Evaluation of a Test to Stay Strategy in…

On July 12, 2021, the California Department of Public Health updated COVID-19 school guidance, allowing a Test to Stay (TTS) strategy to increase access to in-person learning* (1). The TTS strategy enabled unvaccinated students, exposed in school to a person infected with SARS-CoV-2 (the virus that causes COVID-19), to remain in school while under quarantine, if both the infected person and the exposed person wore masks correctly and consistently throughout the exposure. To stay in school during the quarantine period, the exposed student must remain asymptomatic, wear a mask at school, and undergo twice weekly testing for SARS-CoV-2. To date, few studies have evaluated the impact of TTS on transmission (2–4). This study evaluated a TTS strategy implemented by Los Angeles County Department of Public Health (LAC DPH). During September 20–October 31, 2021, among 78 school districts, one half permitted TTS; in total, 432 (21%) of 2,067 schools adopted TTS. TTS schools did not experience increases in COVID-19 incidence among students after TTS implementation, and in 20 identified outbreaks in TTS schools,^† no tertiary transmission was identified. The ratio of student COVID-19 incidence in TTS districts to that in non-TTS districts was similar before and after TTS adoption (rate ratio = 0.5). Non-TTS schools lost an estimated 92,455 in-person school days during September 20–October 31 while students were in quarantine, compared with no lost days among quarantined students in TTS schools. Non-TTS schools cited resource-related reasons for not adopting TTS; 75% of these schools were in LAC’s most disadvantaged neighborhoods. Preliminary data from LAC suggest that a school-based TTS strategy does not increase school transmission of SARS-CoV-2, and might greatly reduce loss of in-person school days; however, TTS might have barriers to implementation and require resources that are not available for some schools. Continued efforts to simplify school quarantine strategies might help to ensure that all students have access to safe in-person education. Although vaccination remains the leading public health recommendation to protect against COVID-19 for persons aged ≥5 years, schools might consider TTS as an option for allowing students with a school exposure who are not fully vaccinated to remain in the classroom as an alternative to home quarantine.

LAC has 78 public school districts with 2,067 schools for students in transitional kindergarten through grade 12.^§ Schools require indoor masking, physical distancing where feasible, vaccination, isolation of persons with confirmed cases, contact tracing, quarantining of close contacts, and SARS-CoV-2 testing (5). School SARS-CoV-2 testing strategies include weekly testing of asymptomatic, unexposed persons and response testing of persons with symptoms or exposures using SARS-CoV-2 nucleic acid amplification tests or antigen tests. LAC DPH is notified of school COVID-19 cases and close contacts of persons who received positive test results via a secure line list or online survey using REDCap (version 10.3.3; Vanderbilt University).

LAC DPH allowed schools to adopt a TTS strategy starting on September 20, 2021. For asymptomatic, unvaccinated students under quarantine orders,^¶ TTS was permitted during the quarantine period if the exposure occurred in school and the exposed student and infected person both wore masks correctly and consistently during the exposure. During TTS, contacts could continue in-person academic activities during regular school hours if they remained asymptomatic, wore a mask while at school (indoors, outdoors, and on school buses), received testing twice weekly by a certified testing program or health care provider,** and agreed to quarantine at home when not at school. Contacts could not participate in extracurricular activities or before- or after-school care during the quarantine period.

School COVID-19 cases were defined as a laboratory-confirmed SARS-CoV-2 infection in a person who was at school anytime during the 14 days before their episode date (symptom onset date or the positive SARS-CoV-2 test result date, whichever was earlier). School cases were verified with test results reported by laboratories or health care providers to the LAC DPH Integrated Reporting and Investigation Surveillance System (IRIS). Cases among students with episode dates during August 16–October 31 and school exposures of student close contacts during August 17–October 31 were used to calculate secondary infection risk (number of quarantined contacts with a COVID-19 diagnosis 1–14 days after exposure divided by the total number of quarantined contacts).^†† COVID-19 student case rates were calculated as the average daily number of student cases during a 7-day period divided by the number of enrolled students.^§§ COVID-19 student rates are presented with 95% CIs; rates with non-overlapping CIs were considered to be significantly different. COVID-19 student rate ratios were calculated by dividing COVID-19 student case rates in TTS schools by those in non-TTS schools.

