White Paper COVID-19 Tools March 17, 2022 Livingston County K-12 education digitally-enabled test-to-stay program Summary Over-the-counter rapid antigen tests and innovations in mobile technology that rely on at-home self-administration and digital reporting offer an opportunity for a test-to-stay program for K-12 students that is safe and rigorous, yet scalable. Livingston County Health Department (LCHD) in Michigan—with support of the National Institute of Health’s (NIH’s) Rapid Acceleration of Diagnostics (RADx®) Tech program’s Clinical Studies Core at UMass Chan Medical School and CareEvolution’s mobile health platform, MyDataHelps—developed a digitally enabled test-to-stay program relying on student (or guardian) self-administration and interpretation of at-home rapid antigen COVID-19 tests. A simple web application delivers an interconnected system allowing for real-time testing and results reporting for students exposed to a COVID-19 case in a school setting, reducing school and health department staff burden. This test-to-stay program also increases accessibility by employing a digital health platform, thus addressing some of inequity in participation seen with traditional programs. Initial concerns around technology adoption, test administration, and inaccurate test results were not observed. The program resulted in 3,653 student school days saved in the fall of 2021 (defined as any weekday where there was a negative test on the prior day or morning of an asymptomatic student presenting to school). This project has been funded by the NIH RADx-Tech program in whole or in part with federal funds from the National Institute of Biomedical Imaging and Bioengineering (under Contract No. 75N92020P00146), and the National Heart, Lung, and Blood Institute (under 3U54HL143541-02S2), National Institutes of Health, Department of Health and Human Services. The program resulted in 3,653 student school days saved in the fall of 2021 Introduction The aim of this pilot is to determine whether at-home rapid antigen testing along with the use of mobile technology can reduce the burden of a test-to-stay program for school administrators during the COVID-19 global pandemic. COVID-19 test-to-stay programs allow for asymptomatic students who are exposed to COVID-19 in the school environment to continue to attend in-person school for the duration of the student’s exclusion period by complying with testing and symptom screening. Without a school test-to-stay program, per evolving Centers for Disease Control and Prevention (CDC) and state health department guidelines, Livingston County (MI) students were excluded from in-person school for 7-10 days after a COVID-19 exposure. A traditional test-to-stay program requires significant coordination between schools, public health, and guardians to ensure testing consent is obtained from guardians and testing resources are made available to schools. Implementation often necessitates pooled testing, which is less actionable than individual testing. With support from NIH, The aim of this pilot is to determine whether at-home rapid antigen testing along with the use of mobile technology can reduce the burden of a test-to-stay program for school administrators during the COVID-19 global pandemic. COVID-19 test-to-stay programs allow for asymptomatic students who are exposed to COVID-19 in the school environment to continue to attend in-person school for the duration of the student’s exclusion period by complying with testing and symptom screening. Without a school test-to-stay program, per evolving Centers for Disease Control and Prevention (CDC) and state health department guidelines, Livingston County (MI) students were excluded from in-person school for 7-10 days after a COVID-19 exposure. A traditional test-to-stay program requires significant coordination between schools, public health, and guardians to ensure testing consent is obtained from guardians and testing resources are made available to schools. Implementation often necessitates pooled testing, which is less actionable than individual testing. With support from NIH, CareEvolution leveraged their digital health technology platform, MyDataHelps, to facilitate Livingston County Health Department’s (LCHD’s) implementation of a test-to-stay program to increase in-person school opportunities for students while also minimizing the burden for school staff. MyDataHelps provides a method for obtaining consent from guardians, distributing test kits to students’ homes, providing instructions to assist with at-home testing, and reporting individual antigen test results via summary dashboards. During the fall of 2021, 4,904 Livingston County students exposed to COVID-19 in the classroom were offered a test-to-stay option in which they could continue attending in-person school if they remained asymptomatic and tested negative on at-home antigen tests. Guardian Enrollment Test Administration Instructions Actionable Results Key distinctions between traditional