The A, B, Cs of Testing: What Effective COVID-19 Prevention Should Look Like in Schools

Last month, as summer subsided, the school year started up and institutions all across the country finally opened their doors… and closed them, and opened them again. With increases in COVID-19 cases, new threats of lawsuits from teachers unions loom large. Clearly, one subject that has not been on the curriculum this semester is effective COVID-19 testing. Though there are as many testing ideas out there, there are few agreed best practices for how to deploy effective testing programs at scale. Countless haphazard plans have forced schools to re-evaluate their initial target goals time and time again.

Los Angeles — which touts the nation’s second-largest school district — hoped to consistently test its 600,000 students and 75,000 employees. We know the LA program is expensive, but is it effective? Looking around the school testing landscape, I see far too many exorbitant testing programs that, still, are not preventing school closure. An effective testing program at scale takes more than just deploying a test across your institution. As the CEO of a technology company that provides testing as a service to many healthcare leaders and partners, I want to share observations across the thousands of test programs we have deployed in the U.S. As the father of school-age children, I feel even more compelled to do so.

Admiral Giroir, the Assistant Secretary for Health who is overseeing federal testing efforts, says that the Center for Disease Control “does not recommend routine baseline testing of all students or all employees.” I could not disagree more strongly. I believe that regular, widespread testing is the foundation of any program that would prevent the spread of COVID-19 across schools — and local governments must invest in such programs. So what are the three pillars of an effective testing program?

1. Detection: Regular testing and analytics
2. Isolation: A working contact tracing and social isolation program
3. Reporting: Real-time reporting of COVID protocol violation

In order to deploy a working program on your campus, you need a COVID team that is given authority to execute the program. This team has to establish all of the required pillars of a successful program. I’ll dive deeper into each of the items above, and make my case for this three-step program.

1. Detection: Regular testing and analytics

Most campuses have been implementing a testing strategy that is based on an initial testing of students on entering campus. This is usually carried out weekly or at random, with institutions sometimes looking specifically for symptoms. However, symptom-based testing makes no sense at a school or on a college campus. Most students will be asymptomatic and by the time you catch them, and it will be too late. In a school with 1,000 students, a 1–5 percent rate of infection will result in 10 to 50 infected students. By the time you see symptoms, you will have to shut down your whole campus. Instead, schools should be carrying out testing at least twice a week with results coming in within 72 hours, at the latest. Running a random testing strategy or weekly testing with results returning in seven days will not help get control of a potential infection.

In my experience, we usually recommend that our clients run saliva testing, which is self administered and easy to use. We work with the world’s largest university-based biorepository to offer self-collection saliva testing that can easily be administered to students in their own dorm rooms or homes. This can then be tracked via software so you can get a population level view of the infection without having a tent setup or clinical staff involved. In general, unless you make the testing easy, it will not work. Asking students to stand in line for hours to do a painful nasal swab in a crowded tent that potentially already contains infection is not a successful testing strategy. There are alternatives to the saliva, which involves pooling the saliva sample or doing a screening saliva testing. The nuances of those variations require a different article.

2. Isolation: A working contact tracing and social isolation

In order to control a potential infection, you also have to deploy a serious contact tracing program. That requires that you keep track of where the students have been on campus, which classes they are attending, which dorms they are staying in, and which group of friends they’re hanging out with. When a student is positive, you have to immediately be in a position to reach out to other students in their social groups, asking them to isolate themselves for 72 hours and get tested to make sure they are negative. You must have a software platform or process that allows you to track these infection clusters in order to verify that those individuals are isolated and negative, thus controlling the spread of the infection.

If you do not create a process around contract tracing and social isolation with a strong operational leadership, you will not be able to manage the spread. This is similar to running a food service on campus. Both require systems that are organized and disciplined enough to run a process day in and day out without surprises. With testing, you start by looking for the infected person. With tracing, you then identify their social groupings, making sure they are socially isolated, and finally verifying that they are not infectious before they are admitted back to class.

3. Reporting: Real time reporting of COVID protocol violations

In order for your COVID testing program to work, you also need a very clear set of policies on campus that must be followed. Any violation of these policies should have significant penalties that are consistently enforced. Your student community has to believe that putting on a face mask is required. Any breach needs to be documented in a central system, and the person must realize there is a consequence to violation of this rule. This should be like crossing a red traffic light. If you don’t comply, you know you will get a ticket.

In a similar fashion, in order for the COVID policies to take effect, the school administration has to be very consistent in their messaging and not leave any room for interpretation or exception. No one will follow the rule if they believe it is never enforced. To help follow this, you can allow for anonymous reporting of violations by sending photos of unmasked individuals to a published email address. Those individuals will get a notification of their violation and they will be asked to isolate in their dorm and get tested. If they are caught twice, perhaps they could get a financial penalty, and on the third violation they may be publicly dismissed. This has to be a real rule, just like getting your license revoked. I can’t emphasize enough how important this step is in creating an effective testing program. Without clear articulations of your rules and potential penalties associated with those rules, your students will not take the policy seriously. This has to be enforced without any exception.

In my experience, a program with these elements implemented early on gives a campus or a community the greatest chance of remaining open while controlling potential infections. By merging this social contract reporting with twice-a-week saliva testing and mandatory isolation, we can approach a far more effective school testing program than anything that is currently out there.