Health departments and school districts can work together to develop a strategy for prioritizing K-12 schools, depending on resources and goals, for school-based testing. Implementation of mitigation strategies (e.g., social distancing, masks, hand hygiene, enhanced cleaning and disinfection) should be implemented with all of the various testing strategies.
Testing people with symptoms: Schools should advise teachers, staff, and students to stay home if they are sick or if they have been exposed to COVID-19. Encourage these individuals to talk to their healthcare provider about getting testing for COVID-19 in a healthcare or public health facility.
If a teacher, staff, or student becomes sick at school or reports a new COVID-19 diagnosis, schools should follow the steps of the new COVID-19 Diagnosis flowchart on what to do next. This includes notifying a student’s parent or guardian, and initiating testing strategies.
- In some schools, school-based healthcare professionals (e.g., school nurses) may perform COVID-19 antigen testing in school-based health centers if they receive a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiverexternal icon. It is important schools-based healthcare professionals have access to, and training on the proper use of personal protective equipment (PPE).
- Not every school or school-based healthcare professional will have the resources or training to conduct testing. Public health officials should work with schools to help link students and their families, teachers, and staff to other opportunities for testing in their community.
Schools can provide options to separate students with COVID-19 symptoms or suspected or confirmed COVID-19 diagnoses by, for example placing students in isolation room/areas until transportation can be arranged to send them home or seek emergency medical attention.
If a COVID-19 diagnosis is confirmed, schools can assist public health officials in determining which close contacts and other potentially exposed persons could be tested and either isolated for 10 days (if they have COVID-19) or quarantined for 14 days (if they are a close contact without symptoms or a negative test result; see Table 2).
Note: CDC’s Coronavirus Self-Checker is an interactive clinical assessment tool that will assist individuals aged 13 years and older, and parents and caregivers of children aged 2 to 12 years, in deciding when to seek testing or medical care if they suspect they or someone they know has contracted COVID-19 or has come into close contact with someone who has COVID-19.
Testing people without symptoms who are close contacts of positive COVID-19 cases: Schools can assist by providing information, where appropriate, to identify close contacts (e.g., class rosters, seating charts, and information to facilitate outreach to contacts). CDC defines close contacts as those within 6 feet of someone with known or suspected COVID-19 for at least 15 minutes, irrespective of whether the contact was wearing a mask or PPE (see Table 3). Additional factors to consider include proximity, the duration of exposure (longer exposure time likely increases exposure risk), and whether the exposure was to a person with symptoms (e.g., coughing likely increases exposure risk). The local health department will facilitate contact tracing and testing for close contacts in coordination with parents or guardians and schools.
All persons who are identified as close contacts need to quarantine for 14 days, even if screening test results are negative, because they can still develop COVID-19 for up to 14 days after being exposed. Quarantine helps prevent spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling symptoms. Close contacts who are in quarantine who develop symptoms should be re-tested.
Testing of persons in an outbreak setting: Classrooms or schools may temporarily suspend in-person instruction when experiencing an active outbreak. The local health department will facilitate contact tracing and testing for schools with an active outbreak. Schools can assist by providing information to identify close contact (e.g., class rosters, seating charts, and information to facilitate outreach to contacts). Persons who are close contacts of anyone confirmed or suspected of having COVID-19 should be quarantined for 14 days from their last contact. Schools in an outbreak setting can use a tiered approach (see Table 3) to determine which close contacts and other potentially exposed persons should be tested and either isolated or quarantined.
Other testing strategies:
- Repeat testing and/or expanded testing of teachers, staff, and students: In schools where the risk of transmission is moderate to high, public health officials working collaboratively with school administrators can determine the appropriateness of offering repeat testing to randomly-selected asymptomatic teachers, staff, and students at the school. Testing teachers and staff should be prioritized over students in any sampling strategy, and older students prioritized over younger students. Persons who have recovered from COVID-19 in the past 3 months should be excluded from random selection. Contact tracing should immediately begin if anyone tests positive for COVID-19. Close contacts of persons with confirmed or probable COVID-19 should be tested and either isolated for 10 days for those with COVID-19, or quarantined for 14 days.
- Entry testing or universal one-time testing: It is not known if testing of all staff, teachers, and students at one point in time (referred to as entry testing or universal one-time testing) provides any additional reduction in virus transmission above the key mitigation strategies recommended for schools. Currently, CDC does not have specific recommendations for entry testing of all students, teachers, and staff. However, if infrastructure is in place, and resources are available, schools can serve as a venue for health departments to offer community-based testing to teachers, staff, students and potentially their family members.
How should schools report results of school-based testing?
Every COVID-19 testing site is required to report to the appropriate state or local health officials all diagnostic and screening tests performed. Schools that use antigen testing must apply for and receive a Clinical Laboratory Improvement Amendments (CLIA)external icon certificate of waiver, and report test results to state or local public health departments as mandated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
In addition, school administrators should notify staff, teachers, families and/or emergency contacts or legal guardians immediately of any case of COVID-19 while maintaining confidentiality in accordance with HIPAA,external icon ADAexternal icon, FERPApdf iconexternal icon, and other applicable laws and regulations. Notifications should be accessible for all students, faculty and staff, including those with disabilities or limited English proficiency (e.g., through use of interpreters or translated materials).
Challenges of school-based testing
These challenges must be considered carefully and addressed as part of plans for school-based testing developed in collaboration with public health officials.
- Not every school system will have the resources or training (including the CLIA certificate of waiver mentioned above) to conduct school-based antigen testing. Public health officials should work with schools to help link students and their families, teachers, and staff to other opportunities for testing in their community.
- School-based testing may require a high degree of coordination and information exchange among health departments, schools, and families.
- There may also be legal factors to consider with onsite school-based testing regarding who will administer the tests, how tests will be paid for, and how results will be reported. Such legal factors include local or state laws defining the services school nurses and other school-based health professionals are permitted to provide.
- The benefits of school-based testing need to be weighed against the costs, inconvenience, and feasibility of such programs to both schools and families.
- Antigen tests usually provide results diagnosing an active SARS-CoV-2 infection faster than molecular tests, but antigen tests have a higher chance of missing an active infection even in symptomatic individuals and confirmatory molecular testing may be recommended. Although antigen tests have not be authorized for use in asymptomatic individuals, FDA and Centers for Medicare and Medicaid Services have allowed the use of these tests in situations where a rapid result is needed.
Considerations before starting ANY testing strategy
Before implementing testing in their schools, K-12 administrators should coordinate with public health officials to ensure there is support for this approach from students, parents, teachers, and staff and to put key elements in place:
- Dedicated infrastructure and resources to support school-based testing.
- CLIA certificate of waiver requirements to perform school-based testing.
- Mechanism to report all testing results (both positive and negative) as required by the state or local public health department.
- Plans for ensuring access to confirmatory molecular testing when needed through the state and local health department because sometimes antigen tests can give false positive results that represent errors and not true infections.
- Ways to obtain parental consent for minor students and assent/consent for the students themselves.
- Physical space to conduct testing safely and privately.
- Ability to maintain confidentiality of results and protect student privacy.
If these conditions are not in place, schools may consider a referral-based testing strategy in collaboration with public health officials.
How can schools adequately plan for testing?
School Administrators considering testing should work with public health officials to address questions related to feasibility, logistics, and ethics of school-based testing, such as the ones listed in Table 3 below.