test-to-stay programs and digitally-enabled test-to-stay programs Test-To-Stay Program Requirements Traditional Test-to-Stay Program Digitally-Enabled Test-to-Stay Program Consent Guardians must approve of student testing prior to administration. Written or verbal communication required Program overview delivered via SMS text & email Guardians enroll in their own time For students not enrolled in test-to-stay, guardians automatically informed of the return to in-person school date at end of enrollment process Test Kit Supply Test kits must be made available to schools and/or guardians. Tests acquired by and stored at schools Initial test kits stored at schools Subsequent test kits delivered to student homes Shipping address provided by guardian during enrollment Test Administration Tests must be administered serially to properly assess infection. Testing administered by school staff Tests often pooled, losing individual-level student precision SMS text & email reminder sent to guardians Web application provides instructions & timers for testing Tests administered at home by student/guardian Test Results Test results must be collected to identify which students are contagious. Collected tests either resulted on-site (for point of care rapid antigen tests) within 15-30 minutes of administration or shipped for analysis (for PCR tests) Reported by guardians via web application with test result image upload Symptom Screening Screening symptoms offers another method for assessing community spread and reducing risk. Not standardized across traditional test-to-stay programs: Either no symptom screening, symptom screening is performed at home before school, or a symptom screen is performed by school personnel SMS text & email reminder sent to guardians Web application prompts student symptoms reporting Data Reporting Data must be aggregated and reviewed prior to taking action. Test results sent to and aggregated by the local health department Test and symptom data are automatically aggregated School and public health staff can view data via an online dashboard Attendance Notifications Students & guardians must be informed if attendance is permitted. Public health staff and/or school administrators must contact guardians Web application informs guardians in real-time regarding student attendance Application provides important information regarding test-to-stay, including: reminders and completion for both testing and symptom screenings Time To Test Prompt How the digitally-enabled program works In lieu of in-person school exclusions for exposed, unvaccinated students who are close contacts of positive cases, the program offers an alternate strategy to maintain safe in-person education: daily at-home COVID-19 antigen testing and symptom screening during the student’s alternate attendance period. If the student remains asymptomatic and tests negative, the student can attend in-person school while masked. This program is voluntary; guardians can elect for their students to be excluded from in-person education after close contact with a positive case. Upon COVID-19 exposure and opt-in to the digitally-enabled test-to-stay program, a QuickVue At-Home OTC COVID-19 test kit is provided to guardians at the student’s school. The remaining test kits are shipped directly to the student’s home through an automated process powered by CareEvolution’s MyDataHelps platform. This alleviates the burden of storing and distributing test kits across the participating school districts, significantly reducing health department staff requirements for the program’s execution. This digital pilot test-to-stay program provides the opportunity for students to attend in-person school while limiting the burden on school staff. Digitally-enabled test-to-stay workflow Student is identified by school or local public health department as a close contact.Upload a list of all close contacts to the MyDataHelps platform. Low risk students (e.g. vaccinated or recently infected) are excused and may continue attending in-person school. For digitally-enabled test-to-stay ineligible students, close contacts are excluded from in-person school for the exclusion period (in the case of an outbreak, school is not participating, etc.). For digitally-enabled test-to-stay eligible students: Guardians receive email and SMS to select how they would like to proceed: a. Digitally-enabled test-to-stay program b. In-person school exclusion Students enrolled in test-to-stay are required to do daily testing and symptom checks through the web application. Based on test and symptom results, the app informs if the student (conditionally) can or cannot attend school that day.If they neglect to test, report symptoms, or test positive, the student is automatically excluded from in-person school and the test-to-stay option ends for this student. The school is automatically notified through an online dashboard. If symptoms are present or the test results are positive, the student is automatically moved to in-person