In the spring of 2021, Joel Strasz had a problem.
Truthfully, as public health officer of Bay County, Strasz (rhymes with “Oz”) had a seemingly endless list of problems. The dizzying roller coaster of student outbreaks and quarantines were disrupting schools and hurting families.
“For parents, it's like, ‘Oh, man, my kid is quarantined again, and so they can't get to the school.’ And they didn't really have any virtual options. A lot of kids suffered as a result of that,” he said.
And public health workers were seeing “a lot of reluctance” on the part of “parents really invested in their children’s sports activities” to disclose the results of their child’s COVID tests, or their close contacts, “because they didn’t want their kid to miss sports activities.”
Meanwhile, community backlash against school quarantines was mounting, after four West Michigan health departments announced they would no longer be enforcing it for students so long as they were asymptomatic. “And that kind of built up pressure around here of, ‘Why are you doing this? We're going to legally challenge you,’ and so on and so forth.’”
To top it off, this was just as Michigan’s third COVID surge was starting to peak, and pediatric hospitalizations were at a record high. “So we took a look at everything that we were doing, you know: facing potential legal challenges, how can we keep kids in school? How can we make sure they’re safe and healthy and that the virus doesn’t spread like wildfire?”
That’s when Strasz and his team started doing some digging into “Test to Stay,” a concept that was gaining popularity in other states. While the details look a little different from place to place, the broad concept is fairly simple: if a student or teacher comes into “close contact” with someone with the virus, you could put them into quarantine at home for 10 days. Or, you could offer them an alternative: every morning before school, they take a rapid COVID test. As long as it’s negative, they can go to class, practice, etc.
Most places were doing daily tests from the first day following exposure, or “day one,” every day for five days, and then again on days seven and nine. So long as those tests continued to come back negative, and the testee wore a mask during this period, they didn’t have to miss in-person learning and the school community could have fewer disruptions. So from May through the end of the school year in June, Strasz and his team gave it a go, testing just over 70 students as part of a pilot program.
And it seemed to work.
“Ninety-eight percent were able to stay in school and didn't have to quarantine,” he said. “They could stay in extracurricular activities, they could go to prom, they could go to graduation without a problem. Everything was great. We actually had two students that were positive, which we probably would not have caught [if it wasn’t for the testing.] So it was a really good process, and most of the parents were very, very happy about it.”
So it’s hardly a surprise that, given the lessons of last year’s disrupted school year, more schools and health departments want to get on board the “Test to Stay” train.
Livingston County, where masks aren't required, offers "alternate quarantine" option
The Livingston County Health Department, which has not issued a school mask mandate, announced a "Test to Stay" program this weeked for interested schools. Health officials are calling it an "alternate quarantine" option, and districts like Pinckney Community Schools (which also isn't requiring masks) are opting in. It "is being implemented by a vast majority of the public, charter and private schools in Livingston County," Pinckney superintendent Rick Todd told families in an email Tuesday.
"Although some may have concerns about the safety of this program, the rationale behind this is being driven with data as an extremely high number of students who were asked to quarantine last year in Livingston County never displayed symptoms or became COVID positive," Todd said.
Students considered "close contacts" in a school or bus setting will be notified by the Livingston County Health Department via text. From there, parents can choose either the "traditional quarantine" option of staying at home for 10 days, or, if their student doesn't have COVID symptoms, the "alternate quarantine" - so long as they abide by the program's protocols.
That means parents must test their kids at home every day before school, interpret the results, and report them to the Livingston County Health Department. Tests can be picked up at the local health department. Students can't participate in extracurricular activities during this period, and they must wear a mask in school and on the bus.
"[F]ailure to follow all the expectations of the Alternative Quarantine option will result in a default back to the Standard Quarantine," Todd said. "If moved to the Standard Quarantine option, there will be no option to return to the Alternative Quarantine, without exception."
Todd also notes that if "large episodes of in-school transmission or a school-outbreak is identified, the LCHD will pause this option for a district, requiring everyone impacted to fulfill a 10-day standard quarantine."
Other counties to offer "Test to Stay" as an option, too
Ingham County Health Officer Linda Vail is interested too, and specifically outlined the option in a recent quarantine order - with some caveats. “Strict mitigation measures, including universal masking” must be in place at the school in order for students to qualify. And schools have to do the testing on site, they can’t just take a student’s word for it that their test was negative.
