Test-to-Stay Programs in Schools Are Effective, but Are They Equitable?

During the 2020–2021 school year, kindergarten through grade 12 schools in underresourced communities were more likely to close because of the coronavirus disease 2019 (COVID-19) pandemic, and students in these schools missed more in-person learning days.¹  Evidence collected during this time demonstrated in-person learning for all kindergarten through 12th-grade students could be conducted safely with layered prevention strategies.²  In August 2021, most US school districts opened with 100% in-person learning. Despite a decrease in cases after the start of fall semester, cases among school-aged populations again increased in December before the winter break because of the highly transmissible Omicron variant.³ 

During the fall 2021 semester, Test to Stay (TTS) became a popular strategy for keeping students in in-person learning. TTS allows school-based close contacts, who would otherwise home quarantine, to continue in-person learning if they remain asymptomatic and test at least twice in the 7 days postexposure. The objectives of TTS are to:

1. reduce the number of days a student is prevented from accessing in-person learning and school-based services;

2. reduce the burden caused by quarantine policies on students and families; and

3. maintain the safety of the school environment.

The Centers for Disease Control and Prevention and others partnered with state and local public health agencies and school districts to assess the feasibility and effectiveness of TTS strategies. Evaluation results, including those of Schechter-Perkins et al⁴  in this issue of Pediatrics, demonstrate minimal onward transmission from TTS participants and considerable days of in-person learning saved.^5–7  However, because of longstanding systematic barriers, TTS may not be an equitable strategy across school districts and families, which may lead to widening disparities in education.⁶ 

COVID-19 testing resources and staff to conduct school-based case investigation and contact tracing are essential to TTS. Schools in underresourced communities may lack staff to conduct thorough contact identification, which may lead to inclusion of students with lower exposure risk as close contacts (eg, an entire class), unnecessarily exhausting limited testing resources and staff time. Overwhelmed contact tracing systems may fail to achieve timely exposure notification, resulting in delays in TTS enrollment and missed testing days, and thus increasing the risk of onward transmission.

Schools in underresourced communities are often overcrowded. When students cannot be spaced at least 3 to 6 feet apart, more students are identified as close contacts, resulting in the need for more resources to implement TTS. Federal emergency resources can be used to enhance school contact tracing capacity and increase access to school-based testing to reach disproportionately affected populations.

TTS schools may offer testing on-site or at centralized locations, or they may allow students to test in the community; on-site testing may facilitate adoption of TTS programs. However, underresourced districts may lack staff to perform on-site testing at each school and lack funding to bring in contracted testing service providers. In some school districts, a single staff member may travel among multiple schools daily to perform on-site testing, placing a substantial strain on available health services. In underresourced communities, parents with barriers to transportation may not be able to comply with a prescribed testing cadence. If TTS participants must seek testing in the community, barriers including out-of-pocket costs, transportation logistics, and access to health care provider-based testing need to be addressed.

Many TTS programs limit allowable activities for participants during their observation period, ranging from allowing only classroom-based activities to allowing extracurricular and after-school activities if masking and distancing can be maintained. Households with lower incomes are more likely to rely on after-school programs, introducing additional barriers to these services when TTS programs allow in-person classroom participation but limit participation in after-school activities.

Unvaccinated students in school districts without the capacity to implement TTS, and students in TTS districts who have barriers to opt in to these programs, may not have equal access to in-person learning.¹  Increasing access to and uptake of COVID-19 vaccines will allow more students to stay in the classroom.

States and school districts have a responsibility to thoughtfully consider inequities when planning TTS strategies and proactively develop plans that ensure availability of TTS to all students across schools. Schools and districts can work with families to define challenges to participation in TTS and together design a strategy allowing for equitable access, while maintaining program fidelity. Regularly monitoring program participation can quickly identify differences in access. School administrators can work to ensure all students who qualify for TTS can access testing, including providing clear and accurate information about testing resources in the community. Finally, public health and education agencies can assist by ensuring schools have adequate contact tracing and testing services and by continuing to promote and provide opportunities for vaccination. Thoughtful consideration and planning of TTS can capitalize on the federal resources available (School Testing for COVID-19 | Centers for Disease Control and Prevention⁸ ) and minimize the barriers experienced by schools and families in under-resourced communities.

COVID-19

coronavirus disease 2019

TTS

Test to Stay