school exclusion for 10 days, without the option to test out on Day 6/7.Students who are not enrolled in the digitally-enabled test-to-stay program do not attend school for the duration of the exclusion period.Students can optionally test during the exclusion period. If their results are negative, they can return to in-person school on Day 8. Digitally-enabled platform CareEvolution’s MyDataHelps platform is the technological backbone for the digitally-enabled test-to-stay program. Staff uploads a list of close contacts to MyDataHelps, which triggers notifications to the appropriate guardians. Households that elect to participate in the digitally-enabled test-to-stay program are able to order test kits through an automated process and then have the kits shipped directly to their homes. The web application serves as a real-time guide for the testing process by timing steps as appropriate and ensuring results are interpreted and recorded within the 15-minute accuracy window of the test strips. CareEvolution’s MyDataHelps platform is the technological backbone for the digitally-enabled test-to-stay program. The web application also: Sends daily reminders Delivers tasks for symptom screening and COVID-19 testing Collects test and symptom results Provides the attendance determination to guardian Displays attendance data to school and health department staff Participant privacy is paramount to the program. MyDataHelps complies with the security and privacy controls defined by NIST 800-53 Rev. 4 at the FISMA Moderate baseline and regularly undergoes external formal assessments by a FedRAMP-accredited Third Party Assessment Organization (3PAO). Actionable Results School and Health Department staff involvement Rather than relying on health department staff to obtain test and symptom data, manage shipment logistics for test kits, and inform school administrators regarding in-person school attendance, CareEvolution’s technology connects households, schools, and health departments to greatly reduce staff burden. The digitally-enabled test-to-stay program still relies on engagement and support from school and health department staff. School staff must access a population-specific attendance dashboard, understand its use and purpose, and ensure only the students who are following the proper protocols are in attendance. For health department staff, accurate and timely reporting of close contacts is necessary for the success of any test-to-stay program. In order to facilitate timely reporting of close contacts, a process must be established between the school and the health department. In addition to creating a communication link between the schools and the health department, CareEvolution’s technology also allows for efficient case investigation and follow-up of students who test positive for COVID-19, which is essential for controlling the spread of COVID-19 within a population. Without such technology, the process for individual case investigation would overburden health department staff and delay reporting which could lead to increased cases. Metrics for test-to-stay eligible students * LCHD Digitally-Enabled Test-to-Stay Pilot, Fall 2021 35.3% Enrolled in test-to-stay 40.3% Opted for in-person school exclusion 24.4 % No response in-person school exclusion (put in school exclusion) 3,653 School days saved across 1,731 enrolled exposures 2.7 Average school days saved per exposure student Improved equity of the digitally-enabled program Traditional test-to-stay programs are hindered by inequity, placing students and schools from underresourced communities at further disadvantage and ultimately widening existing disparities (Neatherlin et al., 2022). In traditional test-to-stay programs, schools are typically expected to manage COVID-19 test procurement, storage, administration, and reporting, as well as test-to-stay program management. These tasks require schools to undertake additional responsibilities and ultimately hire ancillary staff to perform these added duties. This may not be an option for underresourced schools that are already stretched thin so they may not be able to participate in a traditional test-to-stay program. This results in a reliance on student quarantine and remote learning environments. Compounding this issue, remote learning may not be available in underresourced communities as it taxes school resources and students may have limited access to virtual learning resources like internet and computers. This places students from underresourced communities at an additional disadvantage by limiting access to education. A digitally-enabled test-to-stay program eliminates the need for the school to handle testing and program management, so schools are relieved of the burden of participating in a traditional test-to-stay program. Ultimately, a digitally-enabled program allows students from all communities to participate in in-person learning. Future of test-to-stay 85% Americans own a smartphone 90% US population regularly used the internet