School district administrators were interviewed during November 3–16, 2021, to determine whether the district adopted TTS and to assess implementation challenges and reasons for not implementing TTS. TTS districts might have permitted TTS only for certain school levels; therefore, schools were subsequently categorized as having adopted versus not adopted TTS. School outbreak data were reviewed for evidence of tertiary transmission within TTS schools. Tertiary transmission was defined as likely SARS-CoV-2 transmission to a student, from a student participating in TTS who received a positive SARS-CoV-2 test result during the TTS period (i.e., a student with a secondary case). Schools were grouped into quartiles of disadvantage based on the California Healthy Places Index (HPI)^¶¶ (6). Zip codes falling within the lowest HPI quartile represented the most disadvantaged neighborhoods. Among non-TTS schools, estimation of lost in-person school days assumed 5 missed school days for each 7-day student quarantine.*** This analysis was restricted to public school districts; Pasadena Unified School District (USD), Long Beach USD, and non-residents of LAC were excluded.^††† SAS statistical software (version 9.4; SAS Institute) was used for all analyses. This public health surveillance activity was reviewed and approved by LAC DPH.

An estimated 1,292,067 LAC public school students returned to school for the 2021–22 academic year, which commenced on August 16, 2021, for most LAC public schools. During August 16–October 31, an average of 462,189 student and staff member SARS-CoV-2 tests were conducted each week in all schools. During the week of August 16, 0.6% of test results were positive, but this percentage declined to 0.2% by October 31 (Figure 1). Among all schools, 12,919 student COVID-19 cases (1% of the student population) and 57,513 student contacts (4% of the student population) were reported during the 10-week observation period; case numbers peaked at 2,270 during the week of August 16, and the number of contacts peaked at 8,589 during the week of August 23.

During September 20–October 31, among 78 school districts, 39 (50%) permitted TTS; within these districts, 94% of schools (432 of 452) adopted TTS (Table). These TTS schools constitute 21% of LAC public schools. LAC’s largest school district, which accounts for one third of public school students, did not adopt TTS. Overall, within the 1,635 non-TTS schools, 4,322 COVID-19 cases occurred among 967,188 enrolled students (4.7 cases per 1,000 students); among 18,729 student close contacts, the secondary infection risk was 1.3%. Non-TTS districts lost an estimated 92,455 in-person school days during September 20–October 31 while students were in quarantine. Within the 432 TTS schools, among 324,879 enrolled students, 812 COVID-19 cases occurred (2.5 cases per 1,000 students); among 7,511 student close contacts, the secondary infection risk was 0.7%. As a result of the TTS protocol, no in-person school days were lost among quarantined students participating in TTS. Among 20 school outbreaks that occurred in TTS schools after TTS implementation, three outbreaks included four TTS students who were secondarily infected; contact tracing confirmed seven contacts of these patients and identified no tertiary transmission.

Before TTS adoption (August 16–September 19, 2021), average daily student COVID-19 incidence was lower in TTS districts (10 per 100,000 students; 95% CI = 7–13) than in non-TTS districts (20 per 100,000 students; 95% CI = 18–23) (Figure 2). After TTS adoption, average student daily case rates declined in all districts but remained lower on average in TTS districts (6 per 100,000 students; 95% CI = 3–9) compared with non-TTS districts (11 per 100,000 students; 95% CI = 9–13). The ratio of student COVID-19 incidence in TTS districts to that in non-TTS districts was similar before and after TTS adoption (rate ratio = 0.5). (Figure 2).

Among the schools that implemented TTS, 107 of 410 (26%) were categorized as most disadvantaged compared with 1,192 of 1,619 (74%) non-TTS schools.^§§§ Challenges cited to TTS implementation were limited staffing and systems to monitor mask use, testing, and lack of family support (Supplementary Table, https://stacks.cdc.gov/view/cdc/112641). Non-TTS districts reported similar resource barriers.

Acknowledgments

Students, families, and staff members in Los Angeles County schools; Los Angeles County Office of Education; Los Angeles County Department of Public Health (LAC DPH): Usman Akram, Deborah Allen, Sharon Balter, Kevin Barajas,Deanna Bressler-Montgomery, Marcus M. Carreon, Josiah Chung, Katie Chun, Clara Chung, Andrea Collins, John Connolly, Kamilah Daley, Zulfia Davis, Henry Dorantes, Eric El Togby, Michael Espero, Ndifreke Etim, Jessica Ferguson,Gladys Fernandez, Robert Gilchick, Amanda Gittleman, Jason Grant, Caitlin Harvey, Nathan Hatia, Yiping He, Edith Hernandez, Melrick Ibanez, Evan Jun, Sairah Khan, Saloniki Madrid, Laureen Masai, Robert Mitchell, Bret Moulton, Yeghishe Nazinyan, Amparo Estephanie Oceguera, Pastor Osuna, Raina Pandit, Harry Persaud, Matthew Pham, Mia Risberg, Dena Saleh, Christopher Schuchert, Saba Shariati, Dawn Terashita, Shiraya Thompson, Alice Tivarovsky, Carolina Tse, Sophia Vinegar, Tuff Witarama, Nava Yeganeh, Education Sector Outbreak Unit, Education Sector Prevention Unit, Education Sector Vaccine Unit, Wellbeing Center Program.