Operational Strategy for K-12 Schools through Phased Prevention

Table 4. Testing Recommendations by Level of Community Transmission

1Diagnostic testing for SARS-CoV-2 is intended to identify occurrence of SARS-CoV-2 infection at the individual level and is performed when there is a reason to suspect that an individual may be infected, such as having symptoms or suspected recent exposure.

1Screening testing is intended to identify infected asymptomatic individuals who may be contagious so that measures can be taken to prevent further transmission.

3Levels of community transmission defined as total new cases per 100,000 persons in the past 7 days (low, 0-9; moderate, 10-49; substantial, 50-99; high, ≥100) and percentage of positive tests in the past 7 days (low, <5%; moderate, 5-7.9%; substantial, 8-9.9%; high, ≥10%).

4Schools may consider testing a random sample of at least 10% of students or may conduct pooled testing of cohorts/pods for screening testing in areas of moderate and substantial community transmission.

5Schools may consider using screening testing for student athletes and adults (e.g., coaches, teacher advisors) who support these activities to facilitate safe participation and reduce risk of transmission. For an example risk stratification for sports, see https://ncaaorg.s3.amazonaws.com/ssi/COVID/SSI_ResocializationDevelopingStandardsSecondEdition.pdfpdf icon.

When combined with prevention measures, such as mask use, physical distancing, and others, testing protocols might be an effective tool in reducing transmission. Screening testing can be administered directly at a school facility (see Feasibility considerations section below), at a central location through the school district, or through referral to community-based testing providers.

  • Moderate (yellow), substantial (orange), and high (red) community transmission: Students, teachers, and staff participate in regular screening testing to reduce the risk of transmission within the school.
    • Teachers and staff participate in routine screening testing at least once per week. In areas with substantial and high community transmission, twice a week screening testing might be preferable to quickly detect cases among teachers and staff.
    • Students in elementary, middle, and high schools participate in routine screening testing at least once per week. If a confirmed positive case is found, any close contacts are quarantined and tested.
    • Schools might consider testing a random sample of at least 10% of students. For example, a school might randomly select 20% of the students each week for testing out of the entire population of students attending in-person instruction. Alternatively, a school might select one cohort for each grade level each week for testing. Different strategies for random selection can be used based on most adequate fit for a school screening testing strategy.
  • Screening testing for sports: To facilitate safe participation in sports and reduce transmission in activities that have elevated risk, schools may consider requiring screening testing for participation. Schools can implement testing among student athletes/participants, coaches, and trainers, and any other individuals (such as parent volunteers) who could come into close contact with others during these activities.
    • Sports events, competitions, and activities could include universal screening testing the day of the event or one day before.
    • Low and intermediate risk sports3 include those that can be conducted outdoors, or indoors with masks. Testing at least once per week is recommended for these sports.
    • High-risk sports3 include those that cannot be done outdoors or with masks. Testing twice per week in areas of low, moderate, and substantial community transmission is recommended for participation in these sports. High-risk sports should be virtual or canceled in areas of high community transmission.

When considering which tests to use for screening testing, schools or their testing partners should choose tests that can be reliably supplied and that provide results within 24 hours. NAATs are high-sensitivity tests for detecting SARS-CoV-2 nucleic acid. Most NAATs need to be processed in a laboratory with variable time to results (could be 1–3 days), but some NAATs are point-of-care tests with results available in about 15 minutes. Pooled testing—in which samples from multiple people are initially combined—may reduce costs and turn-around times. These may be considered for at least weekly screening testing in areas of moderate (yellow) community transmission.

Antigen tests are generally less sensitive than NAATs, and most can be processed at the point-of-care with results available in about 15 minutes. Antigen test results might need confirmation with a NAAT in certain circumstances, such as a negative test in persons with symptoms or a positive test in persons without symptoms. Schools should work with the health department to develop a confirmation and referral plan before implementing testing. The immediacy of results (test results in 15–30 minutes), modest costs, and feasibility of implementation of antigen tests make them a reasonable option for school-based screening testing. The feasibility and acceptability of tests that use nasal (anterior nares) swabs make these types of tests more readily implemented in school settings. Tests that use saliva specimens might also be acceptable alternatives for younger children, if tests are available and results are returned within 24 hours.

Taking into consideration the potential for limited availability of supplies for screening testing or feasibility of implementing screening testing, schools should consider a prioritization strategy.

  • Schools and public health officials might consider prioritizing teachers and staff over students given the increased risk of severe illness among certain adults.
  • In selecting among students, schools and public health officials might prioritize high school students, then middle school students, and then elementary school students, reflecting higher infection rates among adolescents compared to younger children.

Reporting test results

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 (P.L. 116-136).

Parents should be asked to report positive cases to schools to facilitate contact tracing and ensure communication and planning in schools. In addition, school administrators should notify staff, teachers, families, and emergency contacts or legal guardians immediately of any case of COVID-19 while maintaining confidentiality in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAAexternal icon), the Americans with Disabilities Act (ADAexternal icon), and the Family Educational Rights and Privacy Act (FERPApdf icon), and other applicable laws and regulations. Notifications must be accessible for all students, teachers, and staff, including those with disabilities or limited English proficiency (for example, through use of interpreters or translated materials).

Health equity considerations in school-based testing

Public health officials and school administrators should consider placing a higher priority for access to testing in schools that serve populations experiencing a disproportionate burden of COVID-19 cases or severe disease. These might include:

  • Schools in communities that have experienced disproportionately high rates of COVID-19 cases relative to population size, which may include communities with moderate or large proportions of racial and ethnic groups, such as American Indian/Alaska Native, Black, and Hispanic persons.
  • Schools in geographic areas with limited access to testing due to distance or lack of availability of testing25.