According to Pew Research, over 85% of Americans own a smartphone, including 80% of the rural population (Pew Research Center 2021b, Pew Research Center 2021a). Ninety percent (90%) of the US population regularly uses the internet. By leveraging accessible technology like MyDataHelps and expanding its reach, we can streamline test-to-stay programs by making them digitally-enabled. MyDataHelps provides a test-to-stay platform that obtains consent, ships test kits, facilitates test administration, collects results and symptoms, reports results, and sends notifications regarding school attendance status. MyDataHelps also provides a simple method for communicating changes in COVID-19 masking, testing, and vaccination guidance. By automating a test-to-stay program, school administrators and health department staff can deploy a test-to-stay program at scale, without significant burden. The autonomous, private, and convenient nature of self-administered testing may increase uptake of testing in populations that may otherwise not test. This could be an indicator that the process of self-testing and logging results through the MyDataHelps web application offers a promising modality for supporting efforts to mitigate the spread of COVID-19 in communities. As COVID-19 variants of concern continue to emerge, it is important to maintain a layered approach to mitigating disease transmission. In addition to masking and vaccination, testing is critical to further reduce the spread of COVID-19, especially in school communities. Implementation of a school testing protocol ensures that students can continue in-person education while minimizing risk to others. Test-to-stay programs offer a feasible option to implement a school testing protocol and safely allow students to continue in-person school. The CDC has since published guidance supporting test-to-stay programs, suggesting the need for effective test-to-stay programs and further supporting the adoption of test-to-stay programs in K-12 education (CDC, 2022b). Effective test-to-stay programs improve student developmental and educational outcomes, and households and communities additionally benefit by reducing the need for student home care (CDC, 2022a). As the United States pilots other initiatives to distribute rapid antigen at-home test kits, such as Say Yes! COVID Test (also powered by MyDataHelps), school districts and health departments should likewise consider scalable digital solutions to promote public health in school communities by leveraging the near real-time results of at-home tests. Through digitally enabled test-to-stay programs powered by technology like MyDataHelps, students, teachers, and communities across the world can have better access to health—not only during the COVID-19 pandemic, but in years to come. References CDC. (2021a, March 18). Association of Children’s mode of school instruction with child and parent experiences and well-being during the COVID-19 pandemic – covid experiences survey, United States, October 8–November 13, 2020. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/mmwr/volumes/70/wr/mm7011a1.htm?s_cid=mm7011a1_w CDC. (2021, December 17b). Test-to-Stay Options Can Help Keep Students in School During COVID-19. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/media/releases/2021/s1217-Test-To-Stay.html CDC. (2022a, January 13). K-12 Schools. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html CDC. (2022b, January 24). About Testing in Schools. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/what-you-should-know.html#anchor_1642694226366 Harris-McCoy, K., MSPH, Lee, V., PhD, Munna, C., & Kim, A., PhD. (2021, December 17). Evaluation of a Test to Stay Strategy in Transitional Kindergarten Through Grade 12 Schools – Los Angeles County, California, August 16-October 31, 2021. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/mmwr/volumes/70/wr/mm705152e1.htm Neatherlin, J., Thomas, E. S., & Barrios, L. C. (2022, April 8). Test-to-Stay Programs in Schools Are Effective, but Are They Equitable? American Academy of Pediatrics. Retrieved April 13, 2022 from https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2021-055930/184763/Test-to-Stay-Programs-in-Schools-Are-Effective-but Nemoto, N., MPH, Dhillon, S., MS, Fink, S., MA, Holman, et al. (2021, December 17). Evaluation of Test to Stay Strategy on Secondary and Tertiary Transmission of SARS-CoV-2 in K-12 Schools – Lake County, Illinois, August 9-October 29, 2021. Centers for Disease Control and Prevention. Retrieved March 2, 2022, from https://www.cdc.gov/mmwr/volumes/70/wr/mm705152e2.htm Pew Research Center. (2021a, April 7). Internet/Broadband Fact Sheet. Pew Research Center: Internet, Science & Tech. Retrieved March 2, 2022, from https://www.pewresearch.org/internet/fact-sheet/internet-broadband/ Pew Research Center. (2021b, April 7). Mobile Fact Sheet. Pew Research Center: Internet, Science & Tech. Retrieved March 2, 2022, from https://www.pewresearch.org/internet/fact-sheet/mobile/
