Monday, January 17, 2022

"Test-To-Stay" part of the strategy to keep children in schools

 - Jennifer Middleton, MD, MPH

As the COVID-19 pandemic continues to set records for cases and hospitalizations, some schools in the United States (U.S.) are closing schools again - some due to staff and teacher shortages, and some in an attempt to slow COVID-19 spread. Toward the end of last month, the Centers for Disease Control and Prevention (CDC) released new data demonstrating that "Test-To-Stay" can help keep schools open - and children in schools - safely.

The CDC describes its "Test-To-Stay" (TTS) strategy as:

...a practice comprised of contact tracing and serial testing (testing that is sequentially repeated) to allow school-associated close contacts who are not fully vaccinated to continue in-person learning during their quarantine period. While implementation of TTS may vary, contact tracing and testing as well as masking of contacts during their in-school quarantine period are integral to minimize risk of transmission. 

The CDC cites two U.S. studies (Los Angeles, California and Lake County, Illinois) and one study from the United Kingdom to justify TTS. The LA study compared 39 districts using TTS to 39 districts following traditional quarantine guidance and found no difference in COVID-19 case rates. The Lake County study followed 90 schools using TTS and found only a 1.5% rate of secondary transmission. The UK study randomized 86 schools using TTS to 76 schools that followed traditional quarantine guidance and found no difference in COVID-19 cases. The Lake County study estimated that "up to 8,200 in-person learning days" were saved as a result of their TTS protocol. The CDC emphasizes that TTS must be part of a "layered prevention program" that also includes masks and social distancing

TTS is only necessary for unvaccinated children, but vaccination rates for children aged 5-11 years in the U.S. remain quite low. "[J]ust over 17%" of children aged 5-11 years and 54% of children aged 12-17 years are fully vaccinated as of last week. If those numbers do not substantially improve, which is, unfortunately, not expected to happen, TTS may continue to be needed for the forseeable future.

TTS only works with access to rapid tests, which has proved challenging throughout the U.S. As 2 days ago, the Biden administration now requires U.S. health insurance companies to cover the cost of up to 8 rapid COVID-19 tests per person per month. The Biden administration is "strongly incentivizing health plans and insurers to set up a network of convenient locations...where people... will be able to order online or walk in and pick up at-home over-the-counter COVID-19 tests for free." The Centers for Medicare & Medicaid Services (CMS) advises consumers to check with their health insurance plan to see whether they are supporting a "convenient location" or if they will, instead, need to pay up front and then submit for reimbursement. will also begin accepting orders on January 19 and will not require a credit card. Removing the financial and physical access barriers to testing is a must if TTS is to be successfully implemented. 

CMS has a website with answers to questions regarding access to free rapid tests, and you can read the full details of the requirements here if interested. The AFP By Topic on COVID-19 also includes this Cochrane for Clinicians article on "Rapid Point-of-Care Antigen and Molecular Tests for Diagnosis of SARS-CoV-2 Infection" if you'd like to read more.