“We just put it out there as an option,” said Vail. “I’m going to have a meeting with my superintendents and go over all of this with them, and quite honestly look at the feedback. [If they say] that doesn’t make sense, then we may make some slight revisions.”
One thing the county won’t reconsider: universal masking for schools. “If we’re going to start quarantining kids, it’s going to be the consequences of [noncompliance with the Ingham County mask mandate,]” Vail said. “The consequence is kids being excluded from schools, and in-person learning. What are [parents] going to do about work? What happens if teachers get sick? So that’s what we’re going to see.”
That’s not the school year anyone wants, she said.
“Enforcement is going to be hard. It’s going to be challenging. Fortunately, my districts here mostly instituted mask mandates on their own prior to these [county] orders. But in places where it doesn’t get enforced, we’re going to have outbreaks. You could see entire classrooms have to be quarantined.”
Meanwhile, Ann Arbor Public Schools says it may consider "Test to Stay" down the road. "As our understanding of transmission risk increases this fall, we will considering adding the "testing out" option for unvaccinated students," the districts states in its COVID protocols.
But can it work this year?
In the best-case scenario, "Test to Stay" would let as many kids as possible stay in school, without jeopardizing the health of others, and reducing the amount of clashes health officials have to have over quarantine enforcement.
But does it actually work that way? Even as the concept gets adopted by states like Utah and Illinois, the CDC has said little about whether serial testing post-exposure is as effective at reducing the spread of COVID in schools as quarantines.
It did publish a study out of Utah, where the state health department rolled out two serial testing programs last year: “Test to Play,” where students had to be tested once every 14 days in order to participate in extracurricular activities, and “Test to Stay,” which looks slightly different than the model Bay County used. In Utah, “Test to Stay” involved “school-wide testing to continue in-person instruction as an alternative to transitioning to remote instruction if a school crossed a defined outbreak threshold.”
From November through most of March last year, nearly 60,000 students received testing. Just over 3% had a positive test result. “These programs facilitated the completion of approximately 95% of high school extracurricular competition events and saved an estimated 109,752 in-person instruction student-days,” the researchers wrote.
But those were simpler times. Because even as the highly infectious delta variant has led to rising pediatric COVID cases, deep divisions over masking means more schools aren’t requiring them.
And “Test to Stay” was predicated on universal masking in schools, said Dr. Adam Hersh, senior author on the study and a professor of pediatrics at University of Utah Health.
“Especially for the younger ages, we need to be promoting universal or near universal masking, because it is so effective and it obviates the need for so many other really challenging and less effective additional approaches, like how you manage quarantine again,” Hersh said. “I mean, you can eliminate so many quarantine circumstances when people are wearing masks.”
So much of our hard-won knowledge about how COVID behaves in school settings has been undermined by the delta variant, Hersh said. For instance: how contagious is it if only a few people are wearing masks? What about if only some of the adults, but none of the students, are vaccinated? What happens if you use “Test to Stay” as a quarantine alternative but students or teachers don’t keep their masks on?
It’s not that “Test to Stay” can’t be a useful tool. Rapid tests are still very good at detecting contagious infections with the delta variant, he said. And when used daily for an initial incubation period, your odds of detecting a contagious case are promising.
“The idea that in theory, in the extreme, a school strategy that had no masking, but where everyone was tested every day, would be an interesting world to live in,” Hersh said.
“...What's so frustrating for so many people is, if we do it like we did last year, which is everybody wears masks, a lot of the rest of the stuff [like serial testing,] I don’t want to say it’s a rounding error, but you’re into the margins, right?”
Yet here we are, with many school communities firmly living in those margins. So in an instance where masks aren’t being widely used, and enforcing quarantine becomes challenging or highly disruptive, Hersh said “Test to Stay” is certainly better than nothing.
“And sometimes I think when we use the phrase ‘it's better than nothing,’ we sort of imply that it's no good,” Hersh said. “I don't know in practice how effective that approach will be, but I think it's apt to be substantially better than that.”
It’s also a strategy that works best when overall case numbers are fairly low. Once it becomes a question of mass exposure and quarantines, the logistics get complicated. Imagine testing dozens or hundreds of students every morning in the school gym. Assuming you can even get enough school staff trained to do it, and all of those students wear masks 100% of the incubation period, it’s not something Joel Strasz is looking forward to.
“And we haven't been there yet, and I hope that we don't get there,” he said. “But I'm sure that we'll have schools that will run up to the limitations on this.”
This post was updated September 7, 2021 at 2:15 pm.