Massachusetts is drawing praise and even imitation for its “test-to-stay” approach to keep kids in school during the Covid-19 pandemic. But the realities of the policy’s implementation have been less than rosy, overburdening school nurses and requiring the National Guard be sent in to counter personnel shortages.
Test to stay allows students to attend in-person classes and partake in extracurricular activities provided they test negative every day — an option aimed at keeping more kids in class, more often. In other states, many schools are choosing to quarantine all students who come into close contact with someone who tests positive, which has amounted to tens of thousands of missed days of school for people who have not been infected with the virus.
The approach has been heralded as a “success” and a “simple solution.” This month, there are even some indications that the Centers for Disease Control and Prevention will endorse test to stay. On Oct. 13, CDC Director Rochelle Walensky told reporters during a press briefing that the agency was working with states to evaluate test to stay as a “promising potential new strategy for schools,” and that guidance would be forthcoming.
Massachusetts Education Commissioner Jeff Riley said similar, hinting that “the CDC might even start talking about it in the next few weeks, but clearly we are probably going to be three to six months ahead of everybody else.”
But the program has had a troubled launch. Though the state’s department of education laid out its plans for test to stay as early as July, it and CIC Health, the company contracted to manage the testing, could not keep up with demand for personnel from the more than 2,200 schools that signed up for the program. Instead, on Oct. 12, Gov. Charlie Baker activated 200 members of the National Guard to assist with testing in public schools. On Oct. 17, only 1,410 schools had conducted test-to-stay, symptomatic, or pooled testing in the past week.
That lack of preparation has stymied the state’s efforts and raised questions for a national expansion, said Cathryn Hampson, the president-elect for the Massachusetts School Nurses Organization and the supervisor of health services for the North Middlesex Regional School District. She painted a picture of growing frustration in her district and a messy implementation that has overburdened nurses.
“In other states that are considering doing this, they definitely need to have all of the components in advance,” Hampson said. “Trying to roll it out and get your staffing as you’re going and get your supplies as you’re going is not effective. That’s how you end up with the school nurses adding that to their workload, in addition to everything else, and that is not a sustainable plan.”
There’s already a body of research that shows test to stay can help keep students in class without seeding large outbreaks, experts told STAT.
The most compelling evidence comes from a September study published in The Lancet, said Westyn Branch-Elliman, an assistant professor of medicine at Harvard Medical School and an infectious diseases specialist. Researchers assigned 201 schools to either a typical quarantine protocol or a test-to-stay one and found the two groups had similar rates of symptomatic infections among students and staff during a 10-week study period.
“Over the course of the 2020-21 academic year, it became clear that one of the major barriers to education and learning was intermittent closures due to quarantines,” Branch-Elliman said. “A randomized control trial is the highest level of evidence we have in medicine that this strategy can be used safely without increasing the incidence of infections, while also balancing the need to keep kids in the classrooms.”
According to the Massachusetts Department of Elementary and Secondary Education, its version of policy has cumulatively saved over 48,000 in-person school days that close contacts would have otherwise spent at home in quarantine. Major sporting events like the Tokyo Olympics and NFL games used similar protocols.
The program, however, hasn’t been implemented evenly across each district that voiced interest in it. Hampson said that the state and CIC Health expected 500 districts to sign up, when over quadruple that number did.
The unprecedented scale of the operation contributed to its “rocky” rollout, according to Andrea Ciaranello, an infectious disease physician at Massachusetts General Hospital.
“In the school districts in which the vendor support staff weren’t available right away, the burden really fell to the district staff,” she said. She said that at least anecdotally, districts with support issues were the ones where the vendor was less available, not the ones that were poorer or less resourced overall.
Hampson’s district was told in August that CIC Health would provide the tests, supplies, and personnel needed for test to stay, so it “made no changes” from its standard operations in preparation for the proposed launch date of Sept. 13. Though CIC Health did deliver the BinaxNOW tests used for the program back in September, CIC Health’s promises in terms of personnel — a site tester and coordinator — still have not materialized, and it has pushed back the launch date twice to Nov. 1. CIC Health declined to comment for this story.
In the meantime, Hampson’s nurses have been administering tests to close contacts and conducting interviews, including for one positive case that produced 33 contacts. Hampson said that testing each of the contacts daily, which would ideally take place before school, took up to an hour and a half. Across the district, the additional labor has amounted to on average 10-15 extra hours of work per week, on top of a nurse’s full-time duties.
“It has been extremely stressful for my nurses,” she said, in terms of keeping the program running and dealing with parents’ expectations. “People that I’ve known and worked with in the past have been so frustrated, they’re just yelling at me on the phone.”
Not only that, her nurses have had to set aside other responsibilities when a positive case is identified and spend entire mornings emailing parents, reporting to the health department, and conducting case interviews.
Her best advice to schools considering the program? “Make sure you’ve got all the staff you need before you start it — don’t announce it to parents until you know you can do it.”
Still, some districts have managed to carry out test-to-stay programs even without the promised outside help. In Revere’s school district, test to stay has saved students more than 1,200 days of in-person learning, according to assistant superintendent Richard Gallucci. The district has come out on the other side of hiccups — like a positive case identified on the day before the start of the school year — because it committed early on to hiring health aides to support nurses.
“We have always erred on the side of, ‘Let’s have more resources than not,’ especially with the finances that we were given to get us through this pandemic,” Gallucci said.
Each school has a nurse and a full-time health aide, whose salary is paid for by the district’s emergency funds. The aides administer tests and help nurses with the interviewing and bookkeeping central to the program.
Even with two full-time employees per school, school administrators sometimes have to step in to act quickly when a positive case is identified. Gallucci’s district has standardized the process by revising a script for case investigation created last school year.
“If we interviewed students in regards to their third grade classroom, we may have not asked way back when, at the very beginning, ‘Did you see any type of specialists? Did you go visit a guidance counselor? Did you have a ‘lunch bunch’ group activity during lunch? Did you get pulled for reading intervention?’” he said.
Though each interview typically lasts 10 minutes, the process can get extensive, since several of each student’s classmates and teachers are interviewed per case, Gallucci said.
For a school district or state wishing to implement a test-to-stay program equitably, it’s important to realize that schools often don’t have a dedicated nurse and instead share one among multiple schools, said Laura Faherty, a physician policy researcher at the RAND Corporation and a pediatrician. Even if a school has its own nurse, the approach could fall apart if the nurse falls ill or takes time off work.
Future programs should build in support for nursing staff, for the sake of the program and the staff’s well-being. In Massachusetts, burnout among nurses has gotten to the point where nurses are quitting and positions have remained open for months without applicants, Hampson said.
“The same way they see nurses leaving hospital nursing, we’re seeing nurses leave school nursing,” she said.