Ethical considerations for school-based testing

Testing should not be conducted without informed consent from the individual being tested (if an adult) or the individual’s parent or guardian (if a minor). Informed consent requires disclosure, understanding, and free choice and is necessary for teachers and staff (who are employees of a school) and students’ families to act independently and make choices according to their values, goals, and preferences. Differences in position and authority (i.e., workplace hierarchies), as well as employment and educational status, can affect an individual’s ability to make free decisions. CDC provides guidance and information related to consent for COVID-19 testing among employees. These considerations also apply and can be adapted to school-based testing.

Schools should make a communication plan to notify local health officials, staff, and families immediately of any case of COVID-19 while maintaining confidentiality in accordance with the Americans with Disabilities Act (ADA) external iconand Family Educational Rights and Privacy Act (FERPA)external icon, the Protection of Pupil Rights Amendment (PPRA)external icon, and other applicable laws and regulations. Collaboration with local counsel, education, or public health is recommended to ensure appropriate consent is obtained and maintained and results are retained with appropriate privacy and confidentiality.

Considerations before starting any testing strategy

Before implementing testing in their schools, K–12 school leaders should coordinate with public health officials to ensure there is support for this approach from students, parents, teachers, and staff and to develop a testing plan that has key elements in place, including:

  • Dedicated infrastructure and resources to support school-based testing.
  • Use of tests that are authorized by FDA for the specific intended use (i.e., screening, pooling), and a mechanism in place for prescriptions/test orders by a licensed healthcare provider.
  • CLIA certificate of waiver requirements to perform school-based testing with Emergency Use Agreement-authorized tests.
  • A mechanism to report all testing results (both positive and negative) as required by the state or local health department.
  • 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 and staff privacy.
  • Plans for ensuring access to confirmatory testing when needed through the state or local health department for symptomatic persons who receive a negative test result and asymptomatic persons who receive a positive test result.

If these elements are not in place, schools may consider a referral-based testing strategy in collaboration with public health officials.

Schools should work with local public health officials to decide whether and how to use testing. K–12 schools operated by the federal government (for example, for Department of Defense Education Activity [DoDEA], which operates K–12 schools for DoD Dependents) should collaborate with federal health officials. In addition to state and local laws, school administrators should follow guidance from the Equal Employment Opportunity Commissionexternal icon, and applicable federal laws when offering testing to faculty, staff, and students who are employed by the K–12 school.

Feasibility considerations and 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.

  • In some schools, school-based healthcare professionals (for example, school nurses) can perform COVID-19 viral testing if the school or test site receives a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiverexternal icon. Some school-based healthcare professionals might also be able to perform specimen collection to send to a lab for testing, if trained in specimen collection, without a CLIA certificate. It is important that school-based health care professionals have access to, and training on the proper use of personal protective equipment (PPE). Facilities should be aware of the FDA EUA external iconfor antigen tests external iconand the Center for Medicare & Medicaid (CMS’s) enforcement discretion pdf iconregarding the CLIA external iconcertificate of waiver when using tests in asymptomatic individuals.
  • Not every school system will have the staff, resources, or training (including the CLIA certificate of waiver) 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.
  • School-based testing might require a high degree of coordination and information exchange among health departments, schools, and families.
  • There might also be legal and regulatory factors to consider with onsite school-based testing regarding who will prescribe the tests, who will administer the tests, how tests will be paid for, and how results will be reported. Such factors include local or state laws defining the services school nurses and other school-based health professionals are permitted to provide, as well as applicable privacy laws.
  • 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 NAATs. However, antigen tests have a higher chance of missing an active infection even in symptomatic people, and confirmatory molecular testing might be recommended.

Vaccination for teachers and staff, and in communities as soon as supply allows

Vaccines are an important tool to help stop the COVID-19 pandemic. Teachers and staff hold jobs critical to the continued functioning of society and are at potential occupational risk of exposure to SARS-CoV-2. Vaccinating teachers and staff is one layer of prevention and protection for teachers and staff. Strategies that minimize barriers to access vaccination for teachers and other frontline essential workers, such as vaccine clinics at or close to the place of work, are optimal. To address this important public health priority, the Health and Human Services Secretary issued a Secretarial Directivepdf icon on March 2, 2021, that directs all COVID-19 vaccination providers administering vaccine purchased by the US government to make vaccines available to those who work in K–12 schools. This means that in addition to existing state and local COVID-19 vaccination sites, teachers and staff in schools across the nation can sign up for an appointment at more than 9,000 pharmacy locations participating in the Federal Retail Pharmacy Program for COVID-19 Vaccination.

New CDC resources are available to provide information about this directive:

School officials and health departments can work together to also support messaging and outreach about vaccination for members of school communities. School communication platforms can facilitate outreach to encourage vaccination of household members of school-age children as they become eligible. This should include outreach in a language that limited English proficient family members of students can understand and in alternate formats as needed to facilitate effective communication for individuals with disabilities.

Implementation of layered prevention strategies will need to continue until we better understand potential transmission among people who received a COVID-19 vaccine and there is more vaccination coverage in the community. In addition, vaccines are not yet approved for use in children under 16 years old. For these reasons, even after teachers and staff are vaccinated, schools need to continue prevention measures for the foreseeable future, including requiring masks in schools and physical distancing.

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