testing offers 鈥渢remendous added benefits鈥� of providing data and allaying staff and family concerns, it 鈥渋sn鈥檛 a requirement for schools to reopen for instruction safely.鈥�
What do these testing programs look like?
Testing programs vary widely.
The screening program in Medford, Mass., uses nasal-swab PCR tests, and more than 85 percent of staff and students participate, said David Murphy, an assistant superintendent who oversees the program. Schools have gotten it down to a science, funneling everyone through the swab lines twice a week, during class or at lunch, said Toni Wray, the district鈥檚 director of health services. Its partners, Tufts University and the Broad Institute of MIT and Harvard University, help the district track tests and get results in 24 hours.
To continue testing and manage the cost, Medford switched this winter to pooled PCR testing. Even with CARES Act funding, and more federal money soon available, $50,000 a week for individual testing wasn鈥檛 sustainable, Murphy said. Pooled testing costs $5,000 per week.
There are statewide programs, like in January. Through mid-April, that program is offering free pooled PCR testing for any district that鈥檚 doing in-person instructionor plans to return to in-person learning soon. The state will match districts with vendors to help them collect samples and process results.
The biggest district in the country, New York City, has instituted mandatory weekly testing on a rotating, random sample of students and staff in schools that have reopened for in-person instruction. The tiny McSwain Union district in California is moving from twice-weekly to four-times-weekly rapid antigen testing for staff, and 80 percent participate. Now it鈥檚 asking parents to allow their children to be tested, too, said Superintendent Roy Mendiola.
In Wellesley, Mass., staff members and middle and high school students collect weekly saliva samples at home and drop them off at school. Pooled PCR results come back from a local lab in 24 to 48 hours. A K-8 district in Illinois, LaGrange 102, runs an in-house program, conducting and processing a saliva test developed by its school board vice president, a molecular biologist.
Some Utah districts are using tests as an incentive. In this approach, students in high schools where case counts might force a switch to remote instruction can keep attending in-person if enough of them test negative on rapid antigen tests at school, or get a thumbs-up from an outside lab. A similar approach, called 鈥渢est to play,鈥� is used with sports and extracurricular activities.
What are the biggest challenges of school-based COVID-19 testing?
Districts face a host of legal and regulatory issues, such as obtaining parent consent for student testing, protecting students鈥� confidential medical data, and that lets them collect test samples.
There are logistical issues, too, such as navigating multiple partnerships and scheduling and training staff to fill various roles in the program. Schools also will need a platform that tracks tests and results. And they must be ready to respond with the right programs and supports when they find positive cases or clusters.
Cost could also be an issue in many districts. Even though federal funds are available to support testing programs, districts have many other competing priorities during the pandemic, such as building academic recovery programs and beefing up personal protective equipment and education technology.
Districts that aren鈥檛 able to run their own testing programs should work closely with local health departments to refer staff, students and families for testing, the CDC has said.
鈥淭he benefits of school-based testing need to be weighed against the costs, inconvenience, and feasibility of such programs to both schools and families,鈥� the guidance for K-12 schools.
Vaccines are becoming more available. How long will schools need to do COVID-19 testing?
Experts said they think testing could play an important role in K-12 COVID mitigation at least through the fall.
Massetti noted that there is not yet a vaccine authorized for use in children 16 and younger, and it could take many months to get large numbers of children inoculated.
Coronavirus variants continue to emerge, and people might end up needing booster shots. And even though the current vaccines are highly effective, they don鈥檛 offer 100 percent protection.
鈥淎s good as the vaccines are, it鈥檚 still possible to get COVID,鈥� said Aspinall.
